European principles of care for physiotherapy provision for persons with inherited bleeding disorders: Perspectives of physiotherapists and patients.

INTRODUCTION: In their Chronic Care Model, the World Health Organisation states that people with chronic disorders and their families should be informed about the expected course, potential complications, and effective strategies to prevent complications and manage symptoms. Physiotherapists are a key professional group involved in the triage, assessment and management of musculoskeletal conditions of persons with a bleeding disorder (PWBD). Nevertheless, recent reports describe access to physiotherapy for those with these conditions is only sometimes available. AIM: Access to high quality individualised physiotherapy should be ensured for all PWBD, including those with mild and moderate severities, male and female, people with von Willebrand Disease (vWD) and other rare bleeding disorders. Physiotherapy should be viewed as a basic requisite in their multidisciplinary care. METHODS/ RESULTS: Following a series of meetings with physiotherapists representing the European Association for Haemophilia and Allied Disorders (EAHAD) and PWBD representing the European Haemophilia Consortium (EHC) and a review of publications in the field, eight core principles of physiotherapy care for persons with a bleeding disorder have been co-produced by EAHAD and EHC. CONCLUSION: These eight principles outline optimum standards of practice in order to advocate personalised patient-centred care for physical health in which both prevention and interventions include shared decision making, and supported self-management.

Evolutionary diversification of insulin-related peptides (IRPs) in aphids and spatiotemporal distribution in Acyrthosiphon pisum.

Members of the insulin superfamily activate the evolutionarily highly conserved insulin/insulin-like growth factor signaling pathway, involved in regulation of growth, energy homeostasis, and longevity. In the current study we focus on aphids to gain more insight into the evolution of the IRPs and how they may contribute to regulation of the insulin-signaling pathway. Using the latest annotation of the pea aphid (Acyrthosiphon pisum) genome, and combining sequence alignments and phylogenetic analyses, we identified seven putative IRP encoding-genes, with IRP1-IRP4 resembling the classical insulin and insulin-like protein structures, and IRP5 and IRP6 bearing insulin-like growth factor (IGF) features. We also identified IRP11 as a new and structurally divergent IRP present in at least eight aphid genomes. Globally the ten aphid genomes analyzed in this work contain four to 15 IRPs, while only three IRPs were found in the genome of the grape phylloxera, a hemipteran insect representing an earlier evolutionary branch of the aphid group. Expression analyses revealed spatial and temporal variation in the expression patterns of the different A. pisum IRPs. IRP1 and IRP4 are expressed throughout all developmental stages and morphs in neuroendocrine cells of the brain, while IRP5 and IRP6 are expressed in the fat body. IRP2 is expressed in specific cells of the gut in aphids in non-crowded conditions and in the head of aphids under crowded conditions, IRP3 in salivary glands, and both IRP2 and IRP3 in the male morph. IRP11 expression is enriched in the carcass. This complex spatiotemporal expression pattern suggests functional diversification of the IRPs.

Sustainable laser-based technology for insect pest control.

Aphids damage directly or indirectly cultures by feeding and spreading diseases, leading to huge economical losses. So far, only the use of pesticides can mitigate their impact, causing severe health and environmental issues. Hence, innovative eco-friendly and low-cost solutions must be promoted apart from chemical control. Here, we have investigated the use of laser radiation as a reliable solution. We have analyzed the lethal dose required to kill 90% of a population for two major pest aphid species (Acyrthosiphon pisum and Rhopalosiphum padi). We showed that irradiating insects at an early stage (one-day old nymph) is crucial to lower the lethal dose without affecting plant growth and health. The laser is mostly lethal, but it can also cause insect stunting and a reduction of survivors' fecundity. Nevertheless, we did not notice any significant visible effect on the offspring of the surviving irradiated generation. The estimated energy cost and the harmless effect of laser radiation on host plants show that this physics-based strategy can be a promising alternative to chemical pesticides.

Assessment of a 16S rRNA amplicon Illumina sequencing procedure for studying the microbiome of a symbiont-rich aphid genus.

