[The practice of telemedicine by French internal medicine physicians in 2019]. / La pratique de la télémédecine par les médecins internistes français en 2019.

INTRODUCTION: Telemedicine has been developing in France since 2018. The objective of this survey was to assess the knowledge, attitudes, practices and training of internal physicians regarding telemedicine. MATERIAL AND METHODS: A national descriptive observational study carried out between July and October 2019, via an online self-questionnaire with members of the National Society of Internal Medicine and the Association of Young Internists, included a descriptive and comparative analysis by subgroups of age. RESULTS: Analysis of 309 responses from physicians qualified in internal medicine or practicing in an internal medicine service (61,8%) and residents in internal medicine (38%) showed that 34.6% had notions or a good knowledge of regulation of telemedicine. For 62,1%, 72.5% and 74.1% respectively, it could improve patient care, access to care and exchanges between internists and other doctors. The main obstacles to this practice were the absence of face-to-face with the patient (57.3%) and computer dysfunctions (55%). Only 23.3% practiced it, including 88.9% tele-expertise. Telemedicine was performed informally (telephone and email) in 70.8% of the cases. Doctors over the age of 50 were better acquainted with the regulations and more practiced official telemedicine. In total, 54% wanted to practice telemedicine and 72.8% wanted to train there. CONCLUSION: Attitudes towards telemedicine were positive, but few internists knew about it and practiced it formally, warranting appropriate training.

The immunoproteasome: An old player with a novel and emerging role in alloimmunity.

Modern treatment strategies for the maintenance of allograft acceptance frequently target ubiquitously-expressed pathways, leading to significant side-effects and poor long-term allograft outcomes. Constitutive proteasome inhibitors, which have recently been introduced for the treatment of antibody-mediated rejection, target the ubiquitously-expressed proteasome. To limit off-target effects and serious mechanism-based toxicity, however, these inhibitors are administered intermittently and suboptimally. Immunoproteasomes, which are an inducible subset of proteasomes enriched in immune cells, replace constitutive proteasomes after cell exposure to proinflammatory cytokines such as interferon-γ. While immunoproteasomes were first described as processors of antigen for presentation by major histocompatibility complex molecules, recent findings point to its broader biological roles. These vary from activating different subsets of the immune system, by controlling transcriptional activators and downstream cytokines, to affecting their differentiation and survival. These emerging roles of the immunoproteasome in activated immune cells have made it a rational candidate for the targeted treatment of immune-mediated diseases. Preclinical studies have established its role in maintaining allograft acceptance without significant short- or long-term toxicity. This review provides a brief background of the immunoproteasome and outlines its role in immunological pathways and its potential in alloimmunity.

Codominant Role of Interferon-γ- and Interleukin-17-Producing T Cells During Rejection in Full Facial Transplant Recipients.

Facial transplantation is a life-changing procedure for patients with severe composite facial defects. However, skin is the most immunogenic of all transplants, and better understanding of the immunological processes after facial transplantation is of paramount importance. Here, we describe six patients who underwent full facial transplantation at our institution, with a mean follow-up of 2.7 years. Seum, peripheral blood mononuclear cells, and skin biopsy specimens were collected prospectively, and a detailed characterization of their immune response (51 time points) was performed, defining 47 immune cell subsets, 24 serum cytokines, anti-HLA antibodies, and donor alloreactivity on each sample, producing 4269 data points. In a nonrejecting state, patients had a predominant T helper 2 cell phenotype in the blood. All patients developed at least one episode of acute cellular rejection, which was characterized by increases in interferon-γ/interleukin-17-producing cells in peripheral blood and in the allograft's skin. Serum monocyte chemotactic protein-1 level was significantly increased during rejection compared with prerejection time points. None of the patients developed de novo donor-specific antibodies, despite a fourfold expansion in T follicular helper cells at 1 year posttransplantation. In sum, facial transplantation is frequently complicated by a codominant interferon-γ/interleukin-17-mediated acute cellular rejection process. Despite that, medium-term outcomes are promising with no evidence of de novo donor-specific antibody development.

Serine protease inhibitor-6 differentially affects the survival of effector and memory alloreactive CD8-T cells.

