Cost of care pathways before and after appropriate and inappropriate transfers to the emergency department among nursing home residents: results from the FINE study.

BACKGROUND: Transfers of nursing home (NH) residents to the emergency department (ED) is frequent. Our main objective was to assess the cost of care pathways 6 months before and after the transfer to the emergency department among NH residents, according to the type of transfer (i.e. appropriate or inappropriate). METHODS: This was a part of an observational, multicenter, case-control study: the Factors associated with INappropriate transfer to the Emergency department among nursing home residents (FINE) study. Sixteen public hospitals of the former Midi-Pyrénées region participated in recruitment, in 2016. During the inclusion period, all NH residents arriving at the ED were included. A pluri-disciplinary team categorized each transfer to the ED into 2 groups: appropriate or inappropriate. Direct medical and nonmedical costs were assessed from the French Health Insurance (FHI) perspective. Healthcare resources were retrospectively gathered from the FHI database and valued using the tariffs reimbursed by the FHI. Costs were recorded over a 6-month period before and after transfer to the ED. Other variables were used for analysis: sex, age, Charlson score, season, death and presence inside the NH of a coordinating physician or a geriatric nursing assistant. RESULTS: Among the 1037 patients initially included in the FINE study, 616 who were listed in the FHI database were included in this economic study. Among them, 132 (21.4%) had an inappropriate transfer to the ED. In the 6 months before ED transfer, total direct costs on average amounted to 8,145€ vs. 6,493€ in the inappropriate and appropriate transfer groups, respectively. In the 6 months after ED transfer, they amounted on average to 9,050€ vs. 12,094€. CONCLUSIONS: Total costs on average are higher after transfer to the ED, but there is no significant increase in healthcare expenditure with inappropriate ED transfer. Support for NH staff and better pathways of care could be necessary to reduce healthcare expenditures in NH residents. TRIAL REGISTRATION: clinicaltrials.gov, NCT02677272.

Multicenter harmonization study for PD-L1 IHC testing in non-small-cell lung cancer.

Background: Various programed death ligand 1 (PD-L1) immunohistochemistry (IHC) assays have been developed and used in clinical trials in association with different drugs. In order to harmonize and make PD-L1 testing in non-small-cell lung cancer (NSCLC) widely available, we conducted a multicenter study comparing PD-L1 standardized assays and laboratory-developed tests (LDTs). Methods: IHC with five anti-PD-L1 monoclonal antibodies (28-8, 22C3, E1L3N, SP142 and SP263) was performed concomitantly on 41 NSCLC surgical specimens in 7 centers using Dako Autostainer Link 48 (3 centers), Leica Bond (2 centers) or Ventana BenchMark Ultra (2 centers) platforms. For each matching platform, 22C3, 28-8 and SP263 assays were performed. For nonmatching platforms and other antibodies, LDTs were developed in each center. A total of 35 stainings were performed for each case across different platforms and antibodies. PD-L1 staining was assessed in tumor cells and immune cells by seven trained thoracic pathologists. For statistical analysis, 1%, 50% and 1%, 5%, 10% expression thresholds were used for tumor cells and immune cells, respectively. Results: 28-8, 22C3 and SP263 assays were highly concordant for tumor cells staining across the five Dako or Ventana platforms. Among 27 LDTs developed in 7 centers on Dako, Ventana and Leica platforms, 14 (51.8%) demonstrated similar concordance when compared with reference assays for tumor cell staining. Clone SP263 achieved the highest concordance rate across all platforms. Lower concordance was observed for immune cells staining when using a four categories scale. Conclusion: 28-8, 22C3 and SP263 assays had close analytical performance for tumor cell staining across seven centers. Some LDTs on Dako, Ventana and Leica platforms achieved similar concordance, but caution is warranted for their validation. These LDTs will be further validated in order to provide recommendations for the use of assays and LDT for PD-L1 testing in NSCLC.

Tissue-resident memory T cells play a key role in the efficacy of cancer vaccines.

Resident memory CD8+T cells (TRM) usually defined by the CD103 marker represent a new subset of long-lived memory T cells that remain in the tissues. We directly demonstrate their specific role in cancer vaccine-induced tumor regression. In human, they also seem to play a major role in tumor immunosurveillance.