The bacterial communities inhabiting arthropods are generally dominated by a few endosymbionts that play an important role in the ecology of their hosts. Rather than comparing bacterial species richness across samples, ecological studies on arthropod endosymbionts often seek to identify the main bacterial strains associated with each specimen studied. The filtering out of contaminants from the results and the accurate taxonomic assignment of sequences are therefore crucial in arthropod microbiome studies. We aimed here to validate an Illumina 16S rRNA gene sequencing protocol and analytical pipeline for investigating endosymbiotic bacteria associated with aphids. Using replicate DNA samples from 12 species (Aphididae: Lachninae, Cinara) and several controls, we removed individual sequences not meeting a minimum threshold number of reads in each sample and carried out taxonomic assignment for the remaining sequences. With this approach, we show that (i) contaminants accounted for a negligible proportion of the bacteria identified in our samples; (ii) the taxonomic composition of our samples and the relative abundance of reads assigned to a taxon were very similar across PCR and DNA replicates for each aphid sample; in particular, bacterial DNA concentration had no impact on the results. Furthermore, by analysing the distribution of unique sequences across samples rather than aggregating them into operational taxonomic units (OTUs), we gained insight into the specificity of endosymbionts for their hosts. Our results confirm that Serratia symbiotica is often present in Cinara species, in addition to the primary symbiont, Buchnera aphidicola. Furthermore, our findings reveal new symbiotic associations with Erwinia- and Sodalis-related bacteria. We conclude with suggestions for generating and analysing 16S rRNA gene sequences for arthropod-endosymbiont studies.

Effects of plant protease inhibitors, oryzacystatin I and soybean Bowman-Birk inhibitor, on the aphid Macrosiphum euphorbiae (Homoptera, Aphididae) and its parasitoid Aphelinus abdominalis (Hymenoptera, Aphelinidae).

Transgenic plants expressing protease inhibitors (PIs) have emerged in recent years as an alternative strategy for pest control. Beneficial insects such as parasitoids may therefore be exposed to these entomotoxins either via the host or by direct exposure to the plant itself. With the objective of assessing the effects of PIs towards aphid parasitoids, bioassays using soybean Bowman-Birk inhibitor (SbBBI) or oryzacystatin I (OCI) on artificial diet were performed on Macrosiphum euphorbiae-Aphelinus abdominalis system. OCI significantly reduced nymphal survival of the potato aphid M. euphorbiae and prevented aphids from reproducing. This negative effect was much more pronounced than with other aphid species. On the contrary, SbBBI did not affect nymphal viability but significantly altered adult demographic parameters. Enzymatic inhibition assays showed that digestive proteolytic activity of larvae and adults of Aphelinus abdominalis predominantly relies on serine proteases and especially on chymotrypsin-like activity. Immunoassays suggested that OCI bound to aphid proteins and accumulated in aphid tissues, whereas SbBBI remained unbound in the gut. Bioassays using M. euphorbiae reared on artificial diets supplemented with both OCI and SbBBI showed a fitness impairment of Aphelinus abdominalis that developed on intoxicated aphids. However, only SbBBI was detected in parasitoid larvae, while no PI could be detected in adult parasitoids that emerged from PI-intoxicated aphids. The potential impact of PI-expressing plants on aphid parasitoids and their combined efficiency for aphid control are discussed.

Calcium currents in normal and dystrophic human skeletal muscle cells in culture.

Human muscle cells obtained from biopsy specimens were grown in a primary culture system and electrophysiologically studied. Whole cell patch-clamp recordings revealed the presence of two types of calcium currents: (i) a low-threshold (-60 mV) one (ICa, T) with fast activation and inactivation kinetics (time-to-peak: 39 ms at -30 mV); and (ii) a high-threshold (-10 mV) one (ICa,L) with slower kinetics (time-to-peak: 550 ms at 20 mV). These two types of calcium currents could be also distinguished by their pharmacological characteristics since ICa,L was sensitive to the antagonist and agonist dihydropyridine derivatives contrary to ICa,T which was completely resistant to these compounds. These functional calcium channels existed both in normal and Duchenne dystrophic (DMD) human skeletal muscle cells in culture. We discuss a possible role of these two types of calcium channels in the myoplasmic calcium accumulation observed in the Duchenne muscular dystrophy.