The clonal expansion of effector T cells and subsequent generation of memory T cells are critical in determining the outcome of transplantation. While cytotoxic T lymphocytes induce direct cytolysis of target cells through secretion of Granzyme-B (GrB), they also express cytoplasmic serine protease inhibitor-6 (Spi6) to protect themselves from GrB that has leaked from granules. Here, we studied the role of GrB/Spi6 axis in determining clonal expansion of alloreactive CD8-T cells and subsequent generation of memory CD8-T cells in transplantation. CD8-T cells from Spi6(-/-) mice underwent more GrB mediated apoptosis upon alloantigen stimulation in vitro and in vivo following adoptive transfer into an allogeneic host. Interestingly, while OT1.Spi6(-/-) CD8 T cells showed significantly lower clonal expansion following skin transplants from OVA mice, there was no difference in the size of the effector memory CD8-T cells long after transplantation. Furthermore, lack of Spi6 resulted in a decrease of short-lived-effector-CD8-cells but did not impact the pool of memory-precursor-effector-CD8-cells. Similar results were found in heart transplant models. Our findings suggest that the final alloreactive CD8-memory-pool-size is independent from the initial clonal-proliferation as memory precursors express low levels of GrB and therefore are independent of Spi6 for survival. These data advance our understanding of memory T cells generation in transplantation and provide basis for Spi6 based strategies to target effector T cells.

[Endoscopic brow lift]. / Endoskopisches Brauenlift.

Endoscopic surgical techniques have greatly increased in popularity with the advent of modern endoscopes. Endoscopic brow lifting has largely replaced older, more invasive procedures. With this technique a skilled surgeon can identify and treat a ptotic eyebrow by addressing the relevant anatomy, including the frontalis, corrugator, procerus and orbicularis oculi muscles. The frontalis muscle can then be permanently fixed into a predesignated position using titanium screws and permanent sutures. This approach has allowed facial plastic surgeons to address the ptotic brow with decreased rates of edema, hematoma, hypesthesia, alopecia and scarring.

Essential role of PDL1 expression on nonhematopoietic donor cells in acquired tolerance to vascularized cardiac allografts.

The PD1:PDL1 pathway is an essential negative costimulatory pathway that plays a key role in regulating the alloimune response. PDL1 is expressed not only on antigen-presenting cells (APCs) but also cardiac endothelium. In this study, we investigated the importance of PDL1 expression on donor cardiac allograft in acquired transplantation tolerance in a fully MHC-mismatched model. We generated PDL1 chimeric mice on B6 background that expressed PDL1 on either hematopoietic cells or nonhematopoietic cells of the heart. Sham animals were used as controls. These hearts were then transplanted into BALB/c recipients and treated with CTLA4-Ig to induce tolerance. Cardiac endothelium showed significant expression of PDL1, which was upregulated upon transplantation. While the absence of PDL1 on hematopoietic cells of the heart resulted in delayed rejection and prevented long-term tolerance in most but not all recipients, we observed an accelerated and early graft rejection of all donor allografts that lacked PDL1 on the endothelium. Moreover, PDL1-deficient endothelium hearts had significant higher frequency of IFN-γ-producing alloreactive cells as well as higher frequency of CD8(+) effector T cells. These findings demonstrate that PDL1 expression mainly on donor endothelium is functionally important in a fully allogeneic mismatched model for the induction of cardiac allograft tolerance.

Determination of optimal incubation time for the production of acute phase cytokines ex vivo by peripheral blood mononuclear cells from renal transplant recipients.

Levels of acute phase cytokines secreted ex vivo by peripheral blood mononuclear cells (PBMCs) have been shown to be associated with clinical conditions or histologic lesions in renal transplant recipients. One of the limiting factors for the potential use of this assay as a diagnostic tool is the incubation time needed to measure adequate cytokine levels. Here, we validated that shorter time periods than the usual 48 h are sufficient for the production of acute phase cytokines. Cytokine levels were measured with the Luminex platform. We observed that, in contrast to cytokines associated with adaptive immunity, cytokines such as IL-1ß, IL-6 and TNF-α are measurable as early as 2 h following incubation at a concentration of 1.5 million PBMC/150 µL. Levels obtained in the 2 h cultures have good correlations with the levels obtained after 48 h of culture for IL-1ß and TNF-α (R=0.79, P=0.004 and R=0.92, P<0.001 respectively). We conclude that same-day incubation of PBMCs and measurement of these cytokines following blood collection in transplant recipients is feasible. It provides a rationale for further studies using shorter incubation times for ex vivo cellular assay measuring acute phase cytokine levels.

