[A difficult transition from childhood to adult healthcare: the case of epilepsy]. / Le difficile passage à l'âge adulte en matière de soins : l'exemple de l'épilepsie.

OBJECTIVE: The purpose of this study was to analyze modalities of the transition from pediatric to adult epilepsy care and patients' acquisition of autonomy. METHOD: This study was conducted using semidirected interviews composed of three major parts: the patient's criteria of transition toward adult healthcare (factors taken into account, anticipation, the patient's opinion, etc.), conditions (teamwork with the neurologists, transmission of the medical record, continuity of health care, etc.), and the role played by social workers and psychologists. We interviewed 10 doctors belonging to six major Parisian hospital units involved in the monitoring of children and adolescents with epilepsy and working in Pediatric Neurology Departments of the Île-de-France region. RESULTS: For most of the doctors, reaching 18 years of age was the major argument taken into account to consider transition to adult care. According to the doctors interviewed, parents are generally worried when their child has to find another doctor (7/10). According to eight out of 10 doctors, the neurologist is selected to take over. The doctors recognize the importance of psychologists and social workers even if they are not always included. The process by which the patient gains autonomy depends a great deal on the role played by the pediatricians and parents, although some parents are very protective. This behavior weakens the patient's capacity for autonomy and it varies according to the degree of his or her physical and/or neurological disabilities. Furthermore, developing autonomy requires interdisciplinary work that is not yet fully in place. CONCLUSION: The lack of structures well-adapted to the uniqueness of each patient and the lack of coordination between the various institutions do not favor the acquisition of autonomy. A network that could efficiently respond to the needs of epileptic patients as well as medical care tailored to adolescents would be the answer to this dilemma.

[Breast cancer screening program in France: for optimization of the information]. / Dépistage organisé du cancer du sein en France : pour une optimisation de l'information.

BACKGROUND: Based on international and national recommendations, organized breast cancer screening in France raises questions of medical ethics built around the key concepts of individual autonomy and public health policy. Because of the evolving knowledge, professionals and institutions involved in the program must review the ethical values associated with this medical practice. METHODS: The ethical aspects of organized breast cancer screening were studied. In response to newly acquired knowledge highlighted by a review of texts governing this practice in France, proposals for changes resulting from reflections of a working group coordinated by the National Cancer Institute are presented. RESULTS: Ethical issues raised by screening must find expression in the general principles of the program's organization: acceptability of screening, efficiency, adverse effects, equity of access, free care…, but also at different stages of the procedure: information delivery, first and second invitations, refusal of further diagnostic investigation… CONCLUSION: A better match between breast cancer screening and recently developed knowledge requires optimal information delivery to women targeted by the program as well as a stronger role for the referring healthcare professional.

[Can or must the patient participate to risk management in radiotherapy?]. / Le patient peut-il et doit-il participer à la gestion des risques en radiothérapie ?

PURPOSE: The present study aimed at analyzing if patient participation constitutes a promising way of improvement of patient safety, or not. The hypothesis is that patient participation is a means to develop a safety culture based on the cooperation between patients and healthcare providers, to improve patients' satisfaction and to reduce the costs associated to adverse events. PATIENTS AND METHODS: A half-day session was organized on this theme during a training of radiotherapy professionals on risk management. Professionals were first distributed in three subgroups according to their specialty (radiation oncologists, radiation physicists and medical technicians), and had to work on four main questions relating to participation, among which the collection of real situations in which patients effectively contributed (positively or negatively) to patient safety. Results were then collectively discussed. RESULTS: Patient participation allows not only to detect and recover some mistakes or errors made by the professionals (error of identity), but also to decrease patients' risk behaviors (purposely taking the place of another patient in order to be treated faster). However, it must be seen as a possibility offered to patients, and not as an obligation. CONCLUSION: Patient participation to patient safety is a field of study, which requires to be developed in order to define the conditions enhancing such participation and to implement a set of actions to improve healthcare safety by a cooperative management of this one.

[Decision process in oncology: the importance of multidisciplinary meeting]. / La réunion de concertation pluridisciplinaire : quelle place dans la décision médicale en cancérologie ?