Efficacy and safety of DPP-4 inhibitors in patients with type 2 diabetes: Meta-analysis of placebo-controlled randomized clinical trials.

BACKGROUND: Guidelines for type 2 diabetes (T2D) recommend reducing HbA1c through lifestyle interventions and glucose-lowering drugs (metformin, then combination with dipeptidyl peptidase-4 inhibitors [DPP-4Is] among other glucose-lowering drugs). However, no double-blind randomized clinical trial (RCT) compared with placebo has so far demonstrated that DDP-4Is reduce micro- and macrovascular complications in T2D. Moreover, the safety of DPP-4Is (with increased heart failure and acute pancreatitis) remains controversial. METHODS: A systematic review of the literature (PubMed, Cochrane Library Central Register of Controlled Trials [CENTRAL] and https://clinicaltrials.gov), including all RCTs vs placebo published up to May 2015 and the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS), published June 2015, was performed. Primary endpoints were all-cause mortality and death from cardiovascular causes; secondary endpoints were macrovascular and microvascular events. Safety endpoints were acute pancreatitis, pancreatic cancer, serious adverse events and severe hypoglycaemia. RESULTS: A total of 36 double-blind RCTs were included, allowing analyses of 54,664 patients. There were no significant differences in all-cause mortality (RR=1.03, 95% confidence interval [CI]=0.95-1.12), cardiovascular mortality (RR=1.02, 95% CI=0.92-1.12), myocardial infarction (RR=0.98, 95% CI=0.89-1.08), strokes (RR=1.02, 95% CI=0.88-1.17), renal failure (RR=1.06, 95% CI=0.88-1.27), severe hypoglycaemia (RR=1.14, 95% CI=0.95-1.36) and pancreatic cancer (RR=0.54, 95% CI=0.28-1.04) with the use of DPP-4Is. However, DDP-4Is were associated with an increased risk of heart failure (RR=1.13, 95% CI=1.01-1.26) and of acute pancreatitis (RR=1.57, 95% CI=1.03-2.39). CONCLUSION: There is no significant evidence of short-term efficacy of DPP-4Is on either morbidity/mortality or macro-/microvascular complications in T2D. However, there are warning signs concerning heart failure and acute pancreatitis. This suggests a great need for additional relevant studies in future.

[Cancer immunotherapy: Rational and recent breakthroughs]. / Immunothérapie des cancers : rationnel et avancées récentes.

Cancer immunotherapy has occupied a marginal therapeutic option in cancer despite strong arguments documenting the role of the immune system in controlling the proliferation of cancers. The recent success of immunotherapy results from a change in the past paradigm. From now on, the goal is not only to activate the immune system against tumor, but also to take account of the immunosuppressive tumor microenvironment Among these mechanisms, negative costimulatory molecules (CTLA-4, PD-1, etc.) expressed by T cells in the tumor could explain their lack of effectiveness in inhibiting tumor growth. Blocking these molecules allowed the reactivation of anti-tumor T cells. Clinically, the administration of anti-CTLA-4 antibody (ipilimumab: Yervoy®) was granted marketing authorization for patients with metastatic melanoma. The anti-PD-1 antibodies (nivolumab: Opdivo®, pembrolizumab: Keytruda®) have demonstrated clinical efficacy when compared to the standard therapy in metastatic melanomas, advanced lung cancers and metastatic renal cell carcinoma. In phase I and II clinical trials, other tumors (Hodgkin's disease, head and neck cancers, bladder cancer, gastric cancer, etc.) appear to be responsive to these immunomodulators. These treatments were associated with the occurrence of side effects dominated by autoimmunity predictable by unlocking the breaks exerted by immune system to maintain tolerance against self-antigen. The optimization of therapeutic combination based on these molecules and the search for biomarkers associated with these treatments constitute a challenge for the future for this new therapeutic class of drugs for oncology.

[HPV (Human Papilloma Virus) implication in other cancers than gynaecological]. / Impact de l'HPV (Human Papilloma Virus) dans les carcinomes autres que gynécologiques.

