(210)Po poisoning as possible cause of death: forensic investigations and toxicological analysis of the remains of Yasser Arafat.

The late president of the Palestinian Authority, Yasser Arafat, died in November 2004 in Percy Hospital, one month after having experienced a sudden onset of symptoms that included severe nausea, vomiting, diarrhoea and abdominal pain and which were followed by multiple organ failure. In spite of numerous investigations performed in France, the pathophysiological mechanisms at the origin of the symptoms could not be identified. In 2011, we found abnormal levels of polonium-210 ((210)Po) in some of Arafat's belongings that were worn during his final hospital stay and which were stained with biological fluids. This finding led to the exhumation of Arafat's remains in 2012. Significantly higher (up to 20 times) activities of (210)Po and lead-210 ((210)Pb) were found in the ribs, iliac crest and sternum specimens compared to reference samples from the literature (p-value <1%). In all specimens from the tomb, (210)Po activity was supported by a similar activity of (210)Pb. Biokinetic calculations demonstrated that a (210)Pb impurity, as identified in a commercial source of 3MBq of (210)Po, may be responsible for the activities measured in Arafat's belongings and remains 8 years after his death. The absence of myelosuppression and hair loss in Mr Arafat's case compared to Mr Litvinenko's, the only known case of malicious poisoning with (210)Po, could be explained by differences in the time delivery-scheme of intake. In conclusion, statistical Bayesian analysis combining all the evidence gathered in our forensic expert report moderately supports the proposition that Mr Arafat was poisoned by (210)Po.

Attitudes Regarding Palliative Sedation and Death Hastening Among Swiss Physicians: A Contextually Sensitive Approach.

In Switzerland, where assisted suicide but not euthanasia is permitted, the authors sought to understand how physicians integrate palliative sedation in their practice and how they reflect on existential suffering and death hastening. They interviewed 31 physicians from different care settings. Five major attitudes emerged. Among specialized palliative care physicians, convinced, cautious and doubtful attitudes were evident. Within unspecialized settings, palliative sedation was more likely to be considered as death hastening: clinicians either avoid it with an inexperienced attitude or practice it with an ambiguous attitude, raising the issue of unskilled and abusive uses of sedatives at the end of life.

Erforschung und Antworten auf den vorzeitigen Todeswunsch eines Patienten mit einer schweren fortgeschrittenen Krankheit [Exploring and Responding to a Wish to Hasten Death of a patient with Advanced Illness].

It is not uncommon for patients with an advanced disease to express a desire to their physician to hasten their death. Recent studies show that the motivation of such a desire is multifactorial and multidimensional, including depression, physical, psycho-social and spiritual suffering, fears about the process of dying and/or misunderstandings about the options for end-of-life care. The objective of this paper is to propose to the physician how to explore the dimensions of this request and some elements to answer it.

Impact of Aldosterone Antagonists on Sudden Cardiac Death Prevention in Heart Failure and Post-Myocardial Infarction Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND AND OBJECTIVES: Sudden cardiac death (SCD) is a severe burden of modern medicine. Aldosterone antagonist is publicized as effective in reducing mortality in patients with heart failure (HF) or post myocardial infarction (MI). Our study aimed to assess the efficacy of AAs on mortality including SCD, hospitalization admission and several common adverse effects. METHODS: We searched Embase, PubMed, Web of Science, Cochrane library and clinicaltrial.gov for randomized controlled trials (RCTs) assigning AAs in patients with HF or post MI through May 2015. The comparator included standard medication or placebo, or both. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Event rates were compared using a random effects model. Prospective RCTs of AAs with durations of at least 8 weeks were selected if they included at least one of the following outcomes: SCD, all-cause/cardiovascular mortality, all-cause/cardiovascular hospitalization and common side effects (hyperkalemia, renal function degradation and gynecomastia). RESULTS: Data from 19,333 patients enrolled in 25 trials were included. In patients with HF, this treatment significantly reduced the risk of SCD by 19% (RR 0.81; 95% CI, 0.67-0.98; p = 0.03); all-cause mortality by 19% (RR 0.81; 95% CI, 0.74-0.88, p<0.00001) and cardiovascular death by 21% (RR 0.79; 95% CI, 0.70-0.89, p<0.00001). In patients with post-MI, the matching reduced risks were 20% (RR 0.80; 95% CI, 0.66-0.98; p = 0.03), 15% (RR 0.85; 95% CI, 0.76-0.95, p = 0.003) and 17% (RR 0.83; 95% CI, 0.74-0.94, p = 0.003), respectively. Concerning both subgroups, the relative risks respectively decreased by 19% (RR 0.81; 95% CI, 0.71-0.92; p = 0.002) for SCD, 18% (RR 0.82; 95% CI, 0.77-0.88, p < 0.0001) for all-cause mortality and 20% (RR 0.80; 95% CI, 0.74-0.87, p < 0.0001) for cardiovascular mortality in patients treated with AAs. As well, hospitalizations were significantly reduced, while common adverse effects were significantly increased. CONCLUSION: Aldosterone antagonists appear to be effective in reducing SCD and other mortality events, compared with placebo or standard medication in patients with HF and/or after a MI.

