Evaluation of two modalities of perioperative treatment in the management of extremity and truncal soft tissue sarcomas: neoadjuvant concurrent chemoradiotherapy and sequential treatment.

PURPOSE: Patients with locally advanced grade 2-3 extremity/truncal soft tissue sarcomas (STS) are at high risk of recurrence. The objective of this study was to assess the efficacy and feasibility of neoadjuvant concurrent chemoradiotherapy (cCRT) in selected grade 2-3 patients with limb or trunk wall STS, and to compare this schedule to a sequential approach combining neoadjuvant chemotherapy and adjuvant radiotherapy. METHODS: We retrospectively included patients who underwent neoadjuvant cCRT at two comprehensive cancer centers from 1992-2016. We then compared these results to those of patients treated with preoperative chemotherapy and postoperative radiotherapy from a third comprehensive cancer center with a propensity score matched analysis. RESULTS: A total of 53 patients were treated by neoadjuvant cCRT; 58 patients could be matched with 29 patients in each treatment group after propensity score matching. Disease-free survival and overall survival at 5 years were 54.9 and 63.5%, respectively with neoadjuvant cCRT, with no significant difference when compared to the sequential treatment group. R0 resection rate was higher (90.9 vs 44.8%, p < 0.01) in the cCRT group than in the sequential treatment group during a shorter therapeutic sequence (118 vs 210.5 days, p < 0.01), with no impact on the surgical procedure or postoperative complications. CONCLUSION: cCRT is feasible with acceptable immediate and late toxicities. It could facilitate surgery by increasing the R0 resection rate and improve patient compliance by shortening the therapeutic sequence.

[Suicidal risk prevention in schizophrenia: Importance of family psychoeducation]. / Prévention du risque suicidaire dans la schizophrénie : importance de la psychoéducation des familles.

OBJECTIVES: Although mortality by suicide in schizophrenia seems to have decreased in some countries over the last 30 years, it remains much higher than in the general population. Studies have shown this risk to impact around 5% of patients, corresponding to a risk almost 2.5 times higher than in the general population. Family psychoeducation in schizophrenia has been demonstrated to lead to symptom reductions and to an improvement of the quality of life, two factors that should contribute to decreasing the suicidal risk. Therefore, if families attend an efficient psychoeducation program, we can expect a decrease in the patient suicidal risk. Attending a family psychoeducation program at the beginning of the disease would also be associated with a stronger preventive effect on suicidal mortality. The objective of this study is to describe the suicide attempt rate of patients who suffer from schizophrenia before and one year after one of their relatives participated to the family psychoeducation program Profamille. METHOD: We performed a retrospective study on 1209 people who attended the Profamille (V3.2 version) Family Psychoeducation Program. This program has 2 modules: an initial training module of 14 weekly or fortnightly sessions, and a consolidation module of 4 sessions over 2 years. Sessions last 4 hours and follow a precise and structured course. Data were collected from 40 different centers in France, Belgium and Switzerland and were based on participants assessed at the beginning and one year after the first module. Self-assessment from the relatives participating in the program provided the measure of patients' suicide attempts. An assessment at T0 explored the attempts over the 12 months before the beginning of the program while the assessment at T1 analyzed those during the 12 months following the end of the Program. The Chi2 test was used to compare the suicide attempt rates for each period, using a significance threshold of 0.05. Since the risk of suicide is greater in the first years of the illness, rates of attempts are also calculated according to the age of disorder. The analysis was carried out with the statistical software R. RESULTS: The number of participants reporting that their relative had attempted suicide in the previous 12 months decreased from 41 to 21. The annual attempts rate was evaluated at 6.4 % before the Profamille program and decreased to 2.4 % a year after the end of the program (P=0.0003). The reduction of the attempt rate was observed even for patients with schizophrenia for more than 10 years. CONCLUSION: This study shows the positive impact of Profamille on reducing the rate of suicide attempts in patients with schizophrenia. It has been shown that the risk is highest at the beginning of the disorder. Therefore, based on our results, it would seem appropriate to propose the Profamille program at an early stage.

Subventricular zone involvement at recurrence is a strong predictive factor of outcome following high grade glioma reirradiation.

