Liver disease in germline mutations of telomere-related genes: Prevalence, clinical, radiological, pathological features, outcome, and risk factors

BACKGROUND AND AIM

Germline mutations of telomere-related genes (TRG) induce multiorgan dysfunction, and liver-specific manifestations have not been clearly outlined. We aimed to describe TRG mutations-associated liver diseases.

APPROACH AND RESULTS

Retrospective multicenter analysis of liver disease (transaminases > 30 IU/L and/or abnormal liver imaging) in patients with TRG mutations. Main measurements were characteristics, outcomes, and risk factors of liver disease in a TRG mutations cohort. The prevalence of liver disease was compared to a community-based control group (n = 1190) stratified for age and matched 1:3 for known risk factors of liver disease. Among 132 patients with TRG mutations, 95 (72%) had liver disease, with associated lung, blood, skin, rheumatological, and ophthalmological TRG diseases in 82%, 77%, 55%, 39%, and 30% of cases, respectively. Liver biopsy was performed in 52/95 patients, identifying porto-sinusoidal vascular disease in 48% and advanced fibrosis/cirrhosis in 15%. After a follow-up of 21 months (12-54), ascites, hepato-pulmonary syndrome, variceal bleeding, and HCC occurred in 14%, 13%, 13%, and 2% of cases, respectively. Five-year liver transplantation-free survival was 69%. A FIB-4 score ≥ 3·25 and ≥1 risk factor for cirrhosis were associated with poor liver transplantation-free survival. Liver disease was more frequent in patients with TRG mutations than in the paired control group [80/396, (20%)], OR 12.9 (CI 95%: 7.8-21.3, p < 0.001).

CONCLUSIONS

TRG mutations significantly increase the risk of developing liver disease. Although symptoms may be mild, they may be associated with severe disease. Porto-sinusoidal vascular disease and cirrhosis were the most frequent lesions, suggesting that the mechanism of action is multifactorial.

High risk of lung cancer in surfactant-related gene variant carriers

BACKGROUND

Several rare surfactant-related gene (SRG) variants associated with interstitial lung disease are suspected to be associated with lung cancer, but data are missing. We aimed to study the epidemiology and phenotype of lung cancer in an international cohort of SRG variant carriers.

METHODS

We conducted a cross-sectional study of all adults with SRG variants in the OrphaLung network and compared lung cancer risk with telomere-related gene (TRG) variant carriers.

RESULTS

We identified 99 SRG adult variant carriers (SFTPA1 (n=18), SFTPA2 (n=31), SFTPC (n=24), ABCA3 (n=14) and NKX2-1 (n=12)), including 20 (20.2%) with lung cancer (SFTPA1 (n=7), SFTPA2 (n=8), SFTPC (n=3), NKX2-1 (n=2) and ABCA3 (n=0)). Among SRG variant carriers, the odds of lung cancer was associated with age (OR 1.04, 95% CI 1.01-1.08), smoking (OR 20.7, 95% CI 6.60-76.2) and SFTPA1/SFTPA2 variants (OR 3.97, 95% CI 1.39-13.2). Adenocarcinoma was the only histological type reported, with programmed death ligand-1 expression ≥1% in tumour cells in three samples. Cancer staging was localised (I/II) in eight (40%) individuals, locally advanced (III) in two (10%) and metastatic (IV) in 10 (50%). We found no somatic variant eligible for targeted therapy. Seven cancers were surgically removed, 10 received systemic therapy, and three received the best supportive care according to their stage and performance status. The median overall survival was 24 months, with stage I/II cancers showing better survival. We identified 233 TRG variant carriers. The comparative risk (subdistribution hazard ratio) for lung cancer in SRG patients versus TRG patients was 18.1 (95% CI 7.1-44.7).

CONCLUSIONS

The high risk of lung cancer among SRG variant carriers suggests specific screening and diagnostic and therapeutic challenges. The benefit of regular computed tomography scan follow-up should be evaluated.

Characterization of novel mutations in the TEL-patch domain of the telomeric factor TPP1 associated with telomere biology disorders