Worldwide, approximately 5 to 10% of the population is infected by a Human Papilloma Virus (HPV). Some of these viruses, with a high oncogenic risk (HPV HR), are responsible for about 5% of cancer. It is now accepted that almost all carcinomas of the cervix and the vulva are due to an HPV HR (HPV16 and 18) infection. However, these viruses are known to be involved in the carcinogenesis of many other cancers (head and neck [SCCHN], penis, anus). For head and neck cancer, HPV infection is considered as a good prognostic factor. The role of HPV HR in anal cancer is also extensively studied in high-risk patient's population. The role of HPV infection in the carcinogenesis of esophageal, bladder, lung, breast or skin cancers is still debated. Given the multiple possible locations of HPV HR infection, the question of optimizing the management of patients with a HPV+ cancer arises in the implementation of a comprehensive clinical and biological monitoring. It is the same in therapeutics with the existence of a preventive vaccination, for example.

[Screening for chronic obstructive pulmonary disease by electronic mini-spirometry in general practice]. / Dépistage de la broncho-pneumopathie chronique obstructive par minispirométrie électronique en médecine générale.

INTRODUCTION: Screening for COPD is currently considered to be insufficient. Electronic mini-spirometers allow screening for COPD in general practice. OBJECTIVES: To assess the prevalence of COPD in a population of at-risk patients in general practice (GP) and to identify the high-risk factors for the disease. METHODS: A cross-sectional study was performed in a GP setting. Patients aged between 40 and 75years with a history of smoking, occupational exposure to toxic substances or chronic respiratory symptoms were offered airflow assessments by electronic mini-spirometry. For any value of FEV1/FEV6 less than 70 %, screening for COPD was considered as positive. RESULTS: Of the 778 patients seen during routine consultations, 273 (35.1 %) fulfilled the inclusion criteria. The test was positive in 128 of the eligible patients (46.9 %). The prevalence of proven COPD (ratio<70 %) was 13.9 % (38 patients). The high-risk factors were age over 60years (P=0.03), body mass index over 28 (P=0.04), smoking history of more than 30pack-years (P<0.0001), presence of clinical signs (P<0.0001) and industrial exposure to toxic substances (P=0.03). CONCLUSIONS: Targeted screening of patients with risk factors for COPD can be performed in a GP setting. An electronic mini-spirometer is a reliable and inexpensive screening tool.

Expression and mutational status of treatment-relevant targets and key oncogenes in 123 malignant salivary gland tumours.

BACKGROUND: Malignant tumours of the salivary glands (MSGT) are rare and pleomorphic entities. Patients with advanced disease may benefit from targeted therapy; however, specific targets for optimising and personalising treatments are yet to be identified. DESIGN: Immunohistochemistry for C-KIT, EGFR, HER2, MUC1, phospho-mTOR, androgen/estrogens/progesterone receptors and Ki67 was carried out and evaluated in terms of progression-free and overall survival. High throughput molecular screening of key oncogenes was done in 107 patients using routine diagnostic methods and Sequenom technology. RESULTS: Several therapy leads were identified, including high levels of HER2 and androgen receptors in salivary duct carcinomas, C-KIT in myoepithelial carcinomas and EGFR in mucoepidermoid carcinomas. Recurrent mutations involving downstream elements of the EGFR pathway were found in HRAS, notably in tumours with a myoepithelial component, and in other key oncogenes (KRAS/NRAS/PI3KCA/BRAF/MAP2K). On the other hand, <1% of samples had EGFR or HER2 mutations. CONCLUSION: Several tumour subtypes overexpressed targets of directed therapies suggesting potential therapy leads. Genotyping results suggest activation downstream of EGFR in 18 of the 107 samples that could be associated with low efficacy of EGFR inhibitors. Other molecules, such as PI3K/MEK or mTOR inhibitors, may have anti-tumour activity in this subgroup. The high mutation rate in HRAS highlights a novel key oncogenic event in MSGT.

Factors associated with the presence of glutamic acid decarboxylase and islet antigen-2 autoantibodies in patients with long-standing type 1 diabetes.