We aimed to assess the efficacy of stereotactic irradiation for patients with recurrent high-grade glioma (HGG) and identify predictive factors of progression-free survival (PFS) and overall survival (OS) following reirradiation. We identified 32 patients with recurrent brain HGG who had been treated with either single-dose (stereotactic radiosurgery) or fractionated stereotactic radiotherapy between April 2008 and October 2015. Median follow up was 21.4 months (range 12.9-23.2) and median PFS was and 3.3 months (95% CI [2.3-4.7]), respectively. OS was 90.40% (95% CI [73.09-96.80]) at 6 months and 79.55% (95% CI [59.9-90.29]) at 12 months. Univariate analysis showed that biological effective dose at isocenter ≤ 76 Gy was a poor prognostic factor for both OS (83.33 vs. 100% at 6 months, p = 0.032) and median PFS (2.7 vs. 4.7 months, p = 0.025), as was gross tumor volume (GTV) above 1 cm3 for OS (86.15 vs. 94.12% at 6 months, p = 0.043). Contact with the subventricular zone (SVZ) was also a poor prognostic factor for median PFS (2.3 vs. 4.7 months, p = 0.002). Multivariate analysis showed that SVZ contact remained a poor prognostic factor for PFS (hazard ratio = 3.44, 95% CI [1.21-9.82], p = 0.021). Results suggest that reirradiation is a safe and effective treatment option for recurrent HGG in patients with a good Karnosfsky Performance Scale score, a long progression-free interval since first radiation and limited GTV, and that contact to SVZ is a strong prognostic factor for PFS.

Understanding dental CAD/CAM for restorations--the digital workflow from a mechanical engineering viewpoint.

As digital technology infiltrates every area of daily life, including the field of medicine, so it is increasingly being introduced into dental practice. Apart from chairside practice, computer-aided design/computer-aided manufacturing (CAD/CAM) solutions are available for creating inlays, crowns, fixed partial dentures (FPDs), implant abutments, and other dental prostheses. CAD/CAM dental solutions can be considered a chain of digital devices and software for the almost automatic design and creation of dental restorations. However, dentists who want to use the technology often do not have the time or knowledge to understand it. A basic knowledge of the CAD/CAM digital workflow for dental restorations can help dentists to grasp the technology and purchase a CAM/CAM system that meets the needs of their office. This article provides a computer-science and mechanical-engineering approach to the CAD/CAM digital workflow to help dentists understand the technology.

[Blood-injection-injury phobia: Physochophysiological and therapeutical specificities]. / La phobie du sang-injection-accident : spécificités psychophysiologiques et thérapeutiques.

INTRODUCTION: Seventy-five percent of patients with blood-injection-injury phobia (BII-phobia) report a history of fainting in response to phobic stimuli. This specificity may lead to medical conditions remaining undiagnosed and untreated, incurring considerable cost for the individual and society. The psychophysiology of BII-phobia remains poorly understood and the literature on effective treatments has been fairly sparse. Aims of the systematic review: to synthesize the psychophysiology of BII-phobia and to propose a systematic review of the literature on effectiveness of different treatments evaluated in this indication. RESULTS: Firstly, the most distinct feature of the psychophysiology of BII-phobia is its culmination in a vasovagal syncope, which has been described as biphasic. The initial phase involves a sympathetic activation as is typically expected from fear responses of the fight-flight type. The second phase is characterized by a parasympathetic activation leading to fainting, which is associated with disgust. Subjects with syncope related to BII-phobia have an underlying autonomic dysregulation predisposing them to neurally mediated syncope, even in the absence of any blood or injury stimulus. Many studies report that BII-phobic individuals have a higher level of disgust sensitivity than individuals without any phobia. Secondly, behavioral psychotherapy techniques such as exposure only, applied relaxation, applied tension, and tension only, have demonstrated efficacy with no significant difference between all these techniques. The disgust induction has not improved effectiveness of exposure. CONCLUSION: We have explained the psychophysiology of BII-phobia, the understanding of which is required to study and validate specific techniques, in order to improve the prognosis of this disorder, which is a public health issue.

[Charisma and leadership: new challenges for psychiatry]. / Charisme et leadership: de nouveaux défis pour la psychiatrie.

