Issues with pregnancy in systemic lupus

Systemic lupus erythematosus is a disease that affects a large number of young women of childbearing age. Today, pregnancy is considered safe in almost all women with lupus, especially when the disease is under control. However, pregnancies in this population have a higher risk of maternal complications than in the general population. It is therefore important to plan pregnancies as effectively as possible, using effective contraception and pre-pregnancy counselling. In fact, effective, well-tolerated contraception is essential for patients for whom pregnancy cannot be safely envisaged, particularly in the setting of teratogenic treatment or significant disease activity. Preconception counselling is essential and helps to anticipate several aspects of a future pregnancy. Several recent prospective studies have clearly identified risk factors for obstetric complications and disease flare. High level of lupus activity, low complement, primigravida and a history of lupus nephritis are predictive factors of disease flare when antiphospholipid syndrome or antiphospholipid antibodies (specifically for lupus anticoagulant), damage, activity of lupus are predictive for obstetric events. Appropriate therapeutic management is essential, based primarily on the continuation of hydroxychloroquine, although some recent warnings about its use in pregnancy have been discussed controversially. Corticosteroid therapy can be continued at the lowest possible dose, as can certain immunosuppressive drugs. In the case of a history of lupus nephritis, low-dose aspirin is also prescribed. Although still exceptional, the risk of neonatal lupus is also higher, in patients with anti-SSA and anti-SSB antibodies. The aim of this review is to summarise the risk factors for adverse obstetric outcomes and to improve medical and obstetric management in this population of pregnant women with lupus.

Triplet chemotherapy with or without bevacizumab as first line treatment for metastatic colorectal cancer: An AGEO multicenter real-world study

BACKGROUND

Prior trials validated triplet chemotherapy (Tri-CT) with bevacizumab as first line treatment for metastatic colorectal cancer (mCRC) but real-world data are scarce and practices remain heterogeneous.

AIMS

To evaluate Tri-CT +/- bevacizumab efficacy and safety, and to identify factors influencing treatment decisions.

METHODS

The COLOTRIP retrospective study enrolled mCRC patients treated from 2014 to 2019 in 14 French centers.

RESULTS

Of 299 patients (81% PS 0-1, 58% RAS-mutated and 19% BRAF-mutated), 51% received Tri-CT and 49% Tri-CT + bevacizumab. Metastatic disease was classified as resectable (6.5%), potentially resectable (40%), and unresectable (54%). Bevacizumab use was associated with primary tumor location, mutational status and number of metastases. Median overall survival was 33.5 months in the Tri-CT group and 23.9 months in the Tri-CT + bevacizumab group, with median progression-free survival being 14.5 and 11.4 months. After adjusting for initial characteristics, no difference in survival was noted. Around 30% of patients experienced grade ≥3 adverse events.

CONCLUSIONS

This study highlights several factors influencing Tri-CT use +/- bevacizumab decision and confirms the real-world good oncological outcomes and tolerability of these regimens in mCRC patients. Our results suggest that Tri-CT alone may by an appropriate option for specific subgroups of patients.

Precipitating factors of catastrophic antiphospholipid syndrome: the role of anticoagulant treatment in a series of 112 patients

BACKGROUND

The prevention of catastrophic antiphospholipid syndrome (CAPS), a rare complication of antiphospholipid syndrome (APS), is a major goal.

OBJECTIVES

We analyzed its precipitating factors, focusing on anticoagulation immediately before CAPS episodes.

METHODS

We retrospectively analyzed patients in the French multicenter APS/systemic lupus erythematosus database with at least 1 CAPS episode. Then we compared each patient with known APS before CAPS with 2 patients with non-CAPS APS matched for age, sex, center, and APS phenotype.