AIM: Glutamic acid decarboxylase (GAD) and/or islet antigen-2 (IA-2) autoantibodies (ab) are present in 90% of patients at the onset of type 1 diabetes (T1D). Few studies have shown that they may persist in the long-term. We analysed the frequency of GADab and IA-2ab and the factors associated with their persistency in patients with long-lasting T1D. METHODS: This cross-sectional study included 430 adult patients with T1D of at least 10-year duration, consecutively seen over one year. GADab and IA-2ab were determined by radio-binding assays. Autoantibodies to thyroperoxydase, gastric parietal cells and transglutaminase were assessed in 418 patients, and HLA DRB1 genotyping in 359. Parameters associated with the persistency of antibodies were studied by multivariate analysis. RESULTS: Median age at diagnosis of T1D was 12 years, and median diabetes duration was 19 years. Extrapancreatic autoimmunity was present in 38% of the patients, and associated autoimmune diseases in 21%. GADab and/or IA-2ab were found in 56% of the patients, and in 32% in those with more than 25-year diabetes duration. GADab were more frequent than IA-2ab. Female sex, an older age at diagnosis, and a shorter duration of diabetes were independently associated with the presence of ab. The same factors and the DR3 allele were associated with GADab, while only diabetes duration and the DR4 allele were associated with IA-2ab. CONCLUSION: In a large proportion of the patients with T1D, the long-term persistency of diabetes-associated antibodies allows aetiological diagnosis, even far from the onset of hyperglycaemia.

[Spermatic cord sarcoma in adults: diagnosis and management]. / Les sarcomes du cordon spermatique de l'adulte : diagnostic et prise en charge.

PURPOSE: to clarify the patterns of diagnosis and management of adult spermatic cord sarcoma. PATIENTS AND METHODS: between 1996 and 2009, seven patients with spermatic cord sarcoma were treated at Cochin hospital. After updating the pathological diagnosis according to the new classification of sarcoma we found that all patients had well-differentiated or dedifferentiated liposarcoma. We analysed their clinical presentation, management and carcinological outcome. RESULTS: the patients' age ranged from 51 to 77 years, and their follow-up from 7 to 68 months. In five patients, the diagnosis of well-differentiated liposarcoma (lipoma-like) with some dedifferentiated sectors was made straightaway. In the two other patients, the initial diagnosis was that of leiomyosarcoma, which was reconsidered as dedifferentiated liposarcoma according to the cytogenetical and immunohistochemical techniques available since 2005. In 6/7 patients, a tumour resection with an orchiectomy at the same time (four patients) or secondarily (two patients) was performed. In one patient, only a tumour resection, without orchiectomy, was made. Multiple recurrences were observed in the two patients who were initially diagnosed as leiomyosarcoma. They needed multiple reintervention. One of them died after 68 months of evolution, the other one was treated with chemotherapy and died after 47 months of evolution. Four patients are out of recurrence. One patient was lost to follow-up. CONCLUSION: the diagnosis of liposarcoma must be considered in all adult patients aged of more than 50 with fatty-shaped or containing fibomuscular nodules paratesticular tumours. The surgeon and the pathologist must be well informed and an early and wide resection of fatty masses of the sperm cord with negative margins is advocated. The quality of resection is crucial but its appreciation and carrying out are difficult. The role of complementary treatments, especially radiotherapy, has to be determined.

Growth, structure and magnetic properties of FePt nanostructures on NaCl(001) and MgO(001).

A comparison of the structural and magnetic properties of FePt nanostructures grown at different temperatures on NaCl(001) and MgO(001) substrates is presented. A strong influence of the deposition temperature on the epitaxial growth as well as on the size distribution of FePt nanostructures grown on NaCl substrates is observed. In spite of a large lattice mismatch between FePt and NaCl, a 'cube-over-cube' growth of nanostructures with a narrow size distribution was achieved at 520 K. Moreover, the growth of FePt nanostructures on NaCl(001) is not preceded by the formation of a wetting layer as observed on MgO(001). The higher degree of L1(0) chemical ordering in FePt nanostructures grown on MgO(001) accompanied by the absence of L1(0) variants with an in-plane tetragonal c-axis indicates that the tensile epitaxial stress induced by the MgO substrate is a key factor in the formation of the L1(0) phase with an out-of-plane c-axis. Superparamagnetic behavior is revealed for the FePt nanostructures grown on NaCl(001) due to their small size and relatively poor chemical order.

Cd, Pb and Zn oral bioaccessibility of urban soils contaminated in the past by atmospheric emissions from two lead and zinc smelters.