The role of raptor in cell death

Selon les statistiques, les maladies cancéreuses sont en augmentation dans les pays en développement ainsi que dans les pays industrialisés. Ceci peut s'expliquer largement par les habitudes alimentaires, le tabagisme, les infections, le manque d'activité physique, la pollution et le stress, entre autres. Ainsi, l'Organisation Mondiale de la Santé (OMS) prévoit une augmentation de la fréquence des cancers avec 15 millions de nouveaux cas par an en 2020. La transformation d'une cellule normale en une cellule cancéreuse se déroule en plusieurs étapes avec, au niveau moléculaire, différentes mutations ciblant des protéines régulant la croissance cellulaire. Un des exemples de protéines qui participent au contrôle des voies cellulaires impliquées lors de la prolifération des cellules sont les complexes de protéines mTORCl et mTORC2 (« mammalian target of rapamycin complex 1 and 2 »). Ces complexes mTORCl et mTORC2 activent des processus anaboliques (la synthèse de protéines et de lipides, le métabolisme énergétique, entre autres) et inhibent en même temps des voies de catabolismes cellulaires (autophagie et synthèse de lysosomes). Ils sont souvent mutés dans de nombreux cas de cancers, c'est pourquoi ils sont la cible de nombreux traitements anti-cancéreux. Pour ces raisons, nous nous sommes intéressés aux mécanismes d'actions moléculaires des drogues qui ciblent les complexes mTORCl et mTORC2. Nous avons ainsi découvert qu'une molécule présente uniquement dans le complexe mTORCl, raptor, était clivée en un fragment plus petit lors du traitement de cellules cancéreuses avec des drogues. Des molécules activées durant la mort cellulaire programmée par apoptose, les caspases, se sont révélées responsables du clivage de raptor. Nous avons ensuite décrit de façon précise les sites de clivage de raptor par les caspases durant la mort cellulaire. Il s'est avéré que le clivage de raptor affaiblissait son interaction avec mTOR au sein du complexe mTORCl, ce qui participe à l'inactivation de mTORCl lors de traitements avec des molécules anti-cancéreuses. Ces résultats nous ont permis de mieux comprendre les mécanismes d'actions de différentes drogues anti-cancéreuses au niveau du complexe mTORCl, ce qui peut être utile pour la synthèse de nouvelles molécules ciblant mTORCl ainsi que pour lutter contre les mécanismes de résistance chimiothérapeutiques. -- La protéine « mammalian target of rapamycin » (mTOR) est une sérine/thréonine kinase qui est hautement conservée des protistes à l'être humain. Deux complexes mTOR existent : le complexe 1 mTOR (mTORCl) et le complexe 2 mTOR (mTORC2). Ils régulent positivement des processus anaboliques (synthèse de protéines et de lipides, le métabolisme énergétique, l'organisation du cytosquelette, la survie cellulaire) et négativement des voies cataboliques (autophagic, biogenèse de lysosomes). Les complexes mTORCl et mTORC2 sont sensibles aux signaux mitogéniques tels que les acides aminés, le glucose, les facteurs de croissance, l'état énergétique (ATP) et les niveaux d'oxygène et induisent des voies de croissance cellulaire essentielles. La voie cellulaire regulée par mTORCl peut être hyperactivée dans de nombreux cancers humains. Puisque plusieurs voies cellulaires convergent et régulent les complexes mTORCl et mTORC2, des mutations dans les kinases en amont peuvent mener à une dérégulation de l'activation de mTOR. Des stratégies thérapeutiques ont été développées pour cibler les complexes mTORCl et mTORC2, ainsi que les kinases en amont qui régulent mTOR. Plusieurs drogues ciblant mTORCl, telles que la rapamycine et la curcumine, affectent l'interaction entre mTOR et un composant spécifique de mTORCl, raptor. Dans cette étude, nous nous sommes intéressés aux mécanismes moléculaires des drogues qui ciblent mTORCl, ainsi que leur effet déstabilisant sur l'interaction entre mTOR et raptor dans des lignées cellulaires de lymphomes. Nous avons démontré que raptor était clivé en un fragment de lOOkDa après traitement avec la rapamycine, la curcumine, l'étoposide, la cisplatine, la staurosporine et le ligand Fas (FasL). Etant donné que ces