INTRODUCTION: New challenges arise in medicine, particularly in psychiatry. In the near future, psychiatrists' role may evolve into management of mental health care teams (GPs, nurses, psychologists…) thus creating the need for charisma and leadership. Charisma is defined as « a quality that allows it's possessor to exercise influence, authority over a group ¼; leadership as « the function, the position of chief, and by extension, a dominant position ¼. AIM OF THE STUDY: To offer some reflections on charisma and leadership and the ways to develop them in three situations common in clinical practice: dual communication (between caregivers or with patients), oral communication (e.g., during a symposium) and managing a mental health care team. METHOD: Medline (1966-hits) and Web of Science (1975-hits) were explored according to the PRISMA criteria. The research paradigm was [(psychiatrist OR physician) AND mental health AND (leadership OR charisma)]. RESULTS: Two hundred and eighty articles were found, but only 34 corresponded to our subject and were included in the qualitative analysis. The leader must first ask himself/herself about his/her vision of the future, so as to share it with passion with his/her mental health team. Charisma and leadership are based on several values, among which we can mention: providing understandable, personalized care for the patient, in continuity and confidentiality; adapting care to the general population's request, maintaining one's own physical and mental health, submitting one's daily practice to peer review, engaging in continuous improvement of one's practices in response to new requirements, and recognizing that research and instruction are part of an M.D's professional obligations. The clinician will work on ways to develop his/her own charisma, through interactions with peers and team members, the care of his/her appearance (especially for first meetings) and workplace, and through positive reinforcement (some cognitive-behavioral techniques like assertiveness have been proposed to enhance the charisma, e.g., visualization and affirmation). Leadership does not depend on hierarchical position and administrative responsibilities: leaders should learn to manage and harmonize the different types of personalities within his/her team, paying special attention to passive-aggressive attitudes. We recall here some techniques to improve charisma during oral communication, such as making relationships with people by calling them by their names, making reference to things and people that the audience can identify with (like sport or cooking), using one's own style without trying to imitate someone else, focusing on one major idea, being brief and using anecdotes, using silences effectively and finally having good non-verbal communication. The conclusion should never be neglected, as an audience especially remembers the beginning and the end of a presentation. Although some features are common to all charismatic leaders (dominance, self-confidence, high energy level), a recent theory of leadership (called contingency theory) seeks to examine how different leadership styles can adapt to circumstances. This theory focuses more on the vision, passion, determination and courage of the leader and depends not only on their intrinsic qualities. No research has indeed shown individual characteristics that differentiate leaders from followers. However, doctors have not been prepared in their training to acquire leadership skills that they can use to adapt to the circumstances of their clinical practice. The most important qualities expected of a leader according to the current leadership theorists are: listening, communication, stress management, development of other's capacities, feedback, introspection and risk taking. Moreover, leadership involves positive reinforcement of the team while maintaining the feeling of individual autonomy, and being able to take an innovative decision alone with shared optimism. There is no need to have great management responsibilities in order to succeed in leadership. We reiterate the importance for a charismatic leader to smile, to be able to mock oneself and to regulate one's emotions. CONCLUSION: Charisma seems to be an essential dimension for effective leadership and team management. Beyond psychiatry, we believe these reflections to be useful for all branches of medicine.

[Toxoplasma gondii: a potential role in the genesis of psychiatric disorders]. / Toxoplasma gondii : un rôle potentiel dans la genèse de troubles psychiatriques. Une revue systématique de la littérature.