Donor antioxidant strategy prolongs cardiac allograft survival by attenuating tissue dendritic cell immunogenicity(†).

Ischemic reperfusion injury (IRI) enhances allograft immunogenicity, worsens transplantation outcome, and is the primary cause of activation of the recipient innate immune response, resulting in subsequent amplification of the alloimmune adaptive response. Here, we aimed at demonstrating that the link between innate injury and alloimmunity occurs predominantly through activation of allograft-derived dendritic cells (ADDC). Perfusion of MCI-186, a free radical scavenger, into donor cardiac allografts prior to transplantation resulted in prolongation of complete MHC-mismatched allograft survival in the absence of immunosuppression (MST of 8 vs. 26 days). This prolongation was associated with a reduction in trafficking of ADDC to recipient lymphoid tissue as well as a reduction in T cell priming. Depleting ADDC with diphtheria toxin (using DTR-GFP-DC mice as donors) 24 h prior to transplant resulted in abrogation of the prolongation observed with MCI-186 treatment, demonstrating that the beneficial effect of MCI-186 is mediated by ADDC. This donor-specific anti-ischemic regimen was also shown to reduce chronic rejection, which represents the primary obstacle to long-term allograft acceptance. These data for the first time establish a basis for donor anti-ischemic strategies, which in the ever-expanding marginal donor pools, can be instituted to promote engraftment.

Brucelosis y gestación / Brucelosis and pregnancy

La brucelosis es una zoonosis cuyo reservorio lo constituyen los animales domésticos, en particular cabras, ovejas, vacas y cerdos. La enfermedad en nuestro medio se adquiere tras la ingestión de productos lácteos no controlados. La mujer embarazada no escapa a esta infección. En la comarca de Jerte la incidencia asciende a unos 300 casos por 105 habitantes, lo que la convierte en la zona de mayor endemia del país. Analizamos 16 casos de brucelosis asociados a la gestación en los dos últimos años, con los siguientes resultados: una gestante fue diagnosticada tras ingresar de urgencias por feto muerto intraútero a las 19 semanas y síndrome febril, resultando la serología y hemocultivos positivos. En otra se advirtió enfermedad aguda (hemocultivos positivos) a las 13 semanas y se instauró tratamiento con 600 mg/día de rifampicina, tras lo que se produjo un aborto espontáneo a las 16 semanas. La tercera paciente con infección activa se diagnosticó a las 24 semanas. Se le administró monoterapia con rifampicina a dosis de 600 mg/día durante 45 días, con lo que se negativizaron los hemocultivos posteriormente y evolucionaron favorablemente la gestación y el recién nacido. Los 13 casos restantes sin bacteriemia (hemocultivos negativos) fueron seguidos muy de cerca con serología y hemocultivos mensuales hasta finalizar la gestación, sin que aparecieran complicaciones ni se aplicara tratamiento médico a ninguna paciente (AU)

Two effects of electrical fields on chloroplasts.

An electrical field across a suspension of Chenopodium chloroplasts stimulates the emission of delayed light during the time the field is on. This stimulation can be used to calculate the distance over which the electron moves in the untrapping process that gives the delayed light. An electrical field applied at the time of illumination gives a polarization to the suspension of chloroplasts that lasts for some seconds. This polarization is a new way to study delayed light and fluorescence from chloroplasts.

Photochemical activity of single chloroplasts recorded by the use of nuclear track emulsion.

The photochemistry done by single chloroplasts can be measured when the chloroplasts are embedded in nuclear track emulsion. It has been known for more than 50 years that certain chemicals will blacken photographic plates (chemical fogging). Although this effect has been little used to measure chemical reactions, it may be particulary useful in photochemistry and electrochemistry, since as little as 10(-18) mole can be measured.