RESULTS

We included 112 patients with CAPS (70% women; mean age, 43 ± 15 years). At least 1 standard precipitating factor of CAPS was observed for 67 patients (64%), which were mainly infections (n = 28, 27%), pregnancy (n = 23, 22%), and surgery (n = 16, 15%). Before the CAPS episode, 67 (60%) patients already had a diagnosis of APS. Of the 61 treated with anticoagulants, 32 (48%) received vitamin K antagonists (VKAs), 23 (34%) heparin, and 2 (3%) a direct oral anticoagulant. They were less likely than their matched patients with APS without CAPS to receive VKA (48% vs 66%, p = .001). Among those treated with VKA, 72% had a subtherapeutic international normalized ratio (ie, <2) versus 28% in patients with APS without CAPS (p < .001). Finally, excluding pregnant patients (n = 14) for whom we could not differentiate the effect of treatment from that of pregnancy, we were left with 47 cases, 32 (68%) of whom had recently begun a direct oral anticoagulant, planned bridging therapy, or had VKA treatment with international normalized ratio <2.

CONCLUSION

These results strongly suggest that suboptimal anticoagulation management can trigger CAPS in patients with thrombotic APS.

Cutaneous Involvement in Catastrophic Antiphospholipid Syndrome in a Multicenter Cohort of 65 Patients

Importance

Catastrophic antiphospholipid syndrome (CAPS) is a severe, rare complication of antiphospholipid syndrome (APS), but cutaneous involvement has not yet been adequately described.

Objective

To describe cutaneous involvement during CAPS, its clinical and pathological features, and outcomes.

Design, Setting, and Participants

This cohort study was a retrospective analysis of patients included in the French multicenter APS/systemic lupus erythematosus register (ClinicalTrials.gov: NCT02782039) by December 2020. All patients meeting the revised international classification criteria for CAPS were included, and patients with cutaneous manifestations were analyzed more specifically.

Main Outcomes and Measures

Clinical and pathological data as well as course and outcome in patients with cutaneous involvement during CAPS were collected and compared with those in the register without cutaneous involvement.

Results

Among 120 patients with at least 1 CAPS episode, the 65 (54%) with skin involvement (43 [66%] women; median [range] age, 31 [12-69] years) were analyzed. Catastrophic antiphospholipid syndrome was the first APS manifestation for 21 of 60 (35%) patients with available data. The main lesions were recent-onset or newly worsened livedo racemosa (n = 29, 45%), necrotic and/or ulcerated lesions (n = 27, 42%), subungual splinter hemorrhages (n = 19, 29%), apparent distal inflammatory edema (reddened and warm hands, feet, or face) (n = 15, 23%), and/or vascular purpura (n = 9, 14%). Sixteen biopsies performed during CAPS episodes were reviewed and showed microthrombi of dermal capillaries in 15 patients (94%). These lesions healed without sequelae in slightly more than 90% (58 of 64) of patients. Patients with cutaneous involvement showed a trend toward more frequent histologically proven CAPS (37% vs 24%, P = .16) than those without such involvement, while mortality did not differ significantly between the groups (respectively, 5% vs 9%, P = .47).

Conclusions and Relevance

In this cohort study, half the patients with CAPS showed cutaneous involvement, with a wide spectrum of clinical presentations, including distal inflammatory edema. Skin biopsies confirmed the diagnosis in all but 1 biopsied patient.

Determination of four homogeneous subgroups of patients with antiphospholipid syndrome: a cluster analysis based on 509 cases

OBJECTIVE

Antiphospholipid syndrome (APS) is a heterogeneous disease with different phenotypes. Using an unsupervised hierarchical cluster analysis, we aimed to determine distinct homogeneous phenotypes among APS patients.

METHODS

We performed an observational, retrospective study of APS patients enrolled in the French multicentre 'APS and SLE' registry who meet the Sydney classification criteria. The clustering process involved an unsupervised multiple correspondence analysis followed by a hierarchical ascendant clustering analysis; it used 27 variables selected to cover a broad range of APS clinical and laboratory manifestations.