Multidisciplinary meeting (MDM) in oncology has been institutionalised in France by the Cancer Plan. This study aims to determine the place of MDM in the decision process. From November 2004 to July 2005, we observed 29 meetings at the Tours Hospital and 324 case presentations, 80 in orthopaedics, 151 in gastroenterology and 93 in chest medicine. Forty physicians attending the meetings answered a questionnaire exploring their opinions on MDM and the collegial decision. We found that MDM is mostly the place for technical discussions and that patients' wishes are rarely addressed. The different medical specialities are well represented but we observed that only physicians attend MDM. Decisions for straightforward cases are rapidly validated. For more complex clinical situations (25 to 40% of case presentations), the multidisciplinary approach allows to adapt guidelines or to choose alternative treatments. All the physicians interviewed express that MDM legitimates the medical decision. It occurs that they disagree with the RCP decision. We discuss how MDM impacts on the medical decision as well as the shift from the individual decision to the collective one, particularly in term of responsibility.

[Theoretical risk management and legitimacy of the precautionary principle in medicine. Look back at HIV contamination through blood transfusion in France, twenty years ago]. / La gestion d'un risque potentiel et la légitimité du principe de précaution en médecine. Regard vingt ans après sur la contamination transfusionnelle par le VIH en France.

The precautionary principle first appeared in France during the health crisis following the contamination of patients with HIV via blood transfusion. This study analyses whether the risk associated with blood transfusion was taken into account early enough considering the context of scientific uncertainty between 1982 and 1985. The aim was to evaluate whether a precautionary principle was applied and whether it was relevant. First, we investigated the context of scientific uncertainty and controversies prevailing between 1982 and 1985. Then we analysed the attitude and decisions of the French authorities in this situation to determine whether a principle of precaution was applied. Finally, we explored the reasons at the origin of the delay in controlling the risk. Despite the scientific uncertainties associated with the potential risk of HIV contamination by transfusion in 1983, we found that a list of recommendations aiming to reduce this risk was published in June of that year. In the prevailing climate of uncertainty, these measures could be seen as precautionary. However, the recommended measures were not widely applied. Cultural, structural and economic factors hindered their implementation. Our analysis provides insight into the use of precautionary principle in the domain of blood transfusion and, more generally, medicine. It also sheds light on the expectations that health professionals should have of this principle. The aim of the precautionary principle is to manage rather than to reduce scientific uncertainty. The principle is not a futile search for zero risk. Rather, it is a principle for action allowing precautionary measures to be taken. However, we show that these measures must appear legitimate to be applied. This legitimacy requires an adapted decision-making process, involving all those concerned in the management of collective risks.

[The person of trust, a new tool in the physician-patient relationship]. / La personne de confiance, nouvel outil de la relation médecin patient.

THE NOTION OF A PERSON OF TRUST: Introduced by the law dated March 4th 2002, the person of trust is there to accompany the patient in all his/her measures of care; this person is also conceived as an helper in medical decisions or when the patient participates in biomedical research protocols. DESIGNATION MODALITIES: Any adult, unprotected patient can designate a person of trust, whose intervention is not only limited to hospitalisation (the nursing staff are obliged to propose such a person), but can also intervene during care at home or at the doctor's. The designation is made in writing and can be revoked at any time. The person of trust can be a relative, a friend or even the treating physician. A SPECIFIC ROLE: The person of trust can be of help in medical measures in routine medicine when the patients needs to be accompanied, and in the case of diagnosis or serious prognosis, and when the patient is incapable of expressing him/herself.

Improving protection for research subjects in France: analysis of regional ethics committees.

OBJECTIVE: The aim of this study was to analyze the functioning of the French committees for the protection of people in biomedical research (CCPPRB). DESIGN: An independent evaluator visited all of the committees and analyzed their functioning by assessing the annual activity reports, filling data grids and observing the committees in session. RESULTS: We observed that the representation of a range of professions, which is required by law, was not always respected. This was partly because the administrative authority had accumulated delays in nominating members. Another explanation could be the absence of remuneration for the work and attendance of the members. There was considerable inter-committee variation concerning the way documents were distributed to the members during sessions and the extent of investigator and promoter involvement. Finally, large differences in the number of dossiers handled between committees led us to investigate the fairness of dossier distribution, as the number of dossiers dealt with has consequences, particularly for the finality of the opinions of the committees. CONCLUSIONS: This evaluation of the committees playing a crucial role in protecting participants in research trials provides new information that could be helpful for improving the way in which these committees function in the context of the European Directive.