Ingestion of dust or soil particles could pose a potential health risk due to long-term metal trace element (MTE) exposure. Twenty-seven urban topsoil samples (kitchen garden and lawn) were collected and analyzed for Cd, Pb and Zn using the unified Bioaccessibility Research Group of Europe (BARGE) method (UBM) test to estimate the human bioaccessibility of these elements. The quantities of Cd, Pb and Zn extracted from soils indicated, on average, 68, 62 and 47% bioaccessibility, respectively, in the gastric phase and 31, 32 and 23% bioaccessibility, respectively, in the gastro-intestinal phase. Significant positive correlations were observed between concentrations extracted with UBM and total MTE contents. Stepwise multiple regression analysis showed that human bioaccessibility was also affected by some physico-chemical soil parameters (i.e. total nitrogen, carbonates, clay contents and pH). The unified test presents some valuable data for risk assessment. Indeed, the incorporation of oral bioaccessible concentrations into risk estimations could give more realistic information for health risk assessment.

Assessment of a remediation technique using the replacement of contaminated soils in kitchen gardens nearby a former lead smelter in Northern France.

Vegetables cultivated in kitchen gardens that are strongly contaminated by heavy metals (Pb, Cd) may represent to consumers a means of exposure to these metals. This exposure is more problematic for those families that include a large quantity of home-grown vegetables in their diet. Researchers have shown that the majority of vegetables produced in kitchen gardens in the vicinity of the Metaleurop Nord smelter (Northern France) do not conform to European regulations. This study was carried out in three of these kitchen gardens. The concentrations of Cd and Pb in the topsoils were up to 24 and 3300 mg kg(-1) respectively. The method consisted of delineating a surface area of about 50 to 100 m(2) for each garden, then removing the contaminated soil and replacing it with a clean one. Seven species of vegetables were cultivated from 2003 to 2005 in the original contaminated soils and the remediated ones. The data showed a clear improvement of the quality of the vegetables cultivated in remediated soils, although 17% of them were still over the European legislative limits for foodstuffs. This suggested that there was a foliar contamination due to contaminated dust fallout coming from the closed smelter site and the adjacent polluted soils. In addition, the measurement of the Cd and Pb concentrations in the dust fallout showed that the substantial rise in metal concentrations in the remediated soil was not only due to atmospheric fallout. These results raise questions about possible technical, economic and sociological problems associated with this kind of remediation.

Increased exposure to statins in patients developing chronic muscle diseases: a 2-year retrospective study.

OBJECTIVE: Case reports have suggested that lipid-lowering drugs (LLDs), especially statins, could induce or reveal chronic muscle diseases. We conducted a study to evaluate the association between chronic muscle diseases and prior exposure to LLDs. METHOD: This was a retrospective study of chronic primary muscle disease cases newly diagnosed at the Toulouse University Hospitals between January 2003 and December 2004 among patients living in the Midi-Pyrénées area, France. All patients remained symptomatic for more than 1 year after drug withdrawal, or required drugs for inflammatory myopathy. Data on the patient's exposure to LLDs and to other drugs were compared with that of matched controls (5/1) selected through the Midi-Pyrénées Health Insurance System database. RESULTS: A total of 37 patients were included in the study. Of those, 21 (56.8%) suffered from dermatomyositis (DM) or polymyositis (PM), 12 (32.4%) from genetic myopathy, and 4 (10.8%) from an unclassified disease. The prevalence of exposure to statins was 40.5% in patients and 20% in controls (odds ratio (OR) 2.73, 95% confidence interval (CI) 1.21-6.14; p<0.01). There was a significant positive interaction between statins and proton pump inhibitors exposure (weighted OR 3.3, 95% CI 1.37-7.54; p = 0.02). Statin exposure rate was 47.6% among patients with DM/PM (OR 3.86, 95% CI 1.30-11.57; p<0.01). There was no difference between patients and controls for exposure to fibrates. CONCLUSION: Patients who developed chronic muscle diseases after the age of 50, including DM/PM, had a higher than expected frequency of prior exposure to statins. Further studies are needed to confirm this association and the role of proton pump inhibitors.

Triptan use and risk of cardiovascular events: a nested-case-control study from the French health system database.