Telomeres are nucleoprotein structures that protect the chromosome ends from degradation and fusion. Telomerase is a ribonucleoprotein complex essential to maintain the length of telomeres. Germline defects that lead to short and/or dysfunctional telomeres cause telomere biology disorders (TBDs), a group of rare and heterogeneous Mendelian diseases including pulmonary fibrosis, dyskeratosis congenita, and Høyeraal-Hreidarsson syndrome. TPP1, a telomeric factor encoded by the gene ACD, recruits telomerase at telomere and stimulates its activity via its TEL-patch domain that directly interacts with TERT, the catalytic subunit of telomerase. TBDs due to TPP1 deficiency have been reported only in 11 individuals. We here report four unrelated individuals with a wide spectrum of TBD manifestations carrying either heterozygous or homozygous ACD variants consisting in the recurrent and previously described in-frame deletion of K170 (K170∆) and three novel missense mutations G179D, L184R, and E215V. Structural and functional analyses demonstrated that the four variants affect the TEL-patch domain of TPP1 and impair telomerase activity. In addition, we identified in the ACD gene several motifs associated with small deletion hotspots that could explain the recurrence of the K170∆ mutation. Finally, we detected in a subset of blood cells from one patient, a somatic TERT promoter-activating mutation that likely provides a selective advantage over non-modified cells, a phenomenon known as indirect somatic genetic rescue. Together, our results broaden the genetic and clinical spectrum of TPP1 deficiency and specify new residues in the TEL-patch domain that are crucial for length maintenance and stability of human telomeres in vivo.

Differential diagnosis of small hepatocellular nodules in cirrhosis: surrogate histological criteria of TERT promoter mutations

AIMS

The differential diagnosis of small hepatocellular nodules in cirrhosis between dysplastic nodules and hepatocellular carcinoma (HCC) remains challenging on biopsy. As TERT promoter (pTERT) mutations may indicate the nodules already engaged in the malignant process, the aim of this study was to identify histological criteria associated with pTERT mutations by detecting these mutations by ddPCR in small formalin-fixed paraffin-embedded (FFPE) hepatocellular nodules arising in cirrhosis.

METHODS AND RESULTS

We built a bicentric cohort data set of 339 hepatocellular nodules < 2 cm from cirrhotic samples, divided into a test cohort of 299 resected samples and a validation cohort of 40 biopsies. Pathological review, based on the evaluation of 14 histological criteria, classified all nodules. pTERT mutations were identified by ddPCR in FFPE samples. Among the 339 nodules, ddPCR revealed pTERT mutations in 105 cases (31%), including 90 and 15 cases in the test and validation cohorts, respectively. On multivariate analysis, three histological criteria were associated with pTERT mutations in the test cohort: increased cell density (P = 0.003), stromal invasion (P = 0.036) and plate-thickening anomalies (P < 0.001). With the combination of at least two of these major criteria, the AUC for predicting pTERT mutations was 0.84 in the test cohort (sensitivity: 86%, specificity: 83%) and 0.81 in the validation cohort (sensitivity: 87%, specificity: 76%).

CONCLUSIONS

We identified three histological criteria as surrogate markers of pTERT mutations that may be used in routine biopsy to more clearly classify small hepatocellular nodules arising in cirrhosis.

Meeting the reproductive health needs of female sex workers in Côte d'Ivoire: protecting the human right to dignified health

The sexual and reproductive health needs of female sex workers (FSW) are often understudied and underserved in the context of HIV-related research in countries across Sub-Saharan Africa and West Africa. We assessed the lived experiences of FSW across Côte d'Ivoire to characterize unmet reproductive health needs and opportunities to address them. From February-August, 2020, ENDA Santé, Côte d'Ivoire conducted 75 in-depth interviews and 15 focus group discussions with FSW and community informants in five cities in Côte d'Ivoire. Themes that emerged included the inconsistent use of contraception services, a history of unintended pregnancies, and experiences of stigma at public healthcare facilities. Opportunities to increase the impact of both SRH and HIV services included strengthening existing HIV and family planning service integration for FSW. Taken together, the results highlight the importance of addressing the unmet reproductive health needs of FSW to both optimize the HIV response and increase the delivery of human-rights affirming sexual and reproductive health services for sex workers.

Associations between punitive policies and legal barriers to consensual same-sex sexual acts and HIV among gay men and other men who have sex with men in sub-Saharan Africa: a multicountry, respondent-driven sampling survey

BACKGROUND

Few assessments of associations between structural-level factors and HIV among gay men and other men who have sex with men (MSM) have been conducted, especially in sub-Saharan Africa. Our objective was to examine HIV testing history, HIV status, and stigmas among MSM living in ten countries with heterogeneous legal environments.

METHODS

This study used pooled data from ten country-specific, cross-sectional studies done in 25 sites in Burkina Faso, Cameroon, Côte d'Ivoire, The Gambia, Guinea-Bissau, Nigeria, Senegal, Eswatini, Rwanda, and Togo. MSM were recruited by respondent-driven sampling and were eligible if they met country-specific requirements for age, area of residence, and self reported being assigned male sex at birth and having anal sex with a man in the past 12 months. Policy related to same-sex sexual behaviour for each country was categorised as not criminalised or criminalised. Countries were also categorised on the basis of recent reports of prosecutions related to same-sex sexual acts. Legal barriers were defined as those that legally prevented registration or operation of sexual orientation related civil society organisations (CSOs). Individual data on HIV testing history, HIV status, and stigma were collected via interviewer-administered sociobehavioural questionnaires and HIV testing. Multilevel logistic regression with random intercepts was used to assess the association between policies, recent prosecutions, legal barriers to CSOs, and HIV-related factors with adjusted odds ratios (aORs) and 95% CIs.