drogues ont été décrites comme induisant I'apoptose, l'utilisation d'un inhibiteur de caspases (z- VAD-fmk) a révélé que le clivage de raptor, lors de la mort cellulaire, était dépendant des caspases. Des essais caspases in vitro ont permis d'identifier la caspase-6 (ainsi que probablement d'autres caspases) comme étant une protéase impliquée dans le clivage de raptor. La séquence protéique de raptor a montré potentiellement plusieurs sites de clivage de caspases aux extrémités amino-terminale et carboxy-terminale. La mutagénèse a permis d'identifier les sites de clivages de raptor par les caspases comme étant DEAD LTD (acides aminés 17-23) et DDADD (acides aminés 939¬943). De plus, le clivage de raptor corrèle avec l'inhibition de l'activité de mTORCl envers ces substrats (S6K et 4E-BP1). Nous avons aussi observé que le clivage de raptor affaiblissait l'interaction entre mTOR et raptor, ce qui indique que ce clivage est une étape critique dans l'inhibition de mTORCl durant I'apoptose. Pour terminer, la mutagénèse du site de clivage de raptor DDADD a montré une résistance à la mort cellulaire de cellules cancéreuses. Notre travail de recherche a révélé un nouveau mécanisme moléculaire qui module l'organisation et l'activité de mTORCl, ce qui peut être d'un grand intérêt pour les recherches dans le domaine de mTOR ainsi que pour la découverte de molécules ciblant mTORCl. -- The mammalian target of rapamycin (mTOR) is a serine/threonine protein kinase, which is highly conserved from yeast to humans. Two different mTOR complexes exist: the mTOR complex 1 (mTORCl) and the mTOR complex 2 (mTORC2). They positively regulate anabolic processes (protein and lipid synthesis, energy metabolism, cytoskeleton organization, cell survival) and negatively regulate catabolic pathways (autophagy, lysosome biogenesis). The mTORCl and mTORC2 respond to mitogenic stimuli such as amino acids, glucose, growth factors, energy levels (ATP) and oxygen levels and drive essential cellular growth pathways. The mTORCl pathway can be found hyperactivated in numerous human cancers. As various cellular pathways converge and regulate mTORCl and mTORC2, mutations in upstream protein kinases can lead to a deregulated mTOR activation. Different therapeutic strategies have been developped to target mTORCl, mTORC2, as well as upstream protein kinases regulating mTOR pathways. Various drugs targeting mTORCl, such as rapamycin and curcumin, affect the interaction between mTOR and a specific mTORCl component, raptor. In this study, we investigated the molecular mechanisms of drugs targeting mTORCl, as well as their destabilizing effect on the mTOR-raptor interaction in lymphoma cell lines. We demonstrated that raptor was processed into a lOOkDa fragment after treatment with rapamycin, curcumin, etoposide, cisplatin, staurosporine and FasL. As these drugs were reported to induce apoptosis, the use of a pan-caspase inhibitor (z-VAD-fmk) revealed that the cleavage of raptor under cell death was caspase-dependent. In vitro caspase assays were performed to identify caspases-6 (and probably other caspases) as an important cysteine protease implicated in the cleavage of raptor. Analysis of raptor protein sequence showed several putative caspase-specific cleavage sites at the N-terminal and the C-terminal ends. Mutagenesis studies allowed us to identify the DEADLTD (amino acids 17-23) and the DDADD (amino acids 939-943) as the caspase-dependent cleavage residues of raptor. Furthermore, the cleavage of raptor correlated with inhibition of mTORCl activity towards its specific targets (4E-BP1 and S6K). We also highlighted that raptor processing weakened the interaction between mTOR and raptor, indicating that raptor cleavage is a critical step in the mTORCl inhibition process during apoptosis. Finally, mutagenesis of raptor C-terminal cleavage site (DDADD) conferred resistance to the chemotherapeutic-mediated cell death cascade of cancer cell. Our research work highlighted a new molecular mechanism modulating mTORCl organization and activity, which can be of great interest in the mTOR field research and for designing drugs trageting mTORCl.

