Cost-effectiveness of an educational healthcare circuit for bariatric surgery in France.

OBJECTIVES: An educational healthcare circuit (EHC) is proposed with the objective of preventing weight recovery of patients after bariatric surgery through education and lifestyle change. The objective of this study was to measure the viability of the EHC (shared medical appointments [SMAs] combined with bariatric surgery) through cost-effectiveness analysis. The EHC presented in this study is innovative because it offers a multidisciplinary approach based on medical, psychological and dietetic expertise to combat obesity. The strategy is to give the patient a diagnosis and then a personalised follow-up. STUDY DESIGN: A mathematical model based on a decision tree (1 year) and a Markov model (10 years) to measure the efficiency and cost of an EHC in comparison with the customary care offered in France were built. METHODS: The effects of the EHC were observed for the prevalence of type 2 diabetes and the risk of cardiovascular disease. The chosen financial perspective is from the point of view of the French social security system. RESULTS: The EHC records an incremental cost-effective ratio (ICER) of € 48,315.43 per quality-adjusted life year (QALY) over a 1-year horizon and € 28,283.77 per QALY over 10 years (with discount rate of 8%: € 25,362.85 per QALY). CONCLUSION: The results suggest that an EHC is more expensive yet more effective than usual care. That is, in the short term, the costs are high, but at 10 years, the treatment is cost-effective, representing a feasible alternative for those patients who qualify for bariatric surgery in France.

How obesity relates to socio-economic status: identification of eating behavior mediators.

BACKGROUND: Socio-economic status (SES) is a strong determinant of eating behavior and the obesity risk. OBJECTIVE: To determine which eating and lifestyle behaviors mediate the association between SES and obesity. METHODS: We performed a case-control study of 318 obese people and 371 non-obese people in northern France. Ten eating behavior traits were assessed using the Three-Factor Eating Questionnaire Revised 21-Item and an eating attitude questionnaire (on plate size, the number of servings, reasons for stopping eating and the frequency of eating standing up, eating in front of the television set (TV) and eating at night). The SES score (in three categories) was based on occupation, education and income categories. Mediation analysis was performed using the test of joint significance and the difference of coefficients test. RESULTS: The age- and gender-adjusted obesity risk was higher for individuals in the low-SES groups (odds ratio (OR) (95% confidence interval (CI)=1.82 (1.48-2.24), P<0.0001). Additional servings were associated with a higher obesity risk (OR=3.43, P<0.0001). Cognitive restraint (P<0.0001) and emotional eating (P<0.0001) scores were higher in obese participants than in non-obese participants but did not depend on SES. Of the 10 potential factors tested, eating off a large plate (P=0.01), eating at night (P=0.04) and uncontrolled eating (P=0.03) significantly mediated the relationship between SES and obesity. CONCLUSION: Our results highlighted a number of obesogenic behaviors among socially disadvantaged participants: large plate size, uncontrolled eating and eating at night were significant mediators of the relationship between SES and the obesity risk.

Severe scurvy: an underestimated disease.

Scurvy is one of the oldest diseases in human history. Nowadays, although scurvy tends to become a forgotten disease in developed country, rare cases still occur, especially in people undergoing extreme diet, old people or children with poor diet and patients with malabsorption. We describe three cases of scurvy. The first case is a patient diagnosed with Crohn's disease, the second one is in a context of anorexia nervosa and drug addiction, and the third case is in a context of social isolation. Early recognition of scurvy can be difficult because symptoms may appear nonspecific and can mimic more common conditions. In any patient with spontaneous hematoma and purpura, in the context of nutritional disorder, scurvy should be systematically considered. As this disease can lead to severe complications, such as bone pain, heart failure or gastrointestinal symptoms, nothing should delay vitamin C supplementation, which is a simple and rapidly effective treatment.

Noradrenaline use for septic shock in children: doses, routes of administration and complications.