Abnormal calcium homeostasis in Duchenne muscular dystrophy myotubes contracting in vitro.

Resting intracellular calcium activity was recorded in three kinds of human muscle cells in culture: normal (control) and dystrophic (DMD and FSH), by means of a ratiometric fluorescence method using the calcium probe Indo-1 under laser illumination. DMD cells are characterized by a lack of dystrophin whereas FSH cells express normal dystrophin. The aim of this study was to determine whether, in dystrophin-deficient muscle cells (DMD), contraction destabilized internal calcium homeostasis. Muscle cells were cocultured with rat spinal cord explants to improve the maturation of human myotubes up to the stage where contraction appears. The resting intracellular calcium level was significantly higher in contracting DMD cells (107 +/- 8 nM; n = 44) compared to control cells (66 +/- 6 nM; n = 43) or in FSH cells (56 +/- 6 nM; n = 35). DMD myotubes cocultured in the presence of TTX which inhibited contractile activity, did not develop an increase in free cytosolic Ca2+ concentration. The amplitudes of calcium transients elicited by exposure to acetylcholine (ACh) or high K+ medium (100K) were significantly higher in contracting DMD myotubes than in control ones. The extra-responses were not observed in DMD myotubes cocultured with TTX. This study strongly suggest that: (i) contraction is a dominant factor contributing to Ca2+ abnormalities in DMD cells; and (ii) contracting dystrophin-deficient cells have defective calcium handling mechanisms during electrical events which involve sarcolemma.

Changes in cytosolic resting ionized calcium level and in calcium transients during in vitro development of normal and Duchenne muscular dystrophy cultured skeletal muscle measured by laser cytofluorimetry using indo-1.

Intracellular calcium activity was recorded during in vitro myogenesis of human normal and DMD muscle, using the calcium probe Indo-1 under laser illumination, at rest and during different kinds of stimulation (acetylcholine, high K+, caffeine). In myoblasts, the resting intracellular calcium level was significantly larger in DMD cells (89 +/- 9 nM; n = 40 vs 37 +/- 5 nM; n = 22) but there was no significant difference in myotubes, after fusion (44 +/- 4 nM; n = 34 vs 36 +/- 4 nM; n = 52). A similar evolution was observed in cells cultured from FSH biopsies. The amplitude of ACh- and high K(+)-induced calcium transients was significantly halved in DMD myotubes as compared to control ones and non-significantly decreased for caffeine responses. Some alterations in the kinetics of responses were observed in DMD muscle: the rising phases of ACh- and high K(+)-elicited transients and the decaying phase of the ACh-responses were significantly slowed down. It is concluded that: (i) in aneurally cultured human muscle, an increase in the basal level of internal calcium can occur at early stages of myogenesis before the expression of the dystrophin gene; and (ii) the changes in calcium transients induced by depolarization or direct stimulation of sarcoplasmic reticulum are not susceptible of inducing a calcium overload in DMD cells.

Cationic channels in normal and dystrophic human myotubes.

Human skeletal muscle cells obtained from normal and Duchenne muscular dystrophy patients were cocultured with explants of rat dorsal root ganglions. Single-channel recordings were performed with the cell-attached configuration of the patch-clamp technique and negative pressure was applied via the patch-pipette in order to mechanically stimulate the membrane patch. Inward elementary current activity was recorded under control or negative pressure conditions. Its occurrence and mean open probability were higher in Duchenne muscular dystrophy. Amplitude histograms reveal that these channels have a small unitary conductance of around 10 pS in 110 mM Ca2+ and could be inhibited in a dose-dependent manner by gadolinium. Results show that the membrane stress favoured calcium permeation through these channels. Taken together these data provide arguments for the involvement of such channels in calcium overload previously observed in cocultured dystrophic human (Duchenne muscular dystrophy) muscle cells.

Hypoosmotic shocks induce elevation of resting calcium level in Duchenne muscular dystrophy myotubes contracting in vitro.