FINDINGS

Between Aug 3, 2011, and May 27, 2020, we recruited 8047 MSM with a median age of 23 years (IQR 21-27). 4886 (60·7%) lived in countries that criminalise same-sex sexual acts. HIV prevalence among MSM was higher in criminalised settings than non-criminalised settings (aOR 5·15, 95% CI 1·12-23·57); higher in settings with recent prosecutions than in settings without prosecutions (12·06, 7·19-20·25); and higher in settings with barriers to CSOs than without barriers to CSOs (9·83, 2·00-48·30). HIV testing or status awareness was not associated with punitive policies or practices. Stigma was associated with HIV status but did not consistently vary across legal environments. Disparities in HIV prevalence between MSM and other adult men were highest in punitive settings.

INTERPRETATION

Structural risks including discriminatory country-level policies, prosecutions, and legal barriers might contribute to higher HIV prevalence among MSM. Taken together, these data highlight the importance of decriminalisation and decreasing enforcement, alongside stigma reduction, as central to effective control for HIV.

FUNDING

National Institutes of Health.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Simplex Droplet Digital PCR Assays for the Detection of TERT Promoter Mutations in Urine Samples for the Non-invasive Diagnosis of Urothelial Cancer

Somatic mutations in the telomerase reverse transcriptase (TERT) promoter region are highly frequent in urothelial cancer (UC), and their detection in urine (cell-free DNA from the urine supernatant or DNA from exfoliated cells in the urine pellet) has demonstrated promising evidence as putative non-invasive biomarkers for UC detection and monitoring. However, detecting these tumour-derived mutations in urine requires highly sensitive methods, capable of measuring low-allelic fraction mutations. We developed sensitive droplet digital PCR (ddPCR) assays for detecting urinary TERT promoter mutations (uTERTpm), targeting the two most common mutations (C228T and C250T), as well as the rare A161C, C228A, and CC242-243TT mutations. Here, we described the step-by-step protocol uTERTpm mutation screening using simplex ddPCR assays and give some recommendations for isolation of DNA from urine samples. We also provide limits of detection for the two most frequent mutations and discuss advantages of the method for clinical implementation of the assays for the detection and monitoring of UC.

Genetics in Idiopathic Pulmonary Fibrosis: A Clinical Perspective

BACKGROUND

Unraveling the genetic background in a significant proportion of patients with both sporadic and familial IPF provided new insights into the pathogenic pathways of pulmonary fibrosis.

AIM

The aim of the present study is to overview the clinical significance of genetics in IPF.

PERSPECTIVE

It is fascinating to realize the so-far underestimated but dynamically increasing impact that genetics has on aspects related to the pathophysiology, accurate and early diagnosis, and treatment and prevention of this devastating disease. Genetics in IPF have contributed as no other in unchaining the disease from the dogma of a "a sporadic entity of the elderly, limited to the lungs" and allowed all scientists, but mostly clinicians, all over the world to consider its many aspects and "faces" in all age groups, including its co-existence with several extra pulmonary conditions from cutaneous albinism to bone-marrow and liver failure.

CONCLUSION

By providing additional evidence for unsuspected characteristics such as immunodeficiency, impaired mucus, and surfactant and telomere maintenance that very often co-exist through the interaction of common and rare genetic variants in the same patient, genetics have created a generous and pluralistic yet unifying platform that could lead to the understanding of the injurious and pro-fibrotic effects of many seemingly unrelated extrinsic and intrinsic offending factors. The same platform constantly instructs us about our limitations as well as about the heritability, the knowledge and the wisdom that is still missing.

TERT Promoter Mutations as Simple and Non-Invasive Urinary Biomarkers for the Detection of Urothelial Bladder Cancer in a High-Risk Region