AIM: To report our 10 year experience with noradrenaline use in children with septic shock focusing on doses, routes of administration and complications. METHODS: Retrospective single-centre review of children with septic shock who received noradrenaline between 2000 and 2010. RESULTS: We identified 144 children with septic shock treated with noradrenaline, in 22% as the first-line drug. The median volume resuscitation before vasoactive agent administration was 50 mL/kg interquartile range [IQR: 30-70]. Mean doses of noradrenaline ranged from 0.5 ± 0.4 µg/kg per min (starting dose) to 2.5 ± 2.2 µg/kg per min (maximum dose). Noradrenaline was administered via peripheral venous access or intra-osseous route in 19% of cases for a median duration of 3 h [IQR: 2-4] without any adverse effects. The use of noradrenaline increased over the study period. Mortality rate was 45% with a significant decrease over the study period. Adverse effects included arrhythmia in two children and hypertension in eight children. None of these arrhythmias required treatment and hypertension resolved with the noradrenaline dose reduction. CONCLUSION: Higher doses of noradrenaline than those suggested in the literature may be necessary to reverse hypotension and hypoperfusion. The use of noradrenaline through peripheral venous access or intra-osseous route was safe, without any adverse effects.

[Interferences by a monoclonal IgM in biochemical analyses: detection and recommendations]. / Interférences par une IgM monoclonale dans un bilan biochimique : détection et recommandations.

We present a case of analytical interference on three parameters (lactate dehydrogenase, uric acid and alkalin phosphatase), caused by a monoclonal IgM, evidenced in a patient with Waldenström disease. Mechanism of interference was probably related to the formation of complexes between paraprotein and lithium heparin, which result in precipitation during clinical chemistry assays, inducing a bias in the results. Management recommendations in case of suspicion of interference in clinical chemistry analysis are detailed. Are discussed for the case report, clinical consequences, possible mechanisms and evolution of interference under treatment, according to the concentration of the monoclonal protein.

No loss of genomic imprinting of IGF-II and H19 in placentas of diabetic pregnancies with fetal macrosomia.

OBJECTIVES: Fetal macrosomia is a common complication of maternal diabetes mellitus and is associated with substantial morbidity, but the precise cellular and molecular mechanisms that induce fetal macrosomia are not well understood. The imprinted genes IGF-II and H19 are crucial for placental development and fetal growth. The term placentas from diabetic pregnancies express more insulin-like growth factor II (IGF-II) than those from normal pregnancies. Deregulation of their imprinting status is observed in the macrosomia-associated syndrome, the Beckwith-Wiedemann syndrome. The aim of this study was to determine whether loss of imprinting hence biallelic expression was also a hallmark of macrosomia in diabetic pregnancies. DESIGN AND METHODS: IGF-II and H19 maternal and paternal expressions were studied in placentas from two groups of type 1 diabetic mothers: one with macrosomic babies and the other with babies of normal weight. Maternal or paternal allele specific expressions were defined by using DNA polymorphic markers of the IGF-II and H19 genes. RFLP analysis was performed on PCR products from genomic DNA of the father, the mother and the child, and on RT-PCR products from placental mRNA. RESULTS: RFLP analysis showed that the IGF-II gene remains paternally expressed and the H19 gene remains maternally expressed in all placentas examined, independently of the birth weight status. CONCLUSIONS: These results suggest that, in contrast with Beckwith-Wiedemann syndrome-associated macrosomia, loss of imprinting for IGF-II or H19 is not a common feature of diabetic pregnancies associated with macrosomia.

[Beta(o)/beta(o) thalassemia with a mild phenotype]. / Thalassémie beta(o)/beta(o) avec phénotype "intermédiaire": un diagnostic rare... auquel il faut penser.

We report the case of a 30 years old patient of Algerian origin, presenting a beta-thalassemia major with a phenotype of intermediate severity. Its genotype is beta(o)/beta(o), leading to a complete absence of beta-globin synthesis. This genotype is usually responsible for major clinical complications and a severe anaemia requiring regular transfusions. However, the patient presents with a mild form of the disease and a moderate relatively well tolerated anaemia. This phenotype was found related to a high level of synthesis of foetal haemoglobin, dependent most probably on an homozygous state for the polymorphism (XmnI -158, C>T) in the promoter of the Ggamma gene. This observation shows that it is important to keep in mind that beta-thalassemia major may have a mild or intermediate phenotype because of polymorphisms of the beta locus.

Impaired oxidant/antioxidant status and LDL-fatty acid composition are associated with increased susceptibility to peroxidation of LDL in diabetic patients.

