Life-threatening chlorpromazine-induced acquired haemophilia A in a patient with a cavernous malformation involving the medulla oblongata.

INTRODUCTION: Chlorpromazine is a commonly used drug in several medical conditions associated with a wide range of side effects. Few cases of hemostatic disorder have been reported in the literature. CASE REPORT: A 39-year-old man had previously been diagnosed with a cavernous malformation of the medulla oblongata. Chlorpromazine was started to treat persistent hiccups. Twenty days later, the patient presented hepatitis and a pruritic rash. Haemostasis tests revealed a prolonged partial thromboplastin time associated with isolated decrease of factor VIII level and anti-factor VIII antibodies. Magnetic resonance imaging revealed recent asymptomatic bleeding. Introduction of eptacog alfa and prednisone allowed clinical and biological improvement as well as a prolonged remission after 12 months of follow-up.

The ID NOW COVID-19, a high-speed high-performance assay.

The ID NOW COVID-19 assay is a promising tool for the rapid identification of COVID-19 patients. However, its performances were questioned. We evaluate the ID NOW COVID-19 in comparison to a reference RT-PCR using a collection of 48 fresh nasopharyngeal swabs sampled on universal transport media (UTM). Only 2 false negatives of the ID NOW COVID-19 were identified. They display PCR cycle threshold values of 37.5 and 39.2. The positive percent agreement and the negative percent agreement were 94.9% and 100%, respectively. The Kappa value was 0.88. The ID NOW COVID-19 combines high-speed and accurate processing. Using UTM, the ID NOW COVID-19 could be repeated in the case of invalid result. Further analyses, such as screening of genetic variants or genome sequencing, could also be performed with the same sample. As for all tests, the results should be interpreted according to clinical and epidemiological context.

Impact of rapid diagnostic tests on the management of patients presenting with Enterobacteriaceae bacteremia.

OBJECTIVE: Pathogens are usually identified from blood cultures using a two-step procedure: Gram staining on the day of bacterial growth (D0), followed by identification and susceptibility testing the following day (D1). We aimed to evaluate the use of rapid tests performed on D0 in patients presenting with Enterobacteriaceae bacteremia. PATIENTS AND METHODS: Patients with≥1 positive monomicrobial blood culture with Gram staining suggestive of an Enterobacteriaceae were prospectively included. Two successive strategies were evaluated: i) conventional strategy (CS), ii) combination of a rapid identification test and third-generation cephalosporin susceptibility testing (rapid strategy, e.g. RS). RESULTS: Eighty-three patients were included (CS=42; RS=41). Compared with CS, the median delay of identification was significantly shorter with RS (22 hours [20-27] vs. 47 hours [42-53]; P<0.001). Patients in the RS group more frequently received an effective (82.9% vs. 73.8%, P=0.43) and appropriate (70.7% vs. 54.7%, P=0.17) antibiotic therapy on D1. Moreover, all five RS patients infected with a non-susceptible strain received an effective therapy on D1 versus only three of eight CS patients. CONCLUSIONS: Use of rapid testing was associated with a reduced time to result availability. This strategy should be useful to initiate an early effective and appropriate therapy and to improve the care of patients.

Urinary tract infection after acute stroke: Impact of indwelling urinary catheterization and assessment of catheter-use practices in French stroke centers.

INTRODUCTION: Urinary catheterization and acute urinary retention increase the risk of urinary tract infection (UTI). Our study aimed to investigate the incidence of UTI following acute stroke at our stroke center (SC) and to assess urinary catheter-care practices among French SCs. METHODS: Stroke patients hospitalized within 24h of stroke onset were prospectively enrolled between May and September 2013. Neurological deficit level was assessed on admission using the US National Institutes of Health Stroke Scale (NIHSS). Patients were followed-up until discharge. Indwelling urinary catheterization (IUC) was the only technique authorized during the study. An electronic survey was also conducted among French SCs to assess their practices regarding urinary catheterization in acute stroke patients. RESULTS: A total of 212 patients were included, with 45 (21.2%) receiving indwelling urinary catheters. The overall estimated incidence of UTI was 14.2%, and 18% among patients receiving IUC. On univariate analysis, IUC was significantly associated with older age, longer hospital stays and higher NIHSS scores. Of the 30 SCs that responded to our survey, 19 (63.3%) declared using IUC when urinary catheterization was needed. The main argument given to justify its use was that it was departmental policy to adopt this technique. Also, 27 participants (90%) stated that conducting a study to assess the impact of urinary catheterization techniques on UTI rates in acute stroke patients would be relevant. DISCUSSION: Our results are in accord with previously reported data and confirm the high burden of UTI among acute stroke subjects. However, no association was found between IUC and UTI on univariate analysis due to a lack of statistical power. Also, our survey showed high heterogeneity in catheter-use practices among French SCs, but offered no data to help determine the best urinary catheterization technique. CONCLUSION: Urinary catheterization is common after acute stroke and a well-known risk factor of UTI. However, as high heterogeneity in catheter-use practices is found among French SCs, randomized studies comparing the efficacy of urinary catheterization techniques in terms of UTI prevention in acute stroke patients are now warranted.