RESULTS

These analyses included 509 patients, mainly women (77.8%). Mean (± SD) age at APS diagnosis was 36.2 ± 14.6 years, and mean follow-up since diagnosis 10.3 ± 8.5 years. This hierarchical classification cluster analysis yielded four homogeneous groups of patients: cluster 1, mostly with venous thromboembolism without any associated autoimmune disease; cluster 2, older, lowest proportion of women, history of arterial events, and/or with migraines, arterial hypertension, diabetes mellitus, or dyslipidaemia; cluster 3, younger, highest proportion of women, associated SLE or other autoimmune diseases, and a history of venous thromboembolism or pregnancy morbidity; and cluster 4, mainly with a history of catastrophic antiphospholipid syndrome, aPL-associated nephropathy, and pregnancy morbidity, with frequent triple positivity and more deaths (16.7%).

CONCLUSIONS

Our study applied an unsupervised clustering method to distinguish four homogeneous APS patient subgroups that were predominantly venous; arterial; associated with SLE or another autoimmune disease; and arterial microthrombotic. Heterogeneous pathophysiological mechanisms may explain these findings.

Imported malaria in metropolitan France, from recommendations to clinical practice - proposal for improvement

BACKGROUND

Approximately 5000 cases of imported malaria are observed each year in metropolitan France. Guidelines for the prevention and management of imported malaria were published by the French infectious disease society (French acronym SPILF) in 2017.

OBJECTIVE

Study objective was to describe in a retrospective analysis (2015-2016) imported malaria cases recorded in a Parisian hospital, to analyze the congruence to previous guidelines (2014), deviation in respect to post hoc published guidelines and potential areas for improvement.

RESULTS

Two hundred and one cases were analyzed using medical charts. There was a majority of men (sex ratio 2/1), with a mean age of 43 years at diagnosis. The main area of infection acquisition was sub-Saharan Africa (97%). The average time since return from the endemic area was 20 days. Patients consulted the emergency department for flu-like syndrome (32%), fever or chills (28%), and gastrointestinal symptoms (22%). Blood smears mainly identified Plasmodium falciparum (n=180, 90%). There were 52 (26%) severe malaria episodes.

CONCLUSION

The analysis of national guideline adequacy highlighted difficulties in obtaining a complete biological workup at baseline, managing patients with vomiting, and in the post-treatment follow-up.

Spatial Mobility of the Visually Handicapped Active Person: A Descriptive Study

Specific aspects of mobility and spatial orientation of the visually handicapped have attracted the attention of researchers for a quarter of a century; generally speaking, their work can be placed in four fields of study. First, interest has been focused on the capacity of blind people to move unaided in various spatial settings and to mentally map an environment. A second preoccupation revealed by the literature has been the spatial information transmitted to the visually handicapped by tactile maps, by adapted sign system and by electronic guidance systems. Other projects have focused on the environment in which visually handicapped move and on the environmental aspects that affect their mobility. Finally, some researchers have investigated how the development of technical aids has facilitated the mobility of blind people.

Interleukin-7/Interferon Axis Drives T Cell and Salivary Gland Epithelial Cell Interactions in Sjögren's Syndrome

OBJECTIVE

Primary Sjögren's syndrome (SS) is characterized by a lymphocytic infiltration of salivary glands (SGs) and the presence of an interferon (IFN) signature. SG epithelial cells (SGECs) play an active role in primary SS pathophysiology. We undertook this study to examine the interactions between SGECs and T cells in primary SS and the role of the interleukin-7 (IL-7)/IFN axis.

METHODS

Primary cultured SGECs from control subjects and patients with primary SS were stimulated with poly(I-C), IFNα, or IFNγ. T cells were sorted from blood and stimulated with IL-7. CD25 expression was assessed by flow cytometry. SG explants were cultured for 4 days with anti-IL-7 receptor (IL-7R) antagonist antibody (OSE-127), and transcriptomic analysis was performed using the NanoString platform.

RESULTS

Serum IL-7 level was increased in patients with primary SS compared to controls and was associated with B cell biomarkers. IL7R expression was decreased in T cells from patients with primary SS compared to controls. SGECs stimulated with poly(I-C), IFNα, or IFNγ secreted IL-7. IL-7 stimulation increased the activation of T cells, as well as IFNγ secretion. Transcriptomic analysis of SG explants showed a correlation between IL7 and IFN expression. Finally, explants cultured with anti-IL-7R antibody showed decreased IFN-stimulated gene expression.