This study was carried out to determine the relationships between oxidant/antioxidant status, in vitro LDL oxidizability and LDL-fatty acid composition in diabetes mellitus. Plasma total antioxidant capacity (oxygen radical absorbance capacity, ORAC) and LDL-cholesteryl ester fatty acids were investigated in type 1 and type 2 diabetic subjects with and without complications. The degree of LDL oxidation was determined by the measurement of hydroperoxide levels before and after in vitro peroxidative stress with CuSO4. ORAC values were decreased in diabetic subjects who showed high basal hydroperoxide levels. Oxidizability of LDL in these subjects was higher than in control subjects and it was unrelated to LDL-fatty acid composition. However, in type 2 diabetic subjects with complications, alterations in LDL-fatty acid composition were associated with their enhanced oxidative susceptibility. LDL-fatty acid alterations might be an additional factor that influences LDL oxidizability especially in type 2 diabetes. In conclusion, diabetes mellitus is associated with enhanced oxidative stress and defective antioxidant/oxidant balance regardless the type of diabetes and presence of complications.

Actin-binding properties and colocalization with actin during spermiogenesis of mammalian sperm calicin.

The nucleus of mammalian spermatozoa is surrounded by a rigid layer, the perinuclear theca, which is divided into a subacrosomal layer and a postacrosomal calyx. Among the proteins characterized in the perinuclear theca, calicin is one of the main components of the calyx. Its sequence contains three kelch repeats and a BTB/POZ domain. We have studied the association of boar calicin with F-actin and the distribution of boar and human calicin during spermiogenesis compared with the distribution of actin. Calicin was purified from boar sperm heads under nondenaturating conditions. The molecule bound actin with high affinity (K(d) = approximately 5 nM), and a stoichiometry of approximately one calicin per 12 actin monomers was observed. Gel filtration studies showed that calicin forms homomultimers (tetramers and higher polymers). According to immunocytochemical results, calicin is present (together with actin) in the acrosomal region of round spermatids and is mainly localized in the postacrosomal region of late spermatids and spermatozoa. Taken together, the results suggest that the affinity of calicin to F-actin allows targeting of calicin at the subacrosomal space of round spermatids, and that its ability to form homomultimers contributes to the formation of a rigid calyx.

Is tubulin the sole antigen recognized by a putative anti-bursicon antibody?

A 56-kDa polypeptide suspected to be the tanning hormone 'bursicon' was analyzed using the monoclonal antibody (mAb) 01C10 of Song and Ma. We studied the beetle Tenebrio molitor, for which data on bursicon have been recently published. After purification by two-dimensional gel electrophoresis of brain proteins, the immunoreactive 56-kDa polypeptide was trypsinated and microsequenced. The obtained sequences revealed a high homology with alpha- and beta-tubulins. In a complementary study, immunoreactive clones were isolated, using the 01C10 mAb, from a library in expression vector obtained from Drosophila melanogaster head cDNAs. Again, the isolated clones were found, after cDNA sequencing, to correspond to tubulin. Our results suggest that, although the 01C10 mAb could possibly still have a great affinity for a polypeptide present in very low quantities in a few brain neurosecretory cells, it also proved to have an artefactual affinity for a 56-kDa polypeptide, identified as tubulin, which is not involved in tanning control.

Simple nonisotopic assays for detection of (CAG)n repeats expansions associated with seven neurodegenerative disorders.

To date, eight neurodegenerative diseases, including Huntington's disease, dentatorubral-pallidoluysian atrophy, spinal and bulbar muscular atrophy, and spinocerebellar ataxia (SCA) types 1, 2, 3, 6, and 7, have been proven to be caused by an expanded trinucleotide repeat (CAG)n located within a specific gene for each of these diseases. Except in SCA 6, the CAG repeat is present in approximately 7 to 35 copies in the normal population, whereas patients have CAG expansions of 40 to approximately 75 repeats. Sizing of the repeat length enables molecular diagnosis in affected patients and presymptomatic persons carrying a mutated allele. A molecular protocol for the diagnosis of these diseases was developed based on polymerase chain reaction, denaturing polyacrylamide gel electrophoresis and staining with silver nitrate, and adapted to each disease. This simple and rapid method gives a sensitivity of detection equal to current procedures but avoids isotopic manipulations. Therefore, shorter turnaround time, decreased cost per sample, and simplified screening of these neurodegenerative diseases by PCR-based assays may be attainable using this protocol.