Low IDL-B and high LDL-1 subfraction levels in serum of ALS patients.

INTRODUCTION: Converging evidence highlights that lipid metabolism plays a key role in ALS pathophysiology. Dyslipidemia has been described in ALS patients and may be protective but peripheral lipoprotein subclasses have never been studied. MATERIAL AND METHODS: We collected sera from 30 ALS patients and 30 gender and age-matched controls. We analyzed 11 distinct lipoprotein subclasses by linear polyacrylamide gel electrophoresis (Lipoprint, Quantimetrix Corporation, USA). We also measured lipoprotein (a), apolipoprotein B, and apolipoprotein E levels. RESULTS: ALS patients had significant higher total cholesterol, HDL-cholesterol, and LDL-cholesterol levels than controls (p<0.0001, p=0.0007, and p=0.0065, respectively). The LDL-1 subfraction concentration was higher (1.03±0.41 vs. 0.71±0.28mmol/L; p=0.0006) and the IDL-B subfraction lower (6.5±2% vs. 8.0±2%; p=0.001) in ALS patients than controls. DISCUSSION: Our preliminary work confirmed the association between ALS and dyslipidemia. The low IDL-B levels may explain the hepatic steatosis frequently reported in ALS. The high levels of the cholesterol-rich LDL-1 subfraction is consistent with previously reported hypercholesterolemia. CONCLUSION: This study describes, for the first time, the distribution of serum lipoproteins in ALS patients, with low IDL-B and high LDL-1 subfraction level.

Increase in sexually transmitted infections in a cohort of outpatient HIV-positive men who have sex with men in the Parisian region.

OBJECTIVE: To describe the increased incidence of sexually transmitted infections (STIs) in a cohort of HIV-infected men who have sex with men (MSM), followed in a tertiary hospital of the Île-de-France region. MATERIALS AND METHODS: We performed a monocentric, retrospective, and prospective study. We included symptomatic HIV-infected MSM patients who consulted for their annual consultation. RESULTS: One hundred and eighty patients were seen between 2008-2011 and 215 between 2012-2015. We observed an increased incidence of STIs between the two periods (14 and 29.3%, respectively). These STIs includes: syphilis, hepatitis C, urethritis, and proctitis due to Chlamydia trachomatis and Neisseria gonorrhea. CONCLUSION: A better management of symptomatic and asymptomatic STIs is needed for HIV-infected MSM patients.

[Tetraspanins: a new target for antiangiogenic therapy?]. / Les tétraspanines : une nouvelle cible pour la thérapie anti-angiogénique ?

Inhibition of the vascular endothelial growth factor A or inhibition of its receptors are currently used for the treatment of cancer. However, the results are still modest, especially because of the multitude and redundancy of angiogenic factors. It can be hypothesized that therapies targeting directly endothelial cells themselves could be more effective. The tetraspanins are transmembrane molecules, which are devoid of intrinsic enzymatic activity but can associate with each other and with other molecules such as integrins or proteins of the immunoglobulin superfamily to form a network. The tetraspanins are present on the surface of endothelial cells and in vitro, inhibition of these molecules by antibodies or small interfering RNA suggests that tetraspanins play a role in angiogenesis. These preliminary data have been confirmed by the study of cancer xenografts in tetraspanin-deficient mice, which have a significant decrease in tumor size and tumor angiogenesis. In vivo, it has been shown that intravenous administration of a monoclonal antibody (ALB6) directed against CD9 decreases the tumor growth and angiogenesis and that intravitreal injection of a small interfering RNA decreasing CD9 significantly inhibits choroidal neovascularization induced by laser. Finally, anti-angiogenic effects and potent anti-tumor activity are observed by the intraperitoneal administration of GS-168AT2, a peptide derived from CD9-Partner 1, a molecule belonging to the immunoglobulin superfamily, which interacts strongly with the CD9 and CD81. These data suggest that the pharmacological modulation of the tetraspanin web could play a new promising anti-angiogenic strategy.