CONCLUSION

These results suggest the presence of an IL-7/IFNγ amplification loop involving SGECs and T cells in primary SS. IL-7 was secreted by SGECs stimulated with type I or type II IFN and, in turn, activated T cells that secrete type II IFN. An anti-IL-7R antibody decreased the IFN signature in T cells in primary SS and could be of therapeutic interest.

Immune checkpoint inhibitor treatment of a first cancer is associated with a decreased incidence of second primary cancer

Background

Second primary cancers (SPCs) are diagnosed in over 5% of patients after a first primary cancer (FPC). We explore here the impact of immune checkpoint inhibitors (ICIs) given for an FPC on the risk of SPC in different age groups, cancer types and treatments.

Patients and methods

The files of the 46 829 patients diagnosed with an FPC in the Centre Léon Bérard from 2013 to 2018 were analyzed. Structured data were extracted and electronic patient records were screened using a natural language processing tool, with validation using manual screening of 2818 files of patients. Univariate and multivariate analyses of the incidence of SPC according to patient characteristics and treatment were conducted.

Results

Among the 46 829 patients, 1830 (3.9%) had a diagnosis of SPC with a median interval of 11.1 months (range 0-78 months); 18 128 (38.7%) received cytotoxic chemotherapy (CC) and 1163 (2.5%) received ICIs for the treatment of the FPC in this period. SPCs were observed in 7/1163 (0.6%) patients who had received ICIs for their FPC versus 437/16 997 (2.6%) patients receiving CC and no ICIs for the FPC versus 1386/28 669 (4.8%) for patients receiving neither CC nor ICIs for the FPC. This reduction was observed at all ages and for all histotypes analyzed. Treatment with ICIs and/or CC for the FPC are associated with a reduced risk of SPC in multivariate analysis.

Conclusion

Immunotherapy with ICIs alone and in combination with CC was found to be associated with a reduced incidence of SPC for all ages and cancer types.

•

From 2013 to 2018, 3.9% of the 46 829 patients diagnosed with a first cancer presented with an SPC.

•

Treatment of the first cancer with ICIs was associated with a major reduction of SPC.

•

CC given for an FPC was also associated with a lower magnitude of reduction of SPC.

•

There were no SPC in cancer patients treated with ICIs in the localized phase of their first cancer.

Salivary gland epithelial cells from patients with Sjögren's syndrome induce B-lymphocyte survival and activation

OBJECTIVE

Primary Sjögren's syndrome (pSS) is characterised by chronic hyperactivation of B lymphocytes. Salivary gland epithelial cells (SGECs) could play a role in promoting B-lymphocyte activation within the target tissue. We aimed to study the interactions between SGECs from patients with pSS or controls and B lymphocytes.

METHODS

Patients had pSS according to 2016 European League Against Rheumatism/American College of Rheumatology criteria. Gene expression analysis of SGECs and B lymphocytes from pSS and controls isolated from salivary gland biopsies and blood was performed by RNA-seq. SGECs from pSS and controls were cocultured with B-lymphocytes sorted from healthy donor blood and were stimulated. Transwell and inhibition experiments were performed.

RESULTS

Gene expression analysis of SGECs identified an upregulation of interferon signalling pathway and genes involved in immune responses (HLA-DRA, IL-7 and B-cell activating factor receptor) in pSS. Activation genes CD40 and CD48 were upregulated in salivary gland sorted B lymphocytes from patients with pSS. SGECs induced an increase in B-lymphocyte survival, which was higher for SGECs from patients with pSS than controls. Moreover, when stimulated with poly(I:C), SGECs from patients with pSS induced higher activation of B-lymphocytes than those from controls. This effect depended on soluble factors. Inhibition with anti-B-cell activating factor, anti-A proliferation-inducing ligand, anti-interleukin-6-R antibodies, JAK1/3 inhibitor or hydroxychloroquine had no effect, conversely to leflunomide, Bruton's tyrosine kinase (BTK) or phosphatidyl-inositol 3-kinase (PI3K) inhibitors.