Y-autosome translocation and infertility: usefulness of molecular, cytogenetic and meiotic studies.

An apparently balanced reciprocal translocation 46,X,t(Y;6) (q11.23 approximately q12;p11.1) was observed in an infertile man with severe oligozooteratozoospermia. Different mitotic chromosome banding patterns were performed and fluorescence in situ hybridization indicated a breakpoint in the fluorescent Yq heterochromatin. Molecular genetic deletion experiments for the azoospermia factor region in distal Yq11 showed the retention of the DAZ gene and meiotic pairing configurations suggested that the man's infertility could be due to the pairing behaviour of the Y;6 translocation chromosome with the X chromosome visualised by synaptonemal complex analysis at the electron microscopy level. The morphological appearance of the normal chromosome 6 and the Y;6 translocated chromosome included in the compartment of the sex vesicle may allow an explanation of the degeneration of most spermatocytes after the pachytene stage.

Distribution of gelsolin in human testis.

Gelsolin, an actin-binding and severing protein present in many mammalian cells, was characterized in human testis. Although abundant in testicular extracts, gelsolin was not detected in purified spermatogenic cells by immunoblot analysis. Immunofluorescence studies of testis sections showed that gelsolin has two main localizations: peritubular cells and the seminiferous epithelium. In peritubular cells, gelsolin was present together with alpha-SM actin, in agreement with the myoid cell characteristics of these cells. In a large proportion of the tubules, gelsolin was found mainly, together with actin, in the apical part of the seminiferous epithelium. This localization of gelsolin also was observed in seminiferous tubules with a partial or complete absence of germinal cells, which evokes a presence of gelsolin at the apex of Sertoli cells. However, in normal testis, a complex pattern of gelsolin labeling was also present, mostly in the apical third of the epithelium, around cells or groups of cells, mainly spermatids, and, less frequently, in various other localizations from the apical to the basal part of the seminiferous epithelium. Taken together, these observations suggest that gelsolin may play different functions in the seminiferous epithelium: (1) regulation of the dynamic alterations of the actin cytoskeleton in the apical cytoplasm of Sertoli cells, and (2) modification of actin filaments assemblies in specific structures at germ cell-Sertoli cell contacts. Thereby, the actin-modulating properties of gelsolin are probably involved in reorganization of the seminiferous epithelium related to germ cell differentiation.

[The HLA system: a clinical help?]. / Le système HLA, une aide à la clinique?

UNLABELLED: Chronic diseases are polymorph and influenced by many environmental and genetic factors. The HLA system is implicated in the modulation the onset and the evolution of chronic diseases. These observations are important to be considered for the prediction, prognosis and treatment adaptation. Evaluation tests are mainly statistical and are based on epidemiological studies. Thus, results must be considered with caution. Two aspects are to be considered: DIAGNOSIS: Associations between HLA alleles and chronic diseases are well known but concern very few diseases like narcolepsy or rheumatoid arthritis. Insulin dependent diabetes mellitus is particular because the prediction is limited to familial studies. PROGNOSIS: This point is less documented in clinical applications but is of interest particularly in inflammatory bowel diseases or systemic affections. This observation can be considered as a compartmental response which is a kind of adaptation to stress.

Molecular mapping of a Yq deletion in a patient with normal stature.

The proximal long arm of the Y chromosome probably contains a gene (GCY) involved in stature determination. Recent reports have proposed the critical region extends from interval 4B to interval 5G (or 5E). In the present study, the deletion breakpoint in a male adult patient of normal height with a 46,X,del(Yq) karyotype was defined by the use of sequence-tagged site markers. The breakpoint was found between sY78 (interval 4B) and sY79 (interval 5A). The existence of a normal stature in this patient suggests that the growth determinant is proximal to sY79, therefore probably located in interval 4B or in proximal interval 5A of the Y chromosome.

Molecular localization of free thiols in human sperm chromatin.