BACKGROUND: The use of triptans (5-HT agonists) in the treatment of migraine is associated with a potential increasing risk of cardiovascular events and raises the question of the relationship between overuse and the occurrence of ischemic events. OBJECTIVE: The aim of this study was to examine the association between the intensity of triptan use and occurrence of an cardiac event. METHODS: Using the reimbursed drug prescription database of the National French Health Insurance System in the Midi-Pyrenees area, we identified subjects receiving at least one triptan in the second semester of 2002. From this population, we selected new users and retrieved all reimbursed care data up to 31 December 2003. We estimated the patterns of triptan exposure by calculating the number of defined daily doses (DDD) received per 30-day period. Another reimbursed health care database was used to identify as cases of cardiac outcomes those patients receiving care for the management of a possible heart ischemic event. Each case was randomly matched on age and gender with four controls free of any cardiovascular event before the index date. A conditional logistic regression was performed to assess the relationship between cardiac outcomes and exposure to triptans in the 30 days before the index date. RESULTS: The cohort of new users of triptans included 8625 subjects, 4414 (51.18%) of whom received only one dispensation for triptans during the follow-up period (median duration: 427 days). For the remaining subjects, the peak of triptans delivery was /=30 DDD for 1.92%. Fifty-seven users (0.66%) presented a cardiac history and 1388 patients (16.09%) had cardiovascular risk factors. We identified 155 incident cases of cardiac outcomes during the follow-up and compared these to 620 matched controls. Cases were older and presented more frequently with cardiac history or cardiovascular risk factors than the other users of triptans. The distribution exposure to triptans did not significantly differ between cases and controls with an odds ratio for an exposure 8 DDD equal to 1.14 [95% CI (0.58-2.27)]. CONCLUSION: The proportion of patients showing an overuse of triptans (more than 15 DDD for 30 days) reached 12% in this cohort of new users of triptans. However, we did not find any relationship between the overuse of triptans and cardiac outcomes. This study also shows that some patients with cardiovascular risk factors are actually treated by triptans. These patients are more likely to present a cardiac outcome potentially related to an ischemic event after the introduction of triptan.

[General practice management of obstructive sleep apnea in the Midi-Pyrénées]. / Prise en charge du syndrome d'apnées obstructives du sommeil en médecine générale en Midi-Pyrénées.

INTRODUCTION: Obstructive sleep apnoea syndrome (OSAS) is a significant public health problem. In the French care system general practitioners have an important role to play in its management especially in the field of early diagnosis. METHODS: The first part of this work is a descriptive case-control study looking at health resource usage of OSAS patients treated with continuous positive airway pressure (CPAP) in the MidiPyrénées area. The second part is a descriptive study which involved by interviewing 100 general practitioners settled in the area in order to evaluate their knowledge and their practice regarding OSAS. Results were compared with a previous study (1) performed in 2002 with similar methodology. RESULTS: Our results confirm that OSAS remains to a large extent undiagnosed (mean OSAS patients was less than 6 per physician) and underline the close connection between OSAS and cardiovascular diseases. A low degree of knowledge concerning the symptoms, main complications and treatment of OSAS was observed in this group of physicians. There was, however a relative improvement in the answers compared to the study performed in 2002. Two or more complications were mentioned by 67% of practitioners (33% in 2002) and only 13% of them were unable to identify at least one possible complication of OSAS (50% in 2002). CONCLUSION: This study confirms the impact on health of OSAS, characterized by a higher consumption of various medications than in non OSAS patients. Knowledge of OSAS remains low in general practitioner population in France. An important effort has to be made to improve learning of this disease by continuous medical training and during initial medical course.

[The use of clomiphene citrate in ambulatory medicine practice in the Midi-Pyrénées area: compliance to national guidelines applicable to infertility diagnosis and to prescription and monitoring rules applicable to clomiphene citrate treatments]. / Utilisation du citrate de clomifène en médecine de ville dans la région Midi-Pyrénées: qualité du bilan explorant la stérilité, de la prescription et de la surveillance du traitement.