CONCLUSIONS

SGECs from patients with pSS had better ability than those from controls to induce survival and activation of B lymphocytes. Targeting a single cytokine did not inhibit this effect, whereas leflunomide, BTK or PI3K inhibitors partially decreased B-lymphocyte viability in this model. This gives indications for future therapeutic options in pSS.

Articular manifestations in patients with inflammatory bowel disease treated with vedolizumab

Objective

Vedolizumab (VDZ) has been incriminated in the occurrence of articular manifestations in patients with inflammatory bowel diseases (IBDs). The aim of this study was to describe musculoskeletal manifestations occurring in IBD patients treated by VDZ and to identify risk factors.

Methods

In this retrospective monocentric study, we included all consecutive patients treated by VDZ for IBD in our hospital. Incident musculoskeletal manifestations occurring during VDZ treatment were analysed and characteristics of patients with and without articular inflammatory manifestations were compared.

Results

Between 2013 and 2017, 112 patients were treated with VDZ for IBD: ulcerative colitis (n = 59), Crohn’s disease (n = 49) and undetermined colitis (n = 4). Four patients (3.6%) had a history of SpA, whereas 13 (11.6%) had a history of peripheral arthralgia. Some 102 (91.1%) patients had previously received anti-TNF. After a mean (S.d.) follow-up of 11.4 (8.6) months, 32 (28.6%) patients presented 35 musculoskeletal manifestations, of which 18 were mechanical and 17 inflammatory. Among the latter, 11 had axial or peripheral SpA, 5 had early reversible arthralgia and 1 had chondrocalcinosis (n = 1). Among the 11 SpA patients, only 3 (2.6%) had inactive IBD and may be considered as paradoxical SpA. The only factor associated with occurrence of inflammatory manifestations was history of inflammatory articular manifestation [7/16 (43.8%) vs 10/80 (12.5%), P = 0.007].

Conclusion

Musculoskeletal manifestations occurred in almost 30% of IBD patients treated with VDZ, but only half of them were inflammatory. Since most of the patients previously received anti-TNF, occurrence of inflammatory articular manifestations might rather be linked to anti-TNF discontinuation than to VDZ itself.

Surgery in reference centers improves survival of sarcoma patients: a nationwide study

BACKGROUND

NETSARC (netsarc.org) is a network of 26 sarcoma reference centers with specialized multidisciplinary tumor boards (MDTB) aiming to improve the outcome of sarcoma patients. Since 2010, presentation to an MDTB and expert pathological review are mandatory for sarcoma patients nationwide. In the present work, the impact of surgery in a reference center on the survival of sarcoma patients investigated using this national NETSARC registry.

PATIENTS AND METHODS

Patients' characteristics and follow-up are prospectively collected and data monitored. Descriptive, uni- and multivariate analysis of prognostic factors were conducted in the entire series (N = 35 784) and in the subgroup of incident patient population (N = 29 497).

RESULTS

Among the 35 784 patients, 155 different histological subtypes were reported. 4310 (11.6%) patients were metastatic at diagnosis. Previous cancer, previous radiotherapy, neurofibromatosis type 1 (NF1), and Li-Fraumeni syndrome were reported in 12.5%, 3.6%, 0.7%, and 0.1% of patients respectively. Among the 29 497 incident patients, 25 851 (87.6%) patients had surgical removal of the sarcoma, including 9949 (33.7%) operated in a NETSARC center. Location, grade, age, size, depth, histotypes, gender, NF1, and surgery outside a NETSARC center all correlated to overall survival (OS), local relapse free survival (LRFS), and event-free survival (EFS) in the incident patient population. NF1 history was one of the strongest adverse prognostic factors for LRFS, EFS, and OS. Presentation to an MDTB was associated with an improved LRFS and EFS, but was an adverse prognostic factor for OS if surgery was not carried out in a reference center. In multivariate analysis, surgery in a NETSARC center was positively correlated with LRFS, EFS, and OS [P < 0.001 for all, with a hazard ratio of 0.681 (95% CI 0.618-0.749) for OS].