INTRODUCTION: Toxoplasma gondii is the most common protozoan parasite in developed nations. Up to 43% of the French population may be infected, depending on eating habits and exposure to cats, and almost one third of the world human's population may be infected. Two types of infection have been described: a congenital form and an acquired form. Although the medical profession treats these latent cases as asymptomatic and clinically unimportant, results of animal studies and recent studies of personality profiles, behavior, and psychomotor performance have led to reconsider this assumption. PRECLINICAL DATA: Among rats: parasite cysts are more abundant in amygdalar structures than those found in other regions of the brain. Infection does not influence locomotion, anxiety, hippocampal-dependent learning, fear conditioning (or its extinction) and neophobia in rats. Rats' natural predator is the cat, which is also T. gondii's reservoir. Naturally, rats have an aversion to cat urine, but the parasite suppresses this aversion in rats, thus influencing the infection cycle. Tachyzoites may invade different types of nervous cells, such as neurons, astrocytes and microglial cells in the brain, and Purkinje cells in cerebellum. Intracellular tachyzoites manipulate several signs for transduction mechanisms involved in apoptosis, antimicrobial effectors functions, and immune cell maturation. Dopamine levels are 14% higher in mice with chronic infections. These neurochemical changes may be factors contributing to mental and motor abnormalities that accompany or follow toxoplasmosis in rodents and possibly in humans. Moreover, the antipsychotic haloperidol and the mood stabilizer valproic acid most effectively inhibit Toxoplasma growth in vitro with synergistic activity. CLINICAL DATA: The effects of the parasite are not due to the manipulation in an evolutionary sense but merely due to neuropathological or neuroimmunological effects of the parasite's presence. Toxoplasmosis and schizophrenia: epidemiological studies point to a role for toxoplasmosis in schizophrenia's etiology, probably during pregnancy and early life, this association being congruent with studies in animal models indicating that animal exposures of the developing brain to infectious agents or immune modulating agents can be associated with behavioral changes that do not appear until the animal reaches full maturity. Psychiatric patients have increased rates of toxoplasmic antibodies, the differences between cases and controls being greatest in individuals who are assayed near the time of the onset of their symptoms. The increase of dopamine in the brain of infected subjects can represent the missing link between toxoplasmosis and schizophrenia. Toxoplasmosis and Obsessive Compulsive Disorder (OCD): the seropositivity rate for anti-T. gondii IgG antibodies among OCD patients is found to be significantly higher than the rate in healthy volunteers. Infection of basal ganglia may be implicated in the pathogenesis of OCD among Toxoplasma seropositive subjects. Toxoplasmosis and personality: infected men appear to be more dogmatic, less confident, more jealous, more cautious, less impulsive and more orderly than others. Conversely, infected women seem warmest, more conscientious, more insecure, more sanctimonious and more persistent than others. It is possible that differences in the level of testosterone may be responsible for the observed behavioral differences between Toxoplasma-infected and Toxoplasma-free subjects. CONCLUSION: In the future two major avenues for research seem essential. On one hand, prospective studies and research efforts must still be carried out to understand the mechanisms by which the parasite induces these psychiatric disorders. On the other hand, it has not yet been demonstrated that patients with positive toxoplasmic serology may better respond to haloperidol's or valproic acid's antiparasitic activity. These results may appear as a major issue in the drug's prescribing choices and explain variability in response to the treatment of patients with schizophrenia that is not explained by the genetic polymorphism.

Narrative enhancement and cognitive therapy (NECT) to improve social functioning in people with serious mental illness: study protocol for a stepped-wedge cluster randomized controlled trial.

BACKGROUND: Self-stigma is highly prevalent in serious mental illness (SMI) and is associated with poorer clinical and functional outcomes. Narrative enhancement and cognitive therapy (NECT) is a group-based intervention combining psychoeducation, cognitive restructuring and story-telling exercises to reduce self-stigma and its impact on recovery-related outcomes. Despite evidence of its effectiveness on self-stigma in schizophrenia-related disorders, it is unclear whether NECT can impact social functioning. METHODS: This is a 12-centre stepped-wedge cluster randomized controlled trial of NECT effectiveness on social functioning in SMI, compared to treatment as usual. One hundred and twenty participants diagnosed with schizophrenia, bipolar disorder or borderline personality disorder will be recruited across the 12 sites. The 12 centres participating to the study will be randomized into two groups: one group (group 1) receiving the intervention at the beginning of the study (T0) and one group (group 2) being a control group for the first 6 months and receiving the intervention after (T1). Outcomes will be compared in both groups at T0 and T1, and 6-month and 12-month outcomes for groups 1 and 2 will be measured without a control group at T2 (to evaluate the stability of the effects over time). Evaluations will be conducted by assessors blind to treatment allocation. The primary outcome is personal and social performance compared across randomization groups. Secondary outcomes include self-stigma, self-esteem, wellbeing, quality of life, illness severity, depressive symptoms and personal recovery. DISCUSSION: NECT is a promising intervention for reducing self-stigma and improving recovery-related outcomes in SMI. If shown to be effective in this trial, it is likely that NECT will be implemented in psychiatric rehabilitation services with subsequent implications for routine clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT03972735 . Trial registration date 31 May 2019.

3D-printed face protective shield in interventional radiology: Evaluation of an immediate solution in the era of COVID-19 pandemic.