Bladder cancer (BC) is the 10th most common cancer in the world. While there are FDA-approved urinary assays to detect BC, none have demonstrated sufficient sensitivity and specificity to be integrated into clinical practice. Telomerase Reverse Transcriptase (TERT) gene mutations have been identified as the most common BC mutations that could potentially be used as non-invasive urinary biomarkers to detect BC. This study aims to evaluate the validity of these tests to detect BC in the Kerman province of Iran, where BC is the most common cancer in men. Urine samples of 31 patients with primary (n = 11) or recurrent (n = 20) bladder tumor and 50 controls were prospectively collected. Total urinary DNA was screened for the TERT promoter mutations (uTERTpm) by Droplet Digital PCR (ddPCR) assays. The performance characteristics of uTERTpm and the influence by disease stage and grade were compared to urine cytology results. The uTERTpm was 100% sensitive and 88% specific to detect primary BC, while it was 50% sensitive and 88% specific in detecting recurrent BC. The overall sensitivity and specificity of uTERTpm to detect bladder cancer were 67.7% and 88.0%, respectively, which were consistent across different tumor stages and grades. The most frequent uTERTpm mutations among BC cases were C228T (18/31), C250T (4/31), and C158A (1/31) with mutant allelic frequency (MAF) ranging from 0.2% to 63.3%. Urine cytology demonstrated a similar sensitivity (67.7%), but lower specificity (62.0%) than uTERTpm in detecting BC. Combined uTERTpm and urine cytology increased the sensitivity to 83.8%, but decreased the specificity to 52.0%. Our study demonstrated promising diagnostic accuracy for the uTERTpm as a non-invasive urinary biomarker to detect, in particular, primary BC in this population.

[Telomeres and lung]

Genetic studies of familial forms of interstitial lung disease (ILD) have led to the discovery of telomere-related gene (TRG) mutations (TERT, TERC, RTEL1, PARN, DKC1, TINF2, NAF1, NOP10, NHP2, ACD, ZCCH8) in approximately 30% of familial ILD forms. ILD patients with TRG mutation are also subject to extra-pulmonary (immune-hematological, hepatic and/or mucosal-cutaneous) manifestations. TRG mutations may be associated not only with idiopathic pulmonary fibrosis (IPF), but also with non-IPF ILDs, including idiopathic and secondary ILDs, such as hypersensitivity pneumonitis (HP). The presence of TRG mutation may also be associated with an accelerated decline of forced vital capacity (FVC) or poorer prognosis after lung transplantation, notwithstanding which, usual ILD treatments may be proposed. Lastly, patients and their relatives are called upon to reduce their exposure to environmental lung toxicity, and are likely to derive benefit from specific genetic counseling and pre-symptomatic genetic testing.

Determinants of survival after lung transplantation in telomerase-related gene mutation carriers: A retrospective cohort

Carriers of germline telomerase-related gene (TRG) mutations can show poor prognosis, with an increase in common hematological complications after lung transplantation (LT) for pulmonary fibrosis. The aim of this study was to describe the outcomes after LT in recipients carrying a germline TRG mutation and to identify the predictors of survival. In a multicenter cohort of LT patients, we retrospectively reviewed those carrying pathogenic TRG variations (n = 38; TERT, n = 23, TERC, n = 9, RTEL1, n = 6) between 2009 and 2018. The median age at LT was 54 years (interquartile range [IQR] 46-59); 68% were male and 71% had idiopathic pulmonary fibrosis. During the diagnosis of pulmonary fibrosis, 28 (74%) had a hematological disease, including eight with myelodysplasia. After a median follow-up of 26 months (IQR 15-46), 38 patients received LT. The overall post-LT median survival was 3.75 years (IQR 1.8-NA). The risk of death after LT was increased for patients with myelodysplasia (HR 4.1 [95% CI 1.5-11.5]) or short telomere (HR 2.2 [1.0-5.0]) before LT. After LT, all patients had anemia, 66% had thrombocytopenia, and 39% had neutropenia. Chronic lung allograft dysfunction frequency was 29% at 4 years. The present findings support the use of LT in TRG mutation carriers without myelodysplasia. Hematological evaluation should be systematically performed before LT.

Genotype-Phenotype Relationships in Inheritable Idiopathic Pulmonary Fibrosis: A Greek National Cohort Study

BACKGROUND

Monogenic and polygenic inheritances are evidenced for idiopathic pulmonary fibrosis (IPF). Pathogenic variations in surfactant protein-related genes, telomere-related genes (TRGs), and a single-nucleotide polymorphism in the promoter of MUC5B gene encoding mucin 5B (rs35705950 T risk allele) are reported. This French-Greek collaborative study, Gen-Phen-Re-GreekS in inheritable IPF (iIPF), aimed to investigate genetic components and patients' characteristics in the Greek national IPF cohort with suspected heritability.

PATIENTS AND METHODS

150 patients with familial PF, personal-family extrapulmonary disease suggesting short telomere syndrome, and/or young age IPF were analyzed.

RESULTS

MUC5B rs35705950 T risk allele was detected in 103 patients (90 heterozygous, 13 homozygous, allelic frequency of 39%), monoallelic TRG pathogenic variations in 19 patients (8 TERT, 5 TERC, 2 RTEL1, 2 PARN, 1 NOP10, and 1 NHP2), and biallelic ABCA3 pathogenic variations in 3. Overlapping MUC5B rs35705950 T risk allele and TRG pathogenic variations were shown in 11 patients (5 TERT, 3 TERC, 1 PARN, 1 NOP10, and 1 NHP2), MUC5B rs35705950 T risk allele, and biallelic ABCA3 pathogenic variations in 2. In 38 patients, neither MUC5B rs35705950 T risk allele nor TRG pathogenic variations were detectable. Kaplan-Meier curves showed differences in time-to-death (p = 0.025) where patients with MUC5B rs35705950 T risk allele alone or in combination with TRG pathogenic variations presented better prognosis.