[The precautionary principle applied to blood transfusion. What is its impact on practices and risk management?]. / Le principe de précaution appliqué à la transfusion sanguine: quel impact sur les pratiques et la gestion des risques?

The precautionary principle has boomed in the French public health sector through blood transfusion. There has been, however, no perambulatory reflection on the definition, objectives, methods of application or consequences of this principle. The question of the pertinence of its application remains unanswered. This study, based on interviews with blood transfusion practitioners, aims to establish their perceptions of the precautionary principle's application in this specific field and of its consequences in terms of risk management and patients' rights. The pros and cons of this application are analysed based on these perceptions. According to our analysis, the precautionary principle seems to be born of confusion. It is seen more as a way to protect decision makers than patients and, if taken to extremes, could prejudice medical logic. Nevertheless, it also brings measures which renew and encourage evolution in transfusion risk management.

Alternative splicing in the human interleukin enhancer binding factor 3 (ILF3) gene.

The Interleukin Enhancer Binding Factor 3 (ILF3) gene has been mapped to chromosome 19 in humans and to chromosome 9 in mice. Several reported double-stranded RNA binding proteins including NF90, ILF3, MPP4 and DRBP76 have been suggested to be isoforms of the ILF3 gene but this has not been clearly established. We isolated several ilf3 transcripts from a melanoma cDNA library and two corresponding genomic fragments, and report alternative splicing and polyadenylation site selection in the human ILF3 gene. We show the existence of an alternative splice site responsible for the sequence divergence in the 3' part of the transcripts. Another alternative splicing event at a site between the two double-stranded RNA binding motifs leads to the additional presence in some cases of a four amino acids NVKQ peptide. We also describe the utilization of three distinct polyadenylation signals and the generation of an ilf3 transcript with a long extended 3' UTR. The expression of the different transcripts was evaluated. We used a GenBank sequence for the part of chromosome 19 corresponding to the ILF3 gene to determine the exon-intron organization of the entire gene which spans 38 kb and is divided into 21 exons.

Melanotransferrin gene expression in melanoma cells is correlated with high levels of Jun/Fos family transcripts and with the presence of a specific AP1-dependent ternary complex.

The involvement of the transcription factor AP1 in the regulation of melanotransferrin (MTf) gene expression was investigated. MTf, also known as p97, is a tumour-associated antigen that is overproduced in most melanomas. Its gene expression is under the control of an enhancer element containing two AP1 binding sites. By Northern analysis, we demonstrate that MTf mRNA is detected at various levels in melanoma SK-MEL-28 cells and that its greatest expression coincides with the presence of large amounts of jun and fos transcripts. Gel retardation assays revealed that the induction of expression of these proto-oncogenes is correlated with increased AP1 binding activity and that a region of the MTf enhancer is involved in the formation of a ternary AP1-dependent complex, implicating a second nuclear factor whose binding characteristics are similar to those of nuclear factor of activated T cells (NF-AT). In transient expression experiments, the activity resulting from ternary complex formation was high and specific to melanoma cells. These data provide a possible explanation for the mechanisms of AP1 factor family involvement in MTf up-regulation in melanoma cells.

A 700-bp fragment of the human antithrombin III promoter is sufficient to confer high, tissue-specific expression on human apolipoprotein A-II in transgenic mice.

The human antithrombin III-encoding gene (hAT-III) promoter (phAT-III) was used to generate transgenic mice producing a human hepatic apolipoprotein, apolipoprotein A-II (hApoA-II). Integration of the transgene into the mouse genome resulted in the efficient production of hApoA-II in plasma, reaching up to 0.40 g/l in two transgenic lines. The human ApoA-II mRNA was detected at high levels, both in the liver and in the kidney of transgenic mice. The rat AT-III gene shows the same expression pattern. In contrast, as previously described, the same promoter permitted the expression of the SV40 large T antigen only in the liver of transgenic mice. In view of the extra-hepatic distribution of the ApoA-II mRNA, a preliminary characterization of the hAT-III proximal promoter (phAT-III), driving the expression of the transgene, was realized. Using DNase I footprinting analysis with liver nuclear extracts, four protected regions (I-IV) were identified in the first 175 bp of the 5' region of hAT-III. Electrophoretic mobility shift assays performed with liver and kidney nuclear extracts indicate that region III (nucleotides (nt) -67 to -90) interacts with the liver-enriched HNF4 nuclear factor. Furthermore, our data suggest that region I (nt -123 to -138) interacts with the liver-enriched HNF3 transcription factor family, both in liver and kidney. Taken together, these results demonstrate that phAT-III is a useful tool to create transgenic mice producing high plasma levels of a human apolipoprotein due to expression of the transgene in liver and kidney.(ABSTRACT TRUNCATED AT 250 WORDS)

Regulation of melanotransferrin gene in melanoma cells. Analysis of the enhancer region.