PURPOSE: The purpose of this study was to report the clinical evaluation of a 3D-printed protective face shield designed to protect interventional radiologists from droplet transmission of the SARS-Cov-2. MATERIALS AND METHODS: A protective face shield consisting in a standard transparent polymerizing vinyl chloride (PVC) sheet was built using commercially available 3D printers. The 3D-printed face shield was evaluated in 31 interventional procedures in terms of ability to perform the assigned intervention as usual, quality of visual comfort and tolerance using a Likert scale (from 1, as very good to 5, as extremely poor). RESULTS: The mean rating for ability to perform the assigned intervention as usual was 1.7±0.8 (SD) (range: 1-4). The mean visual tolerance rating was 1.6±0.7 (SD) (range: 1-4). The mean tolerability rating was 1.4±0.7 (SD) (range: 1-3). CONCLUSION: The 3D-printed protective face shield is well accepted in various interventions. It may become an additional option for protection of interventional radiologists.

Adherence to treatment guidelines in clinical practice for using electroconvulsive therapy in major depressive episode.

BACKGROUND: ECT is the most effective treatment of major depressive episode (MDE) but remains a neglected treatment. The French Society for Biological Psychiatry and Neuropsychopharmacology aimed to determine whether prescribing practice of ECT followed guidelines recommendations. METHODS: This multicenter, retrospective study included adult patients with major depressive disorder (MDD) or bipolar disorder (BD), who have been treated with ECT for MDE. Duration of MDE and number of lines of treatment received before ECT were collected. The reasons for using ECT, specifically first-line indications (suicidality, urgency, presence of catatonic and psychotic features, previous ECT response, patient preference) were recorded. Statistical comparisons between groups used standard statistical tests. RESULTS: Seven hundred and forty-five individuals were included. The mean duration of MDE before ECT was 10.1 months and the mean number of lines of treatment before ECT was 3.4. It was significantly longer for MDD single episode than recurrent MDD and BD. The presence of first-line indications for using ECT was significantly associated to shorter duration of MDE (9.1 vs 13.1 months, p<0.001) and lower number of lines of treatment before ECT (3.3 vs 4.1, p<0.001). LIMITATIONS: This is a retrospective study and not all facilities practicing ECT participated that could limit the extrapolation of the results. CONCLUSION: Compared to guidelines, ECT was not used as first-line strategy in clinical practice. The presence of first-line indications seemed to reduce the delay before ECT initiation. The improvements of knowledge and access of ECT are needed to decrease the gap between guidelines and clinical practice.

[Interest of image-guided radiotherapy for brain tumors and positioning control]. / Apport du guidage par l'image pour le repositionnement au cours de la radiothérapie des tumeurs encéphaliques.

A narrow therapeutic index and more and more patients with long survival characterize primary and second brain tumors. Image-guided radiotherapy can increase accuracy of the patient's position during a course of intracranial irradiation thanks to a direct or indirect visualization of targets volumes. Treatment reproducibility and organ at risk-sparing are the primary issues, particularly with the development of stereotactic radiotherapy and protontherapy. Regarding intracranial treatments, image-guided radiotherapy seems to be a repetitive task based on skeletal structures registration. And yet, this innovation makes possible to assess the dosimetric impact of daily positioning variations avoiding invasive immobilizations. Image-guided radiotherapy offers automated tools to limit time consumption and furthers adaptive radiotherapy opportunities. Nevertheless, medical evaluation is still necessary and image processing should be strictly defined (frequency, use, performance). The purpose of this article is to describe image-guidance in brain irradiation, as repositioning tool and to focus on its recent prospects.

Impact of an antimicrobial stewardship programme to optimize antimicrobial use for outpatients at an emergency department.