The presence in human sperm nuclear proteins of a limited amount of unoxidized thiol groups, stabilized by reversible binding to zinc ions, has been presumed to play a role in the decondensation of sperm within the oocyte. In the present study, the number and molecular localization of free sulfhydryls in the major proteins of human sperm chromatin, protamines P1 and P2, were determined by alkylation of reactive thiols with 14C-iodoacetamide, isolation of protamines, and peptide mapping. Less than 1.5% of the cysteines of protamines were found as reactive thiols, a proportion strikingly lower than that reported previously for whole human sperm proteins. The amount of sulfhydryls was unaffected by the zinc chelating agent EDTA. Labeling was evenly distributed on every cysteine of protamines P1 and P2. The results confirm the extensive stabilization of sperm chromatin by disulfide bridges and show that the unoxidized cysteines remaining at the end of epididymal transit in some protamine molecules may be one of the six (protamine P1) or five (protamine P2) cysteines present in the sequence of each class of protamines. This even distribution of the reactive cysteines could facilitate decondensation of sperm nuclei initiated by a thiol-disulfide exchange.

An improved strategy for HLA-DRB1 subtyping by digestion of PCR-amplified DNA with allele-specific restriction endonucleases.

We developed a simple, rapid and inexpensive method of DRB1 alleles genotyping by digestion of amplified DNA with allele-specific restriction fragments endonucleases. We took advantage of this protocol, initially described by Yunis et al. (1991) and called AFLP (Amplification Length Fragment Polymorphism) to standardise amplification procedure. Typing strategy was particularly studied to limit the number of restriction endonucleases. The determination of DRB1 allele was established on lysed fragments size which allows: (1) the absence of nonidentified allele and (2) a nonambiguous determination of each heterozygous allele. Six specific pairs of primers were chosen to amplify three generic groups: HLA DR 124 (DRB1 1, 2 and 4), HLA DR356810 (DRB1 3, 5, 6, 8 and 10) and DR79 (DRB1 7 and 9) with the same PCR protocol. Forty-eight from the 60 DRB1 alleles may be identified without any ambiguity. With our protocol, the three alleles associated with the most important autoimmune diseases (i.e., DRB1*02, *03 and *04) were totally subtyped. Our amplification procedure is reliable and extremely useful in routine-practice for the study of HLA-DRB1 genotyping of large series of samples and for the determination of DRB1 susceptibility factors involved in different autoimmune diseases.

Interaction of human P1 and P2 protamines with DNA.

The interaction of two classes of human sperm protamines, P1 (HP1) and P2 (HP2, HP3, HP4), with DNA was investigated. Gel mobility shift assays with a range of DNA fragments of defined sizes show that, whatever its length, all the DNA is complexed with protamines at arginine to phosphate ratio of 0.1. Further addition of protamine molecules leads to a precipitation of the protamine-DNA complexes for arginine-phosphate ratio > or = 1.2. Fluorescence studies using the dye Hoescht 33258 as a fluorophore and DNAase I footprinting experiments suggest that P1 and P2 protamines bind at the DNA surface without apparent location in the minor or major groove of DNA. No differences in protamine-DNA interaction were observed between the two classes of human protamines P1 and P2. Moreover the binding to DNA was not influenced by the presence of zinc which induces the formation of a zinc-finger structure in protamine P2.

Interaction of mammalian sperm nuclear protamines and peptides derived thereof with immobilized zinc.

The interaction of mammalian and human protamines with zinc was studied by immobilized metal ion affinity chromatography (IMAC). The affinity of protamines containing blocked cysteine residues was found to correlate in part with the presence and number of histidine residues in the protamine structure: absence or low affinity of P1 protamines containing 0 or 1 histidine residue; high affinity of human P2 protamine containing 9 histidines. Nevertheless a fraction strongly retained on an IDA-Zn(II) column was observed for P1 protamines with one histidine in the N-terminal sequence (ram and boar protamines). The strong binding was found to be related to the presence of tyrosine, serine and threonine closely spaced to the histidyl side chain. In the case of human protamine P2, the strong retention on the IDA-Zn(II) column seems to result from the additive contribution of all the histidine residues of the molecule. Thus, strong retention of protamines in IMAC seems to depend on an additive contribution of amino-acid side chains: histidine, tyrosine, serine, threonine and perhaps arginine. The high affinity of protamines, more especially P2 protamines, for zinc suggests that this metal ion could play a role for their correct folding and binding to DNA.