[Lack of bioavailability of generic lopinavir/ritonavir not prequalified by WHO marketed in Africa (Congo Brazzaville)]. / Absence de bio-équivalence d'un générique du lopinavir/ritonavir non préqualifié par l'OMS commercialisé en Afrique (Congo Brazzaville).

Although second-line generic antiretroviral drugs are of great value in developing countries there are concerns regarding their quality and safety. This study is a case report and pharmacological study in healthy volunteers. A French subject of sub-saharan origin who visited Republic of Congo received a post-exposure treatment with AZT+3TC and LPV/r (200/50 mg, Arga-L®, India) following unprotected sexual intercourse. Two days later, in France, tests showed that plasma concentrations of lopinavir and ritonavir were undetectable. The WHO prequalification list showed Arga-L® was not prequalified. A pharmacological study in healthy volunteers evaluated oral bioavailability: plasma concentrations of generic LPV/r Arga-L® and LPV/r Kaletra® (400/100 mg) were measured after one single dose at 7 days apart in four healthy volunteers. Concentrations of Arga-L® at 12 h after intake were considerably lower than those of Kaletra®, revealing very low oral bioavailability of generic lopinavir and ritonavir (<10%) compared to the brand-name drug. We found that Arga-L®, despite having adequate qualitative and quantitative drug contents, had very poor bio availability compared to Kaletra®. In order to avoid the selection and the spread of drug-resistant HIV strains, rigorous pharmacological monitoring of generic antiretroviral drugs that are not pre-qualified by WHO, but are marketed in Africa, must be a priority for health authorities.

Importance of ERK activation in As2O3-induced differentiation and promyelocytic leukemia nuclear bodies formation in neuroblastoma cells.

Neuroblastoma malignant cell growth is dependent on their undifferentiated status. Arsenic trioxide (As2O3) induces neuroblastoma cell differentiation in vitro, but its mechanisms still remains unknown. We used three human neuroblastoma cell lines (SH-SY5Y, IGR-N-91, LAN-1) that differ from their MYCN and p53 status to explore the intracellular events activated by As2O3 and involved in neurite outgrowth, a morphological marker of differentiation. As2O3 (2µM) induced neurite outgrowth in all cell lines, which was dependent on ERK activation but independent on MYCN status. This process was induced either by a sustained (3 days) or a transient (2h) incubation with As2O3, indicating that very early events trigger the induction of differentiation. In parallel, As2O3 induced a rapid assembly of promyelocytic leukemia nuclear bodies (PML-NB) in an ERK-dependent manner. In conclusion, mechanisms leading to neuroblastoma cell differentiation in response to As2O3 appear to involve the ERK pathway activation and PML-NB formation, which are observed in response to other differentiating molecules such as retinoic acid derivates. This open new perspectives based on the use of treatment combinations to potentiate the differentiating effects of each drug alone and reduce their adverse side effects.

What role for angiogenesis in childhood acute lymphoblastic leukaemia?

The role of angiogenesis in acute leukaemia has been discussed since the cloning of the gene of vascular endothelial growth factor (VEGF) from the acute myelogenous leukemia cell line (HL60) and, thereafter, when the first studies reported increased bone marrow vascularity and elevation of angiogenic cytokines in acute lymphoblastic leukaemia (ALL). VEGF and basic fibroblast growth factor (bFGF) are the major proangiogenic cytokines that have been studied, and evaluation of their prognostic impact in childhood ALL has been reported in several studies, though with controversial results. The antiangiogenic response, contributing to the angiogenic balance, has scarcely been reported. The origin of the factors, their prognostic value, and their relevance as good markers of what really happens in the bone marrow are discussed in this paper. The place of antiangiogenic drugs in ALL has to be defined in the global treatment strategy.

A truncated form of CD9-partner 1 (CD9P-1), GS-168AT2, potently inhibits in vivo tumour-induced angiogenesis and tumour growth.