BACKGROUND: Antimicrobial stewardship programmes (ASPs) have been effective in optimizing antibiotic use for inpatients. However, an emergency department's fast-paced clinical setting can be challenging for a successful ASP. AIM: In April 2015, an ASP was implemented in our emergency department and we aimed to determine its impact on antimicrobial use for outpatients. METHODS: This was a single-centre study comparing the quality of antibiotic prescriptions between a one-year period before ASP implementation (November 2012 to October 2013) and a one-year period after its implementation (June 2015 to May 2016). For each period, antimicrobial prescriptions for all adult outpatients (hospitalized for <24h) were evaluated by an infectious disease specialist and an emergency department physician to assess compliance with local prescribing guidelines. Inappropriate prescriptions were then classified. FINDINGS: Before and after ASP, 34,671 and 35,925 consultations were registered at our emergency department, of which 25,470 and 26,208 were outpatients. Antimicrobials were prescribed in 769 (3.0%) and 580 (2.2%) consultations, respectively (P < 0.0001). There were 484 (62.9%) and 271 (46.7%) (P < 0.0001) instances of non-compliance with guidelines before and after ASP implementation. Non-compliance included unnecessary antimicrobial prescriptions, 197 (25.6%) vs 101 (17.4%) (P<0.0005); inappropriate spectrum, 108 (14.0%) vs 54 (9.3%) (P=0.008); excessive treatment duration, 87 (11.3%) vs 53 (9.1%) (P>0.05); and inappropriate choices, 11 (1.4%) vs 15 (2.6%) (P>0.05). CONCLUSION: The implementation of an ASP markedly decreased the number of unnecessary antimicrobial prescriptions, but had little impact on most other aspects of inappropriate prescribing.

Biological and psychological predictors of posttraumatic stress disorder onset and chronicity. A one-year prospective study.

BACKGROUND: Few studies have prospectively examined risk factors for posttraumatic stress disorder (PTSD) in the aftermath of a traumatic exposure. The aim of this study is to identify the concurrent influence of psychological and biological diatheses on PTSD onset and maintenance, taking into account socio-demographic factors and psychiatric antecedents. METHODS: A total of 123 civilians (61.8% of women) recruited in emergency units, were assessed using validated instruments during the first week and then at 1, 4, and 12 months post-trauma. Baseline assessment included evaluation of the psychological diathesis (i.e. psychiatric history and peritraumatic distress and dissociation), and the biological diathesis [i.e. cortisol, norepinephrine, epinephrine, c-reactive protein, total cholesterol, HDL cholesterol, glycosylated haemoglobin, waist-to-hip ratio (WHR), body mass index, diastolic and systolic blood pressure (SBP), and heart rate]. RESULTS: Multivariate logistic regression analyses demonstrated both psychological and biological diatheses to be independent risk factors for PTSD. Peritraumatic distress and dissociation predicted onset (1-month) and mid-term PTSD (4-months), respectively. PTSD risk was associated positively with SBP and negatively with WHR, throughout the follow-up. In addition, a higher level of 12 h-overnight urinary norepinephrine independently predicted mid-term PTSD (4-months). CONCLUSIONS: This prospective study shows that peritraumatic psychological and biological markers are independent predictors of PTSD onset with specificities according to the stage of PTSD development; the psychological diathesis, i.e. peritraumatic distress and dissociation, being a better predictor of short-term dysfunction whereas biological diathesis was also predictive of development and maintenance of PTSD.

Results of a phase II trial of a combination of oral cytarabine ocfosfate (YNK01) and interferon alpha-2b for the treatment of chronic myelogenous leukemia patients in chronic phase.

Cytarabine ocfosfate (YNK01) is a prodrug analogue of cytarabine which is resistant to systemic deamination after oral administration. Following initial studies indicating significant anti-tumour activity of YNK01 a phase II trial was initiated in order to assess the tolerability and efficacy of a combination of this agent with interferon alpha-2b (IFN-alpha2b) in recently diagnosed chronic phase CML patients (n = 98). The treatment was subdivided into cycles consisting of 4 weeks of continuous administration of IFN-alpha-2b (3 MU/m(2)/day 1st week and then 5 MU/m(2)/day) and 14 days of oral YNK01 (600 mg/day 1st cycle). At the end of each cycle the dose of YNK01 was adjusted according to the blood count observed during the previous 4 weeks. The median time from diagnosis to inclusion in the trial was 2 months (range 6 days to 7.5 months). At 12 weeks, 62 patients (63%; 95% CI, 54-73) achieved a complete hematological response. At 24 weeks, of 98 patients, two achieved a complete cytogenetic response, 14 a partial response (16% major cytogenetic response rate; 95% CI, 9-24) and 34 a minor response; 19 patients were not evaluable for cytogenetic response. During the trial, 20 patients progressed to accelerated (6) or blastic phases (14). The median time to progression was 15 months (range 2-38 months). At 3 years the overall survival was 79% (95% CI, 70-88). Although the complete hematological response rate compared favorably with the 40% response rate previously obtained with the subcutaneous formulation of Ara-c, the cytogenetic response rate was less than expected. Most of the patients experienced side-effects and all permanently stopped YNK01. Although the combination seems attractive the initial dose of 600 mg per day is probably too high and should be reconsidered in further trials.