CONCLUSION

The Gen-Phen-Re-GreekS in iIPF identified multiple and overlapping genetic components including the rarest, underlying disease's genetic "richesse," complexity and heterogeneity. Time-to-death differences may relate to diverse IPF pathogenetic mechanisms implicating "personalized" medical care driven by genotypes in the near future.

Interstitial lung diseases associated with mutations of poly(A)-specific ribonuclease: A multicentre retrospective study

BACKGROUND AND OBJECTIVE

Poly(A)-specific ribonuclease (PARN) mutations have been associated with familial pulmonary fibrosis. This study aims to describe the phenotype of patients with interstitial lung disease (ILD) and heterozygous PARN mutations.

METHODS

We performed a retrospective, observational, non-interventional study of patients with an ILD diagnosis and a pathogenic heterozygous PARN mutation followed up in a centre of the OrphaLung network.

RESULTS

We included 31 patients (29 from 16 kindreds and two sporadic patients). The median age at ILD diagnosis was 59 years (range 54 to 63). In total, 23 (74%) patients had a smoking history and/or fibrogenic exposure. The pulmonary phenotypes were heterogenous, but the most frequent diagnosis was idiopathic pulmonary fibrosis (n = 12, 39%). Haematological abnormalities were identified in three patients and liver disease in two. In total, 21 patients received a specific treatment for ILD: steroids (n = 13), antifibrotic agents (n = 11), immunosuppressants (n = 5) and N-acetyl cysteine (n = 2). The median forced vital capacity decline for the whole sample was 256 ml/year (range -363 to -148). After a median follow-up of 32 months (range 18 to 66), 10 patients had died and six had undergone lung transplantation. The median transplantation-free survival was 54 months (95% CI 29 to ∞). Extra-pulmonary features were less frequent with PARN mutation than telomerase reverse transcriptase (TERT) or telomerase RNA component (TERC) mutation.

CONCLUSION

IPF is common among individuals with PARN mutation, but other ILD subtypes may be observed.

Disclosure of same-sex practices and experiences of healthcare stigma among cisgender men who have sex with men in five sub-Saharan African countries

BACKGROUND

For men who have sex with men (MSM) across sub-Saharan Africa (SSA), disclosure of same-sex practices to family and healthcare workers (HCWs) can facilitate access to HIV prevention services and support, but can also lead to experiences of stigma.

METHODS

We performed mixed-effects regressions on pooled data from MSM in Cameroon, Senegal, Côte d'Ivoire, Lesotho, and eSwatini to assess associations between disclosure and sexual behavior stigma in healthcare contexts; we used logistic regressions to analyze country-specific data.

RESULTS

Compared to participants who had not disclosed to either family or HCWs, those who had disclosed only to family were more likely to have been gossiped about by HCWs (aOR = 1.70, CI = 1.18, 2.45); the association between having disclosed to family and having felt mistreated in a health center approached, but did not achieve, statistical significance (aOR = 1.56, CI = 0.94, 2.59). Those who had disclosed only to HCWs were more likely to have feared to seek health services (aOR = 1.60, CI = 1.14, 2.25), avoided health services (aOR = 1.74, CI = 1.22, 2.50), and felt mistreated in a health center (aOR = 2.62, CI = 1.43, 4.81). Those who had disclosed to both were more likely to have feared to seek health services (aOR = 1.71, CI = 1.16, 2.52), avoided health services (aOR = 1.59, CI = 1.04, 2.42), been gossiped about by HCWs (aOR = 3.78, CI = 2.38, 5.99), and felt mistreated in a health center (aOR = 3.39, CI = 1.86, 6.20). Country-specific analyses suggested that data from Cameroon drove several of these associations.

CONCLUSIONS

Research to determine the factors driving disclosure's differential effect on healthcare stigma across contexts is needed. Ultimately, supportive environments enabling safe disclosure is critical to understanding HIV-acquisition risks and informing differentiated HIV-prevention, treatment, and testing services for MSM across SSA.