CONCLUSION

This nationwide registry of sarcoma patients shows that surgical treatment in a reference center reduces the risk of relapse and death.

Liver hypertrophy: Underlying mechanisms and promoting procedures before major hepatectomy

Various procedures can promote hypertrophy of the future liver remnant (FLR) before major hepatectomy to prevent postoperative liver failure. The pathophysiological situation following portal vein embolization (PVE), hepatic artery ligation/embolization or hepatectomy remains unclear. On one hand, the main mechanisms of hepatic regeneration appear to be driven by hepatic hypoxia (involving the hepatic arterial buffer response), an increased portal blood flow inducing shear stress and the involvement of several mediators (inflammatory cytokines, vasoregulators, growth factors, eicosanoids and several hormones). On the other hand, several factors are associated with impaired liver regeneration, such as biliary obstruction, malnutrition, diabetes mellitus, male gender, age, ethanol and viral infection. All these mechanisms may explain the varying degrees of hypertrophy observed following a surgical or radiological procedure promoting hypertrophy the FLR. Radiological procedures include left and right portal vein embolization (extended or not to segment 4), sequential PVE and hepatic vein embolization (HVE), and more recently combined PVE and HVE. Surgical procedures include associated liver partition and portal vein ligation for staged hepatectomy, and more recently the combined portal embolization and arterial ligation procedure. This review aimed to clarify the pathophysiology of liver regeneration; it also describes radiological or surgical procedures employed to improve liver regeneration in terms of volumetric changes, the feasibility of the second step and the benefits and drawbacks of each procedure.

Associating portal embolization and artery ligation to induce rapid liver regeneration in staged hepatectomy

BACKGROUND

Insufficient volume of the future liver remnant (FLR) is a major cause of unresectability in patients with bilobar colorectal liver metastases (CLM). The objective of this study was to evaluate the safety and efficacy of the novel associating portal embolization and artery ligation (APEAL) technique before extended right hepatectomy during a two-stage procedure for CLM.

METHODS

All patients who had undergone extended right hepatectomy during two-stage surgery for CLM between 2012 and 2014 were identified retrospectively from a prospectively maintained database. In the first stage, right portal vein embolization, partial right hepatic artery ligation and devascularization of segment IVb along the round ligament without parenchymal transection were associated with clearance of the FLR and/or primary tumour resection. Liver volumetry was performed using OsiriX software on postoperative day (POD) 7 and 30.

RESULTS

Ten patients underwent the APEAL procedure. During the first stage, APEAL was combined with colorectal resection in seven patients. The median (range) interval between the two stages was 45 (31-71) days. The FLR volume increased from 327 (214-537) cm(3) before surgery to 590 (508-1072) cm(3) on POD 7 and 701 (512-1018) cm(3) on POD 30. This corresponded to a FLR regeneration rate of 104 (42-185) and 134 (53-171) per cent respectively. There were no deaths. The overall morbidity rate was 60 per cent (6 of 10) after each procedure, with severe morbidity occurring in two and three of ten patients after the first and second procedures respectively.

CONCLUSION

APEAL induces fast, safe, reproducible and effective FLR growth when an extended right hepatectomy is scheduled in patients with multiple bilobar CLM.

Radiofrequency ablation for colorectal liver metastases

The management of hepatic metastases from colorectal cancer (HMCRC) is multimodal including chemotherapy, surgical resection, radiation therapy, and focused destruction technologies. Radiofrequency ablation (RFA) is the most commonly used focused destruction technology. It represents a therapeutic option that may be potentially curative in cases where surgical excision is contra-indicated. It also increases the number of candidates for surgical resection among patients whose liver metastases were initially deemed unresectable. This article explains the techniques, indications, and results of radiofrequency ablation in the treatment of hepatic colorectal metastases.