A natural biomimetic porous medium mimicking hypomineralized enamel.

OBJECTIVES: In order to evaluate the clinical impact of low viscosity resin infiltration in hypomineralized enamel, it is necessary to obtain a biomimetic porous substrate capable of mimicking enamel. The specifications for the biomimetic porous medium are defined using the literature data on hypomineralized enamel. Based on these specifications, we propose to use deproteinized dentin, the latter being deproteinized by heat treatment. METHODS AND RESULTS: Thermogravimetry analysis (TGA), field emission scanning electron microscopy (FESEM) observations, mercury intrusion porosimetry (MIP) tests and nanoindentation are performed on the deproteinized dentin tissue. Heat treatment is shown to be an effective and reproducible method for removing organic fluids and protein residues in dentin. Deproteinizing dentin also enables forming nanovoids by eliminating its organic matrix. The interconnected open nanoporosities (porosities of less than 100 nm) created at 600°C are distributed between 14 nm and 32 nm and the total porosity is 39% (including 36% due to nanoporosities). At 800°C, they are distributed between 60 nm and 100 nm and total porosity is 37% (including 33% arising from the nanoporosities). The hydroxyapatite crystal structure is transformed less at 600°C, so this temperature should be preferred. SIGNIFICANCE: Besides providing new understanding of the dentin tissue itself, this study led to characterizing a porous medium made of natural apatite, and proposing and validating its use as a porous medium mimicking hypomineralized enamel. The next logical step of this study is the characterization of resin infiltration in this medium and its mechanical reinforcement.

Cloning, transcription and chromosomal localization of the porcine whey acidic protein gene and its expression in HC11 cell line.

The whey acidic protein (WAP) is the major whey protein of rodent, rabbit and camel. Recently, it was identified in the milk of swine (Simpson et al., 1998. J. Mol. Endocrinol. 20, 27-35). In this paper, the cloning of the pig WAP cDNA and of bacterial artificial chromosome (BAC) construct containing the entire porcine WAP gene is reported. The comparison of the coding sequence of the pig WAP gene to rodent or lagomorph WAP sequence already published demonstrated that only exon sequences are partially conserved. The porcine WAP gene was localized on the subtelomeric region of the chromosome 18. The estimation of the expression of the swine WAP gene in the mammary gland from lactating animals revealed a high level of expression. In order to compare the expression level of the porcine WAP gene from the large genomic fragment which contained 70 kb downstream and 50 kb upstream the pig WAP gene or the smaller one (1 kb downstream and 2.4 kb upstream), these two genomic fragments were transfected in HC11 cell line. The BAC construct was expressed 15 times higher than the plasmid when reported to the integrated copy number. This report suggests that the HC11 cell line is a useful tool to identify the regulatory sequences of milk protein genes.

The RU5 ('R') region from human leukaemia viruses (HTLV-1) contains an internal ribosome entry site (IRES)-like sequence.

RNA fragments containing the complete R region and the beginning of the U5 region ('R') from the human T cell leukaemia virus 1 (HTLV-1) stimulated the translation of the second cistrons in bicistronic mRNAs. The 5' untranslated region from SV40 early genes (SU) which was unable to stimulate translation of second cistrons amplified markedly the internal ribosome entry site (IRES) effect of the HTLV-1 'R' fragments. The 'R' regions from HTLV-1 have therefore properties similar to internal ribosome entry sites (IRES) originally found in picornavirus. The beginning of the U5 region from HTLV-1 contains a polypyrimidine sequence which is known to play an essential role in the IRES activity in picornavirus. The same experiments carried out using the 'R' region from bovine leukaemia virus (BLV) showed that this sequence has at most a weak IRES effect. One retroviruses, HTLV-1 and perhaps others contain therefore an IRES activity. Interestingly, the combined SU 'R' sequence worked efficiently with different cistrons, different promoters and in all tested cell lines, whereas the poliovirus IRES was active in CHO cells but not in the mouse mammary cell line HC11. The SU 'R' sequence may therefore preferably be used to generate active bicistronic mRNAs.