OBJECTIVE: Evaluate the compliance to the national guidelines from ANDEM (1996) and AFSSAPS (2003) concerning the diagnosis of infertility, the prescription of clomiphene and the monitoring of these treatments. PATIENTS AND METHODS: Retrospective study of female patients from 16 to 50 y.o. having benefited from reimbursement of clomiphene citrate treatment between 1st April 2002 and 30th June 2002. After random sampling stratified on age, data on diagnosis procedures and treatments were extracted from the Social Security reimbursement database. These data were validated and completed by patients' interviews. RESULTS: A total of 283 women were included. 30% were subject to the basic hormonal tests (FSH, LH, estradiol). The proportion of patients explored by hysterosalpingogram, post-coital test and echography were respectively 50%, 35% and 68%. A semen analysis was found in 60% of the partners. The complete set of recommended tests before start of treatment was realised in 1.5% of women. In 7% of cases, women were treated without prior exploration. The proportion of tests performed was comparable below and above the age of 35. 77% of treatments were initiated after at least one year of waiting for a spontaneous conception. 69% of women were monitored during treatment by other methods than clinical follow-up. CONCLUSION: Prescription of clomifene citrate is too frequently realised without compliance to guidelines applicable to infertility investigations and therefore without persuasive diagnosis. These practices can lead to loss of childbearing opportunities and complications.

Presence of exon I.4 mRNA from CYP19 gene in human granulosa cells.

Estrogens are synthesized from C19 steroids by a unique form of cytochrome P450 aromatase. Expression of the human CYP19 gene involves tissue specific use of alternative promoters. In the present study, an RT-PCR procedure was used to amplify and quantify various transcripts expressed in human granulosa cells. Cells were aspirated together with follicular fluid from Periovulatory ovarian follicles present in ovaries of 14 patients undergoing a treatment for in vitro fertilization. Sequencing of PCR products demonstrated the presence of exon I.4-specific transcripts in addition to exon P.II, exon I.3 and I.3-truncate transcripts. Quantitative results confirmed that exon P.II specific transcripts were largely predominant compared to other exon-specific transcripts, and that exon I.4-specific transcripts were the least abundant.

The Vicia faba leghemoglobin gene VfLb29 is induced in root nodules and in roots colonized by the arbuscular mycorrhizal fungus Glomus fasciculatum.

To investigate similarities between symbiotic interactions of broad bean (Vicia faba) with rhizobia and mycorrhizal fungi, plant gene expression induced by both microsymbionts was compared. We demonstrated the exclusive expression of 19 broad bean genes, including VfENOD2, VfENOD5, VfENOD12 and three different leghemoglobin genes, in root nodules. In contrast, the leghemoglobin gene VfLb29 was found to be induced not only in root nodules, but also in broad bean roots colonized by the mycorrhizal fungus Glomus fasciculatum. In uninfected roots, none of the 20 nodulin transcripts investigated was detectable. VfLb29 has an unusually low sequence homology with all other broad bean leghemoglobins as well as with leghemoglobins from other legumes. It can be regarded as a novel kind of leghemoglobin gene not described until now and the induction of which is common to symbiotic interactions of broad bean with both Rhizobium and a mycorrhizal fungus.

Curare and the efferent vestibular system. An electrophysiological study in the frog.

In the frog we have studied the action of d-tubocurarine on the spontaneous discharge recorded from the whole horizontal semicircular canal (HC) nerve and from single HC afferent fibres. Gross activity was recorded in isolated head preparations. In each case, the spontaneous frequency was measured 6 min before and 16 min after a drop of D-tubocurarine (0.1 microliter, 5.10(-6)M) dissolved in Ringer or after a similar drop of Ringer was injected into the perilymph near the HC ampulla. Curare elicited a significant increase of the discharge frequency in about 60% of the preparations and a decrease in 6-8% of the cases, whether the contralateral eighth nerve was cut or not, while Ringer had no effect. After severing of the ipsilateral eighth nerve anterior branch, curare had no significant effect on the mean resting rate (calculated from 25 preparations), while in a few cases it evoked an increase or a decrease of the discharge frequency. Single afferent discharges were recorded in intact frogs. The mean frequency calculated from about 200 afferent fibres was 21.4 +/- 1.7 spikes/s after curare treatment, while it was only 15.6 +/- 1.3 spikes/s after Ringer injection; these two values are highly significantly different. From these results we conclude that the ampullary receptors are tonically subject to an inhibitory influence probably due to the tonic activity of the cholinergic efferent vestibular system. Moreover, the activity of the hair cells is probably also controlled by another, as yet unknown cholinergic mechanism.