Excitatory action of vasopressin in the brain of the rat: role of cAMP signaling

Brain vasopressin plays a role in behavioral and cognitive functions and in pathological conditions. Relevant examples are pair bonding, social recognition, fear responses, stress disorders, anxiety and depression. At the neuronal level, vasopressin exerts its effects by binding to V1a receptors. In the brainstem, vasopressin can excite facial motoneurons by generating a sustained inward current which is sodium-dependent, tetrodotoxin-insensitive and voltage-gated. This effect is independent of intracellular calcium mobilization and is unaffected by phospholipase Cβ (PLCβ) or protein kinase C (PKC) inhibitors. There are two major unsolved problems. (i) What is the intracellular signaling pathway activated by vasopressin? (ii) What is the exact nature of the vasopressin-sensitive cation channels? We performed recordings in brainstem slices. Facial motoneurons were voltage-clamped in the whole-cell configuration. We show that a major fraction, if not the totality, of the peptide effect was mediated by cAMP signaling and that the vasopressin-sensitive cation channels were directly gated by cAMP. These channels appear to exclude lithium, are suppressed by 2-aminoethoxydiphenylborane (2-APB) and flufenamic acid (FFA) but not by ruthenium red or amiloride. They are distinct from transient receptor channels and from cyclic nucleotide-regulated channels involved in visual and olfactory transduction. They present striking similarities with cation channels present in a variety of molluscan neurons. To our knowledge, the presence in mammalian neurons of channels having these properties has not been previously reported. Our data should contribute to a better knowledge of the neural mechanism of the central actions of vasopressin, and may be potentially significant in view of clinical applications.

Deciphering the H-Ras pathway in Xenopus oocyte

Xenopus oocytes are arrested in prophase of the first meiotic division. In response to progesterone, they re-enter meiosis and arrest again in metaphase of the second meiotic division. This process, called meiotic maturation, is under the control of the Cyclin B-Cdc2 complex, M phase promoting factor (MPF). Injection of a constitutively active Xenopus H-Ras protein activates MPF, suggesting that Ras proteins could be implicated in the progesterone transduction pathway. The aim of this study was (1) to elucidate the pathway triggered by H-Ras leading to MPF activation in Xenopus oocytes and (2) to investigate whether endogenous H-Ras is involved in the physiological process of meiotic maturation. We generated three constitutively active double mutants, each of them recruiting a single effector in mammalian cells, mitogen-activated protein kinase (MAPK), phosphatidylinositol 3-kinase (PI3K) or RalGDS. Our results show that the activation of a PI3K-related enzyme is crucial for H-Ras-induced MPF activation, whereas the recruitment of either MAPK or RalGDS is not. However, although the H-Ras/PI3K pathway is functional in Xenopus oocytes, it is not the physiological transducer of progesterone responsible for meiotic resumption.

From progesterone to active Cdc2 in Xenopus oocytes: a puzzling signalling pathway

Since almost two decades, it is known that progesterone is responsible of the release of the prophase I arrest of amphibian oocytes and leads to the activation of the universal MPF, through a puzzling transduction pathway. It involves negative regulation of the cAMP-dependent protein kinase (PKA) and synthesis of new proteins, among them the c-Mos protooncogene product. The implication of the Mos/mitogenic activated protein kinase (MAP kinase) pathway in Cdc2 activation has been extensively studied and is now at the centre of a controversial debate. In this paper, we discuss the current progress and our recent results on the molecular mechanisms allowing progesterone to activate MPF and propose a model to partly resolve the long-standing inconsistencies concerning the role of Mos/MAP kinase during this process.

[Surgical treatment of acute cholecystitis. A retrospective study of a series of 192 patients operated on over a period of 3 years]