BACKGROUND: Tetraspanins are transmembrane proteins known to contribute to angiogenesis. CD9 partner-1 (CD9P-1/EWI-F), a glycosylated type 1 transmembrane immunoglobulin, is a member of the tetraspanin web, but its role in angiogenesis remains to be elucidated. METHODS: We measured the expression of CD9P-1 under angiogenic and angiostatic conditions, and the influence of its knockdown onto capillary structures formation by human endothelial cells (hECs). A truncated form of CDP-1, GS-168AT2, was produced and challenged vs hEC proliferation, migration and capillaries' formation. Its association with CD9P-1, CD9, CD81 and CD151 and the expressions of these later at hEC surface were analysed. Finally, its effects onto in vivo tumour-induced angiogenesis and tumour growth were investigated. RESULTS: Vascular endothelial growth factor (VEGF)-induced capillary tube-like formation was inhibited by tumour necrosis factor α and was associated with a rise in CD9P-1 mRNA expression (P<0.05); accordingly, knockdown of CD9P-1 inhibited VEGF-dependent in vitro angiogenesis. GS-168AT2 dose-dependently inhibited in vitro angiogenesis, hEC migration and proliferation (P<0.05). Co-precipitation experiments suggest that GS-168AT2 corresponds to the sequence by which CD9P-1 physiologically associates with CD81. GS-168AT2 induced the depletion of CD151, CD9 and CD9P-1 from hEC surface, correlating with GS-168AT2 degradation. Finally, in vivo injections of GS-168AT2 inhibited tumour-associated angiogenesis by 53.4±9.5% (P=0.03), and reduced tumour growth of Calu 6 tumour xenografts by 73.9±16.4% (P=0.007) without bodyweight loss. CONCLUSION: The truncated form of CD9P-1, GS-168AT2, potently inhibits angiogenesis and cell migration by at least the downregulation of CD151 and CD9, which provides the first evidences for the central role of CD9P-1 in tumour-associated angiogenesis and tumour growth.

The protein Z/protein Z-dependent protease inhibitor complex. Systemic or local control of coagulation?

Protein Z (PZ) is a vitamin K-dependent factor identified in human plasma in 1984 but it has no enzymatic activity. It is a cofactor of a serpin, the protein Z-dependent protease inhibitor (ZPI), and the complex PZ/ZPI inhibits activated factor X on phospholipid surfaces. In mice, the disruption of PZ or ZPI gene is asymptomatic, but enhances the thrombotic phenotype and mortality of other thrombotic risk factors. Most of the clinical studies focused on PZ. Despite conflicting results, a recent meta-analysis indicated that PZ deficiency could be a risk for venous and arterial thrombosis and early fetal loss. However, these conclusions are drawn from case-control studies of small size, constituting an important limitation. Recently, it was shown that PZ and/or ZPI are synthesised by normal kidney and different cancer cells, suggesting that the complex PZ/ZPI could play a role in inhibiting the tissue deposition of fibrin. The physiopathological consequences of these observations remain to be established. At this time, the measurement of plasma PZ and ZPI or analysis of their gene polymorphisms should not be performed routinely for the exploration of thrombophilia.

CD9P-1 expression correlates with the metastatic status of lung cancer, and a truncated form of CD9P-1, GS-168AT2, inhibits in vivo tumour growth.

BACKGROUND: Loss of CD9 expression has been correlated with a higher motility and metastatic potential of tumour cells originating from different organs. However, the mechanism underlying this loss is not yet understood. METHODS: We produced a truncated form of partner 1 of CD9 (CD9P-1), GS-168AT2, and developed a new monoclonal antibody directed towards the latter. We measured the expression of CD9 and CD9P-1 in human lung tumours (hLTs), and monitored the level of CD9 in NCI-H460, in vitro and in vivo, in the presence and absence of GS-168AT2. RESULTS: Loss of CD9 is inversely related to the expression of CD9P-1, which correlates with the metastatic status of hLT (n=55). In vitro, GS-168AT2 is rapidly internalised and degraded at both the membrane and cytoplasm of NCI-H460, and this correlates with the association of GS-168AT2 with both CD9 and CD81. Intraperitoneal injections of GS-168AT2 in NCI-H460-xenografted Nude mice led to drastic inhibition of tumour growth, as well as to the downregulation of CD9, but not of CD81, in the tumour core. CONCLUSION: These findings show for the first time that CD9P-1 expression positively correlates with the metastatic status of hLT, and that the upregulation of CD9P-1 expression could be one of the mechanisms underlying the loss of CD9 in solid tumours. Our study also reveals that, under certain conditions, loss of CD9 could be a tumour growth-limiting phenomenon rather than a tumour growth-promoting one.