Reduction in the use of diagnostic tests in infants with risk factors for early-onset neonatal sepsis does not delay antibiotic treatment

BACKGROUND: Despite a low positive predictive value, diagnostic tests such as complete blood count (CBC) and C-reactive protein (CRP) are commonly used to evaluate whether infants with risk factors for early-onset neonatal sepsis (EOS) should be treated with antibiotics. STUDY DESIGN: We investigated the impact of imple- menting a protocol aiming at reducing the number of dia- gnostic tests in infants with risk factors for EOS in order to compare the diagnostic performance of repeated clinical examination with CBC and CRP measurement. The primary outcome was the time between birth and the first dose of antibiotics in infants treated for suspected EOS. RESULTS: Among the 11,503 infants born at 35 weeks during the study period, 222 were treated with antibiotics for suspected EOS. The proportion of infants receiving an- tibiotics for suspected EOS was 2.1% and 1.7% before and after the change of protocol (p = 0.09). Reduction of dia- gnostic tests was associated with earlier antibiotic treat- ment in infants treated for suspected EOS (hazard ratio 1.58; 95% confidence interval [CI] 1.20-2.07; p <0.001), and in infants with neonatal infection (hazard ratio 2.20; 95% CI 1.19-4.06; p = 0.01). There was no difference in the duration of hospital stay nor in the proportion of infants requiring respiratory or cardiovascular support before and after the change of protocol. CONCLUSION: Reduction of diagnostic tests such as CBC and CRP does not delay initiation of antibiotic treat- ment in infants with suspected EOS. The importance of clinical examination in infants with risk factors for EOS should be emphasised.

Implication of different domains of the Leishmania major metacaspase in cell death and autophagy.

Metacaspases (MCAs) are cysteine peptidases expressed in plants, fungi and protozoa, with a caspase-like histidine-cysteine catalytic dyad, but differing from caspases, for example, in their substrate specificity. The role of MCAs is subject to debate: roles in cell cycle control, in cell death or even in cell survival have been suggested. In this study, using a Leishmania major MCA-deficient strain, we showed that L. major MCA (LmjMCA) not only had a role similar to caspases in cell death but also in autophagy and this through different domains. Upon cell death induction by miltefosine or H2O2, LmjMCA is processed, releasing the catalytic domain, which activated substrates via its catalytic dyad His/Cys and a proline-rich C-terminal domain. The C-terminal domain interacted with proteins, notably proteins involved in stress regulation, such as the MAP kinase LmaMPK7 or programmed cell death like the calpain-like cysteine peptidase. We also showed a new role of LmjMCA in autophagy, acting on or upstream of ATG8, involving Lmjmca gene overexpression and interaction of the C-terminal domain of LmjMCA with itself and other proteins. These results allowed us to propose two models, showing the role of LmjMCA in the cell death and also in the autophagy pathway, implicating different protein domains.

Caspase-mediated cleavage of raptor participates in the inactivation of mTORC1 during cell death.

The mammalian target of rapamycin complex 1 (mTORC1) is a highly conserved protein complex regulating key pathways in cell growth. Hyperactivation of mTORC1 is implicated in numerous cancers, thus making it a potential broad-spectrum chemotherapeutic target. Here, we characterized how mTORC1 responds to cell death induced by various anticancer drugs such rapamycin, etoposide, cisplatin, curcumin, staurosporine and Fas ligand. All treatments induced cleavage in the mTORC1 component, raptor, resulting in decreased raptor-mTOR interaction and subsequent inhibition of the mTORC1-mediated phosphorylation of downstream substrates (S6K and 4E-BP1). The cleavage was primarily mediated by caspase-6 and occurred at two sites. Mutagenesis at one of these sites, conferred resistance to cell death, indicating that raptor cleavage is important in chemotherapeutic apoptosis.