Emergency conditions make laparoscopic treatment of acute cholecystitis challenging. The aim of this study is to retrospectively analyse our experience of cholecystectomy for acute cholecystitis performed between January 1995 and December 1997. In order to be included, patients had to present (i) symptoms of acute cholecystitis correlated with laboratory blood tests and ultrasonographic studies (ii) evidence of acute inflammation during the operation and (iii) histological confirmation of acute or subacute inflammation of the excised gallbladder. 192 patients were treated: 62 were totally managed laparoscopically (group CCN), 33 managed laparoscopically but required conversion to open cholecystectomy (group CCC) and 97 were managed conventionally by laparotomy (group CL). Mean age was significantly different between the three groups, (CCN: 55.6 +/- 15 years, CCC: 64.2 +/- 13 years, CL: 66.5 +/- 17 years), as was ASA score (CCN: ASA 3 and ASA 4: 16%, CCC: ASA 3 and ASA 4: 48%, CL: ASA 3 and ASA 4: 46%), and initial infectious signs (temp. > or = 38 degrees C: CCN: 35%, CCC: 39%, CL: 63%). Mean operative delay was significantly higher in the converted group [8.7 +/- 13 days (CCC) vs 4.5 +/- 8 days (CCN) and 5.4 +/- 8 days (CL)]. There were two (1%) bile duct injuries, one in the CCC group, the other in the CL group. Operative mortality was 2% (CCC: 0%, CCN: 0%, CL: 4%) and operative morbidity was 40% (CCN: 21%, CCC: 24%, CL: 57%). The mean postoperative hospital stay was shorter in the CCN group (6.5 +/- 3.5 days) and CCC group (9.6 +/- 4.4 days) vs the mean stay in the CL group (14.7 +/- 11.6 days). Appears to be beneficial for selected patients with low surgical risk to conclude laparoscopic cholecystectomy. It has yet to be shown whether this benefit can be extended to patients with a high surgical risk.

[Mucinous ductal ectasia of the pancreas]

We report a new case of mucinous ductal extasia of the pancreas observed in a 64-year-old man with a history of chronic exocrine failure. Diagnosis was obtained by CT, duodenal endoscopy and retrograde cholangio-pancreatography. Risk of malignant degeneration and increased CA 19-9 led to duodenopancreatectomy. Histology confirmed the diagnosis but revealed no malignant lesion. After a 3-year follow-up, the patient is in excellent health. Based on this observation and a review of the literature, we present the characteristic features of mucinous ductal ectasia of the pancreas.

Necrobiotic xanthogranuloma: a case without paraproteinemia but with transepithelial elimination

We report a female patient, now aged 60, followed for 20 years for lesions originally diagnosed as necrobiosis lipoidica diabeticorum. In fact, the anatomical and clinical features of her disorder correspond to the new entity described as necrobiotic xanthogranuloma. Two elements distinguish this from earlier cases: 1) two examinations failed to reveal paraproteinemia; 2) there was transepithelial elimination of cholesterol crystals and degenerated xanthomatous cell debris via hair follicles. This demonstrates the characteristic histology of the disorder and indicates that the diagnosis of necrobiotic xanthogranuloma should be considered even in the absence of paraproteinemia.

Eosinophilic fasciitis (Shulman syndrome) in association with morphea, immunological disturbance and profuse achromia

A case of localized eosinophilic fasciitis (EF) is reported. Profuse hypopigmentation, guttate morphea and immunological disturbances accompanied the subcutaneous changes. The case links Shulman's syndrome with classical localized cutaneous scleroderma.

Chloroquine-induced hypopigmentation of hair and freckles. Association with congenital renal failure

Hypopigmentation of hair and freckles occurred in a patient receiving chloroquine sulfate therapy. This patient had a severe congenital renal failure that presumably increased plasma and tissue levels of the drug substantially, accounting for the hypopigmentation.

[Mammary lymphatic scintiscans by intratumoral injection in the assessment of breast cancer. 105 examination in 100 patients (author's transl)]

One hundred and five scintiscans of the mammary lymphatic system were performed in 100 patients with breast cancer by intratumoral injection of 99 m Tc-labelled colloidal rhenium. The progression of the radioactive colloidal agent was followed on a series of films taken 1, 2 and 4 hours after the injection, and the images obtained were compared with post-operative findings of lymph node involvement. Patients with more than 3 carcinomatous lymph nodes had less than 2 foci of activity, while those with less than 3 carcinomatous lymph nodes had more than 2 foci of activity, owing to more rapid progression of the compound. The difference was highly significant (p less than 0,001).