In Duchenne muscular dystrophy (DMD) muscle cells which lack dystrophin, contraction seems to be a dominant factor contributing to the abnormal elevated intracellular calcium level. Human normal and DMD contracting myotubes cocultured with nervous cells were exposed to a hypotonic medium to mimic contraction-induced mechanical stress on the membrane, and the cytoplasmic calcium activity was simultaneously monitored (Indo-1). Hypotonic shocks induced a reversible [Ca2+]i increase in 81% of the DMD cells vs. 54% of control. In addition, responses were qualitatively different: most of DMD myotubes displayed a fast increase of Ca2+ flowing from the edge of the myotube while the response in normal cells was slow and diffuse. The fact that these responses were not affected by ryanodine, was in favour of an external source of Ca2+ involved in the hypoosmotic shocks. The localized increase of Ca2+ in DMD myotubes, inhibited by Gd3+, could result from sites of high mechanosensitive channel activity or density which could constitute a pathway for Ca2+ entry provided these cells contract.

The effect of methylprednisolone on intracellular calcium of normal and dystrophic human skeletal muscle cells.

Clinical trials have shown that a glucocorticoid, the methyiprednisolone (PDN), has a beneficial effect on muscle strength and function in Duchenne muscular dystrophy (DMD) patients. The aim of this study was to test if the effect of PDN could be mediated via a possible action on intracellular calcium. The intracellular calcium activity, at rest and during calcium mobilizing drug superfusion protocols was recorded in normal and dystrophic human cocultured muscle cells. PDN (10 microM) pretreatment induced an elevation of the resting calcium concentration of 51, 34 and 38% in proliferating normal myoblasts, DMD myoblasts and DMD myotubes, respectively, while normal myotubes resting [Ca2+]i was not altered.

A third type of calcium current in cultured human skeletal muscle cells.

A third type of calcium current could be recorded on a non-negligible number of human skeletal muscle cells (normal and Duchenne dystrophic (DMD)) in primary culture. This transient current exhibited a maximum at 0 mV, a time-to-peak around 30 ms, an inactivation time constant around 70 ms and was insensitive to nifedipine. On these basis, it differentiates from T- and L-type previously described and looks like the neuronal N-type. However, this third type of current was not sensitive to omega-Cgtx, a specific N-type blocker. The occurrence and the possible role of this current are briefly discussed.

Obtaining maximal use of expanded scalp rotation flaps via an experimental model.

The relative inelasticity of scalp skin and the irregular convexity of the cranial vault necessitate careful planning in the design and mobilization of scalp flaps. Rotation flaps adapt particularly well to the curves of the cranial vault. An experimental model has enabled us to study the design and mobilization of expanded scalp rotation flaps and to obtain maximal efficiency from the tissue expansion process. The use of a round tissue expander situated immediately adjacent to a scalp defect is an excellent method for the creation of a rotation flap. To optimize the use of the expanded tissues, the flap should be designed so that its border passes along the periphery of these expanded tissues. In cases in which it is advisable to separate the expander from the defect, such as when the defect is highly contaminated, efficient use of the expanded tissues can still be obtained by placing the expander at the site of a rotation flap backcut. Furthermore, although this study focuses on rotation flaps only, this same model can be used to examine and compare different closure methods using other types of flaps as well.

In-vitro biomechanical study of a dorso-lumbo-sacral posterior supple instrumentation with variable section.

This study is designed to analyse the behavior, in the sagittal plane, of a complete human dorso-lumbar rachis, made rigid by the posterior instrumentation used for the treatment of scoliosis, on subjects suffering from DMD (Duchenne Muscular Dystrophy). The object of this analysis is to demonstrate the reliability of early surgery made possible by new instrumentation. Close review of the literature shows that the currently used Harrington or Luque instrumentations lead to mechanical complications, especially rod breaking, at the thoraco-lumbar junction. 8 specimens were non-destructively tested in-vitro. Compression and flexion were applied. For each test, rachis movements with and then without instrumentation, and also rod restraints were noted. The results show a linear stiffness multiplied by 8.3 in flexion and 11.6 in extension. The maximum restraint recorded for physiological displacements is 77 MPa. This remains largely under the fatigue-breaking limit of the metal used (stainless steel hammer-hardened 316 L, Young's modulus = 200,000 MPa, Poisson's ratio = 0.21, endurance limit = 350 MPa at 5 x 10(6) cycles). The results of this study encourage us to continue and develop early surgery in children affected by myopathy, with fixation of the complete rachis, including a lumbo-sacral arthrodesis and a supple dorsal part of the mounting, in the sagittal plane.