NHP2 deficiency impairs rRNA biogenesis and causes pulmonary fibrosis and Høyeraal-Hreidarsson syndrome

Telomeres are nucleoprotein structures at the end of chromosomes. The telomerase complex, constituted of the catalytic subunit TERT, the RNA matrix hTR and several cofactors, including the H/ACA box ribonucleoproteins Dyskerin, NOP10, GAR1, NAF1 and NHP2, regulates telomere length. In humans, inherited defects in telomere length maintenance are responsible for a wide spectrum of clinical premature aging manifestations including pulmonary fibrosis (PF), dyskeratosis congenita (DC), bone marrow failure and predisposition to cancer. NHP2 mutations have been so far reported only in two patients with DC. Here, we report the first case of Høyeraal-Hreidarsson syndrome, the severe form of DC, caused by biallelic missense mutations in NHP2. Additionally, we identified three unrelated patients with PF carrying NHP2 heterozygous mutations. Strikingly, one of these patients acquired a somatic mutation in the promoter of TERT that likely conferred a selective advantage in a subset of blood cells. Finally, we demonstrate that a functional deficit of human NHP2 affects ribosomal RNA biogenesis. Together, our results broaden the functional consequences and clinical spectrum of NHP2 deficiency.

[Ensuring continuity of care at the time of COVID-19: challenges for the Dakar Integrated Support Center for Addictions]

The COVID-19 pandemic has an impact on health systems, whose modes of adaptation and response on the ground are still poorly documented and are evolving. The Dakar Integrated Support Center for Addictions (CEPIAD) has been implementing risk reduction since 2014, particularly with drug users. The COVID-19 pandemic and related public health measures were an obstacle to its attendance by patients, in particular due to movement restriction. In addition to the implementation of individual and collective preventive measures in the center, CEPIAD has experimented "take-home" for methadon that is generally provided daily through directly observed treatment. The center has also taken care of amnestied incarcerated cannabis users. Several aspects of this experience, perceived positively, could be relevant outside the pandemic context.

Intersectional stigmas and HIV-related outcomes among a cohort of key populations enrolled in stigma mitigation interventions in Senegal

OBJECTIVES

The current study aims to assess longitudinal differences in stigma and HIV outcomes among key populations at risk for and living with HIV.

DESIGN

Key populations enrolled into two parallel prospective cohorts; one for female sex workers and one for sexual and gender minorities (SGMs). Participants were recruited from three urban areas in Senegal; were followed for 24 months; and had the option to participate in an integrated stigma mitigation intervention.

METHODS

Participants included individuals both at risk for and living with HIV. Sociobehavioral questionnaires and biological HIV testing were administered every 3-4 months. Longitudinal analyses used nonparametric Chi-squared test for trends and multivariable logistic regression with generalized estimating equations.

RESULTS

183 SGM and 192 sex workers were enrolled. Among SGM participants, 39.9% were living with HIV at baseline and incidence over 24 months was 3.21/100 person-years. Among sex workers, 36.6% were living with HIV at baseline and incidence was 1.32/100 person-years. Among SGM, perceived healthcare stigma (P < 0.001), anticipated healthcare stigma (P < 0.001), and perceived friend stigma (P = 0.047) reduced, but differed by HIV status for perceived [adjusted odds ratio (aOR): 3.51; 95% confidence interval (CI): 1.75, 7.06] and anticipated healthcare stigmas (aOR: 2.85; 95% CI: 1.06-7.67). Among sex workers perceived healthcare stigma (P = 0.043) and perceived friend stigma (P = 0.006) reduced. Viral suppression increased among SGM (P = 0.028) and was associated with perceived (aOR: 2.87; 95% CI: 1.39-5.55) and enacted healthcare stigma (aOR: 0.42; 95% CI: 0.18-0.99).

CONCLUSION

Overall, there were decreases in stigmas observed but clear differences in stigma patterns by HIV status. These data highlight the need to consider specific strategies to address multiple intersecting stigmas as a means of improving HIV-related prevention and treatment outcomes among key populations with diverse identities.

Characterizing social cohesion and gender identity as risk determinants of HIV among cisgender men who have sex with men and transgender women in Côte d'Ivoire

PURPOSE

HIV prevalence has been previously estimated among cisgender men who have sex with men (MSM) in Côte d'Ivoire; however, limited data exist relating to the role of social cohesion and gender identity within this population. This study aims to examine these factors as risk determinants of HIV among MSM in Côte d'Ivoire.

METHODS

We conducted a cross-sectional study using respondent-driven sampling for recruitment with a structured sociobehavioral instrument and testing for HIV. After respondent-driven sampling adjustment, chi-squared tests and bivariate logistic regression and multivariate logistic regression analyses were performed to characterize social and identity-based risk determinants of biologically confirmed prevalent HIV infection.

RESULTS

HIV prevalence was 11.2% (n = 146/1301). Transgender woman identity was associated with higher odds of HIV compared with cisgender MSM (aOR = 3.4, 95% CI [2.0-5.8], P < .001). Having a combined social cohesion score of medium (aOR = 0.4, 95% CI [0.2-0.8], P < .01) or high (aOR = 0.2, 95% CI [0.1-0.3], P < .001) was associated with lower odds of HIV compared with a low score.