Expression of a single betaalpha chain protein of equine LH/CG in milk of transgenic rabbits and its biological activity.

Equine chorionic gonadotropin (eCG) is a heavily glycosylated glycoprotein composed of non-covalently linked alpha- and beta-subunits. eCG possesses the particularity to bind to both LH and FSH receptors in species other than horses and to have a prolonged plasma half-life. All these properties make it of utmost interest for livestock fertilization program. Up to now, the only source of eCG is the serum of pregnant mare. Rabbit mammary gland is considered as a system able to produce recombinant glycoproteins in sufficient quantity for pharmaceutical use. Here we described the production of a recombinant single betaalpha chain of eLH/CG in the milk of transgenic rabbit. The construction of a single-chain permits to by-pass the problem of association-dissociation of the subunits. This recombinant hormone is greatly expressed (21.7 mg/l) and presents similar in vitro LH and FSH bioactivities. However, betaalphaeLH/CG shows an extremely rapid clearance (approximately 10 min), which could explain the absence of in vivo biological activity. So the rabbit mammary gland is not appropriate for the production of a recombinant active eLH/CG.

The stimulation of gene expression by the R region from HTLV-1 and BLV.

The 5' untranslated regions (5'UTR) of mRNA are known to stimulate or inhibit more or less translation. SR alpha, an association of SV40 early gene promoter and of the R region plus the first 39 nucleotides of the U5 region (designated as R) from the human T-cell leukemia virus (HTLV-1) is currently used to stimulate expression of various coding regions. Its effect is considered to take place at the translational level. In all studies published so far, the R region was associated with the promoter and 5'UTR from SV40 early genes. In the present work, the role of SV40 5'UTR and HTLV-1R region was evaluated separately using different promoters, reporter genes and cells. Both SV40 5'UTR (SU) and R region (R) from HTLV-1 stimulated separately the expression of adjacent reporter genes. When associated, the SV40 5'UTR and the R region from HTLV-1 (SUR) were a more potent stimulator of gene expression and their effects were more than additive. This effect was very potent in HeLa and HC11 cells and almost inexistent in CHO and COS 7 cells. It was of various intensity in other cell types including bird and fish cells. The presence of SUR in gene constructs favoured the accumulation of the mRNAs. SUR stimulated gene expression when added between the cap and the initiation codon. Unexpectedly, SUR was never inhibitory. SUR can therefore be considered essentially as potent and specific stimulator of gene expression favoring mRNA accumulation.

The effect of various introns and transcription terminators on the efficiency of expression vectors in various cultured cell lines and in the mammary gland of transgenic mice.

Various combinations of promoters, introns and transcription terminators were used to drive the expression of bovine growth hormone (bGH) cDNA in different cell types. In constructs containing the human cytomegalovirus (hCMV) promoter and the SV40 late genes terminator, the intron from SV40 genes (VP1) was much more efficient, than the intron from the early genes (t). The synthetic intron SIS generated by the association of an adenovirus splice donor and an immunoglobulin G splice acceptor showed the highest activity. The respective potency of these introns was similar in several mammalian (CHO, HC11 and COS) and fish (TO2 and EPC) cells. The rabbit whey acidic protein (WAP) gene promoter was highly efficient to drive the expression of bGH gene in the HC11 mammary cell lines. In contrast, the bGH cDNA under the control of the same promoter was much less efficiently expressed when the SV40 VP1 intron and transcription terminator were used. The rabbit WAP gene and the human GH gene terminators did not or only moderately enhanced the expression of the construct WAP bGH cDNA. Introduction of a promoter sequence from the mouse mammary tumor virus (MMTV) LTR in the VP1 intron increased very significantly the expression of the WAP bGH cDNA. Although several of these vectors showed high potency when expressed stably in HC11 cells, all of them were only moderately efficient in transgenic mice. These data indicate that the VP1 and the SIS introns may be used to express foreign cDNAs with good efficiency in different cell types. The addition of an enhancer within an intron may still reinforce its efficiency. However, transfection experiments, even when stable expression is carried out, are poorly predictive of the potential efficiency of a vector in transgenic animals.