[Primary results of laser recanalization in the endovascular treatment of arterial stenosis and occlusion of the lower limbs. Apropos of 45 treated cases]. / Résultats primaires de la recanalisation par laser dans le traitement endovasculaire des sténoses et occlusions artérielles des membres inférieurs. A propos de 45 lésions traitées.

Forty-five lower limb arterial lesions were treated by Nd Yag laser angioplasty using 1.4 and 2 mm hybrid catheters in 31 patients. This population comprised 28 men and 3 women (average age 63.8 +/- 3 years) 20 were in Stage II, 5 in Stage III and 6 in Stage IV of Fontaine's classification. The arteriographic lesions were 22 occlusions with an average length of 12.3 cm and 23 stenoses averaging 87% luminal reduction a few millimeters long to a maximum of a string of stenoses. Seventeen of these lesions were very calcified. The stenoses were situated on the iliac artery (7 cases), superficial femoral artery (28 cases), popliteal artery (9 cases) and the tibio-peroneal artery (1 case). There were no fatalities or recourse to emergency surgery. All patients underwent complementary balloon dilatation. The immediate patency rate was 91% in stenotic and 72% in occlusive lesions. At one week, the patency rate for stenotic lesions was unchanged but it had fallen to 59% for occlusive lesions (arteriographic evaluation). Angioscopy was used 22 times: it was indissociable to laser angioplasty as it enabled diagnosis and controlled the result. The use of thermal laser with hybrid catheters (metallic window tip) in endovascular procedures is a safe and effective method of treating stenosis and occlusion of lower limb arteries.

[Electrocardiogram after complete repair of tetralogy of Fallot]. / L'électrocardiogramme après réparation complète de la tétralogie de Fallot

207 cases of Fallot's tetralogy having undergone complete surgical correction have been studied in this work as regards the electrocardiographic changes induced by surgery. The observed anomalies were the following: --Intraventricular conduction disturbances --179 cases (86,5%) --Atrio-ventricular block --33 cases (16%) --Arrhythmias --29 cases (14%) --Myocardial infarction patterns --6 cases (2.9%). In the atrioventricular conduction disturbances, right complete bundle-branchblock was most frequently observed (126 cases, 70.4%). In 22 cases, it was combined with left anterior hemiblock, the onset of which seemed to be favoured by the previous existence of a minor left anterior hemiblock. Of the 33 cases of atrio-ventricular block which started during operation or immediately afterwards, 13 will remain permanent, 10 of which were of a high degree, requiring implantation of an intracorporeal pacemaker in 8 cases. No case of block started later on, the cases of delayed block being in fact recurrences of transient blocks which had appeared during or immediately after the operation. The candidates to sudden death by paroxysmal block are therefore patients who had a transient block during of following operation, especially if they had besides bilateral bundle-branch block. The arrhythmias were on the whole devoid of danger. 6 cases of myocardial infarction (2.9%) were observed; their incidence is therefore not negligible.

[Intra-sinus echo: demonstration using direct intracavitary recording of the sinus potential]. / Echo intrasinusal: démonstration par enregistrement direct du potentiel sinusal par voie endocavitaire.

The authors searched for intra-sinusal echos during electrophysiological investigation of 53 patients (41 men, 12 women, average age: 61 +/- 12 years). Cycles of sinus echos were recorded in 8 patients (15 per cent). The period during which sinus echos could be recorded was 125 ms (average 40.6 +/- 34 ms). Indirect assessment of sinus node function in patients with sinus echos was normal (corrected sinus node recovery time, estimated atrio-sino atrial conduction times using Narula's technique). A valid and reproducible direct recording of the sinus node potential was only possible in one patient. In this case the echo cycles were provoked by stimulation periods of between 440 and 320 ms (echo zone of 120 ms). All the echos obtained were preceded by a sinus node potential with a different duration and morphology to that observed during basal sinus cycles (respective sino-atrial conduction times 105 and 115 ms). In this patient we were also able to induce sinus echos after a single extrastimulus during the spontaneous rhythm. the echo zone was 130 ms and with a shorter coupling interval (310 ms) two successive sinus echos were recorded. The demonstration of intrasinusal echos by direct recording of the sinus node potential supports the experimental data of Allessie and Bonke on isolated right atrial tissues of the rabbit. Improvements in the technique of endocavitary direct recording of the sinus node potential in man should complete this data by showing the possibility of sinoatrial tachycardias due to reentry.