CONCLUSION

These data suggest that social cohesion is a determinant of prevalent HIV infection in Côte d'Ivoire among gay men, other cisgender MSM, and transgender women. The differences in HIV burden and social cohesion between transgender women and cisgender MSM highlight the need to better target the diversity of people traditionally included in the MSM umbrella to ensure comprehensive HIV prevention and treatment interventions.

Pilot experience of multidisciplinary team discussion dedicated to inherited pulmonary fibrosis

Background

Genetic testing is proposed for suspected cases of monogenic pulmonary fibrosis, but clinicians and patients need specific information and recommendation about the related diagnosis and management issues. Because multidisciplinary discussion (MDD) has been shown to improve accuracy of interstitial lung disease (ILD) diagnosis, we evaluated the feasibility of a genetic MDD (geneMDD) dedicated to the indication for and interpretation of genetic testing. The geneMDD group met monthly and included pediatric and adult lung specialists with ILD expertise, molecular and clinical geneticists, and one radiologist. Hematologists, rheumatologists, dermatologists, hepatologists, and pathologists were also invited to attend.

Results

Since 2016, physicians from 34 different centers in 7 countries have participated in the geneMDD. The medical files of 95 patients (53 males) have been discussed. The median age of patients was 43 years [range 0–77], 10 were ≤ 15 years old, and 6 were deceased at the time of the discussion. Among 85 analyses available, the geneMDD considered the rare gene variants pathogenic for 61: 37 variants in telomere-related genes, 23 variants in surfactant-related genes and 1 variant in MARS. Genetic counseling was offered for relatives of these patients. The geneMDD therapeutic proposals were as follows: antifibrotic drugs (n = 25), steroids or immunomodulatory therapy (n = 18), organ transplantation (n = 21), watch and wait (n = 21), or best supportive care (n = 4).

Conclusion

Our experience shows that a dedicated geneMDD is feasible regardless of a patient’s age and provides a unique opportunity to adapt patient management and therapy in this very rare condition.

Sexual behavior stigma and depression among transgender women and cisgender men who have sex with men in Côte d'Ivoire

PURPOSE

Transgender women (TGW) and cisgender men who have sex with men (cisMSM) across sub-Saharan Africa experience health inequalities relative to other adults. Recent research has also revealed health inequalities between these often-conflated groups. Among TGW and cisMSM in Côte d'Ivoire, we sought to determine whether transgender female identity was associated with probable depression, and whether sexual behavior stigma mediated this association.

METHODS

In 2015-2016, a cross-sectional respondent-driven sampling survey of adult TGW and cisMSM was conducted across five cities. We conducted a three-way decomposition of mediation and interaction of gender identity and sexual behavior stigma. Depression was measured by the nine-item Patient Health Questionnaire (PHQ-9).

RESULTS

Of 1301 participants, 339 (26.1%) were TGW. The prevalence of probable depression was 22.7% among TGW and 12.2% among cisMSM (P < .001). After confounder adjustment, the relative risk of depression attributable to transgender female gender identity was 1.68 (95% CI = 1.36, 2.00) with 69.9% (95% CI = 42.6, 97.1) of this effect mediated by sexual behavior stigma. The effect of stigma on depression did not differ significantly by gender.

CONCLUSIONS

These data suggest that stigma mitigation interventions specifically addressing the stigma affecting transgender women may also address mental health inequalities between transgender women and cisMSM in Côte d'Ivoire.

Usefulness of Dried Blood Spots (DBS) to perform hepatitis C virus genotyping in drug users in Senegal

The aim of this pilot study was to analyze the Hepatitis C Virus (HCV) genotypes circulating in Senegal among Drug User (DUs), using Dried Blood Spots (DBS) as RNA source for molecular assays. Heroin and/or cocaine users (n = 506) were recruited in Dakar from April to July 2011, using a Respondent Driven Sampling (RDS) method. DBS preparation consisted of five drops of whole blood from finger applied to a Whatman paper card. HCV infection was screened by the detection of anti-HCV antibodies, using a rapid immune-chromatographic test. HCV RNA was quantified on anti-HCV positive DBS, using the Abbott RealTime HCV® Genotyping was performed on DBS with detectable viral load with Versant® HCV Genotype 2.0 Assay (LiPA) and Abbott RealTime HCV Genotype II assay®. Among the 506 participants, 120 were tested as positive for anti-HCV antibodies and their samples were analyzed for HCV RNA viral load and genotype. Out of the 120 DBS tested, HCV RNA was detected on 25 (20.8%). The median viral load was 15,058 IU/ml (ranging from 710 to 766,740 IU/ml). All positive DBS were suitable for the genotyping assay, that showed a predominance of genotype 1 (21/25) including 16 genotypes 1a and 5 genotypes 1b. HCV genotype 1 prevails in a DU population in Dakar. DBS could be useful for HCV RNA genotyping, but optimal storage conditions should required avoiding RNA impairment. Acknowledging this limitation, DBS could be a great interest for detecting and genotyping HCV viremic patients. J. Med. Virol. 89:484-488, 2017. © 2015 Wiley Periodicals, Inc.