The human iron-binding protein melanotransferrin is up-regulated in most skin melanomas. With the goal to understand the mechanisms controlling the expression of the gene in these tumor cells, we previously reported the identification of an enhancer exhibiting melanoma specificity. We show here that, in the highly expressing SK-MEL-28 melanoma cell line, the chromatin structure in the enhancer region is in an open configuration and that the transcription factors governing its activity belong to the helix-loop-helix and the Jun/Fos leucine zipper families.

Identification of an enhancer involved in the melanoma-specific expression of the tumor antigen melanotransferrin gene.

Melanotransferrin (MTf) is a tumor associated antigen found in abundance on the surface of melanoma cells. It is a transferrin-like protein found in low amount in most adult tissues and whose gene is reminiscent of house-keeping genes. With the goal of understanding the regulatory mechanisms which might explain the enhancement of expression in tumor cells, we report here the characterization of a regulatory element located 2 kbp upstream from the promoter and whose deletion specifically impairs gene expression in melanoma cells; we show that this element is part of an enhancer composed of two modules which are each the target for the AP1 transcription factor. The two modules present a synergistic mode of action specific for melanoma cells which requires both of the 130 bp away AP1 sites. Furthermore, we show that the enhancer behaves differently according to the promoter context.

Simple chemical synthesis and hybridization properties of non-radioactive DNA probes.

A simple chemical method for the synthesis of non-radioactive DNA probes is described: triazolyl-containing sequences were built by incorporation of 4-triazolylpyrimidin-2-ones instead of cytidines during oligodeoxyribonucleotide synthesis. The activating triazolyl groups were then displaced by a diamine which was further derivatized by a label, such as biotin. Synthesized DNA probes were oligonucleotides complementary to a cloned human antithrombin III DNA sequence. These probes, containing the same label at different positions of the sequence, were hybridized to their target DNA immobilized on nitrocellulose. Their hybridization specificity and stability were studied. Hybrid detection was performed either colorimetrically by the streptavidin-alkaline phosphatase-based system or by autoradiography after 5'-32P labeling of the probes: 15 fmol (0.05 microgram) of complementary sequence could be visualized in the two cases.

Structural arrangements of transcription control domains within the 5'-untranslated leader regions of the HIV-1 and HIV-2 promoters.

Promoter-proximal downstream regions of the human immunodeficiency viruses (HIV-1 and HIV-2) mediate the action of the viral transcription activator protein, Tat. We demonstrate here that the downstream domain of each virus interacts with two RNA polymerase II transcription factors. One of these, CTF/NF I, is a multifunctional protein associated previously with activation of transcription and DNA replication. The other cellular protein, designated LBP-1 (leader-binding protein-1), recognizes repeated elements within an extended region of DNA corresponding to part of the 5'-untranslated leader. Analysis of clustered point mutants in the HIV-1 leader for DNA-binding and transcription activity in vitro and in vivo suggests a role for LBP-1 as part of the basal promoter. A complex overlapping arrangement is observed between sequences required for the interaction of LBP-1 and CTF/NF I proteins and those defined previously for regulation by the HIV-1 Tat protein.

Modified oligonucleotides as alternatives to the synthesis of mixed probes for the screening of cDNA libraries.

Two simple alternatives to the synthesis of mixed oligodeoxyribonucleotide probes are described: mixed deblocking of triazolodeoxynucleosides for the A/G and C/T degeneracies or incorporation of 2-amino-2'-deoxyadenosines into a determined sequence for a higher stability of the hybridization duplexes. The synthetic oligodeoxyribonucleotides obtained were successfully tested in comparison with a classical mixed probe for their capacity to identify specific cDNA clones of human antithrombin III. The results are discussed with respect to the utilization of these synthetic oligonucleotides as hybridization probes for the isolation of cloned cDNA sequences.