[The mitral apparatus and surgery of sub-valvular aortic stenosis]. / L'appareil mitral et la chirurgie des sténoses aortiques sous-valvulaires

The authors present three eases of subvalvular aortic stenosis caused by an abnormality of the mitral valve mechanism which required placement of a prosthetic valve. They describe the types of mitral valve abnormality which are reported in the literature to have caused obstruction to the aortic outflow tract. They analyse the criteria for diagnosis of this condition, and the surgical treatment. The placement of a prosthetic mitral valve does not always remove the obstruction to the aortic outflow, especially if there is an abnormality in the position of the mitral ring.

[Crenelation of Beall's prostheses in mitral position: apropos of 21 reoperated cases]. / Le crénelage des prothèses de Beall en position mitrale. A propos de 21 réinterventions.

The authors report their experience of 21 revision operations for malfunction of the Beall Surgitool 104 prosthesis used in the mitral position. The incidence and uniformity of the disorders found in the prostheses suggest that these changes are produced inevitably usually during the fourth year. The disc becomes kinked, the mountings eroded, and the teflon ring torn. The clinical features are the onset of heart failure, anaemia, or a thrombo-embolic episode. These three findings may occur individually or in association. The authors do not advise systematic revision surgery, but conclude that close follow-up is essential in the case of all patients who have had a Beall prosthesis. Early signs of failure should be revealed by clinical examination, the level of LDH, and by phonocardiogram and echocardiogram studies. Leaving aside thrombo-embolic episodes and severe anaemia which themselves constitute indications for revision surgery, the decision to replace the damaged prosthesis should be taken as soon as the first signs of cardiac failure are detected.

[Calculation of the ejection fraction from simultaneously recorded systolic intervals and angiography. Comparative study]. / Le calcul de la fraction d'éjection d'après les intervalles systoliques et l'angiographie simultanément enregistrés. Etude comparative.

Garrard, Weissler and Dodge have reported a close correlation (r = -0,90) between angiographic ejection fractions (EF) and the ratio of left ventricular preejection and ejection periods (PEP/LVET) in patients with left ventricular disease without simultaneous recording equation Y" = 1,25 - 1,25 x where x is the PEP/LVET ratio and Y" the ejection fraction. Using this formula a theoretical EF may be calculated when the PEP/LVET ratio is known. A number of precautions must be taken in measuring systolic time intervals (synchronous recordings, rapid and constant recording speeds of at least 100 mm/s, good quality tracings). Respecting these conditions, close correlations between the theoretical and angiographic EF were obtained. However, discrepancies were observed in some cases and so the relationship was examined with and without simultaneous recordings in 28 patients (19 with coronary artery disease). The equations obtained were Y = 1,2 - 1,51 x and Y = 1,04 - 1,04 x respectively. The correlations in the whole group and in the coronary subgroup were not as good when the recording was not simultaneous (r = -0,78, compared to r = -0,85). The theoretic EF appeared to be "optimised" under these conditions. The "optimisation" increased with increasing values of the PEP/LVET ratio. A downward correction had to be made for abnormally high values (for example for a PEP/LVET of 0,38, the EF had to be corrected by -3,1% and for a value of 0,50 by -10,5%). This was also applicable in the patients with coronary artery disease. Curiously, the equation relating simultaneous EF and PEP/LVET was very close to that obtained by Garrard (Ya = 1, 12 - 1,27 x, ra = -0,80). The theoretical EF calculated from this equation was very close to the angiographic value. However, it was slightly higher or lower in coronary patients with or without myocardial infarction. Garrard's equation would appear to be useful for repeated studies of the ejection fraction in these patients.