A novel HLA-B*37 allele, HLA-B*37:58, identified in a Turkish family

New allele HLA-B*37:58 differs from HLA-B*37:01:01 by one nucleotide at position 449 in exon 2.

Mutations in the maternally imprinted gene MKRN3 are common in familial central precocious puberty

CONTEXT AND OBJECTIVE

Idiopathic central precocious puberty (iCPP) is defined as early activation of the hypothalamic-pituitary-gonadal axis in the absence of identifiable central lesions. Mutations of the makorin RING finger 3 (MKRN3) gene are associated with iCPP. We aimed to assess the frequency of MKRN3 mutations in iCPP and to compare the phenotypes of patients with and without MKRN3 mutations.

DESIGN

An observational study was carried out on patients recruited at pediatric hospitals in France and Italy. Forty-six index CPP cases were screened for mutations in the MKRN3 coding sequence: 28 index cases of familial cases and 18 cases did not report any familial history of CPP. The endocrine phenotype was compared between MKRN3 mutated and non-mutated patients.

RESULTS

MKRN3 mutations were identified in one sporadic and 13 familial cases. We identified five new heterozygous missense mutations predicted to be deleterious for protein function and two frameshift mutations, one new and the other recurrent, predicted to result in truncated proteins. Age at puberty onset varied very little among patients with MKRN3 mutations and puberty occurred earlier in these patients than in those without MKRN3 mutations (6.0 years (5.4-6.0) vs 7.0 years (6.0-7.0), P=0.01).

CONCLUSIONS

MKRN3 mutations are common in familial iCPP. MKRN3 is one of the gatekeepers of the postnatal activation of the gonadotropic axis.

[Clinical and psychopathological postpartum depression: eleven Senegalese cases report]

INTRODUCTION

The postpartum depression is a frequent puerperium psychiatric disorder. The authors study the clinical, therapeutic and evolutionary aspects of the postpartum depression among eleven Senegalese women.

MATERIAL AND METHOD

They examined the medical reports and hospital registers of eleven patients belonging to a sample of 52 women presenting psychic disorders of the puerperality. The diagnosis was made by using the International Classification of the Diseases.

RESULTS

The symptoms of depression were irritability, bad concentration, multiple somatic complaints, of insomnia of drowsiness, loss of the usual interests. All the patients profited from psychotherapy and have received chemotherapy with antidepressant treatment associated tranquillizing in six cases. They improved from 29 to 43 days after their admission.

CONCLUSION

The pregnancy and the childbirth, the parity, personal history of the patient, their social environment and the cultural representations of maternity are factors of depression of the postpartum. The antidepressant is always essential in the treatment.

[Caries patterns and diet in early childhood caries]

INTRODUCTION

Early childhood caries (EEC) are multiple carious lesions affecting the primary teeth of infants and preschool children. They are related to a prolonged and night bottle-feeding rich in fermentable carbohydrates. The carious lesions characterised by their patterns and the rapidity of their process can lead to a widespread tooth destruction. The aim of this study was to evaluate the patterns of the carious lesions and their relationship to the diet.

MATERIAL AND METHOD

This prospective study was carried out in Dakar in public heath structures that have a dental office. It has included 68 children of both sex aged from two to 6 years consisted of 35 boys (51% of the sample) and 33 girls (49%) with the predominance of the 5-year-old children. These children were examined using a plan mouth mirror and probes and their mothers were interviewed.

RESULTS

The observed carious lesions were distributed on all tooth surfaces but the complete coronal destruction was the most common lesions observed and represented 25 of the lesions, followed by lesions in three faces of the tooth (17%). The most frequently affected tooth was the association maxillar incisors and molars and the mandibular molars (32.4%). The incisor alone represented 22.1% of the affected teeth. The children were breast-fed associated with either pap or with hard food (52.9%). The bottle was added to this association in 32.4% of the cases and 10% of the children were exclusively breast-fed. The carious lesions were more severe and more frequent in children fed with breast associated with pap and hard food and in those fed with breast associated with the bottle pap and food than to children exclusively breast-fed. These differences were not statistically significant (p = 0.73 > 0.05).

CONCLUSIONS

Early childhood caries are related to a diet rich in carbon hydrate. They lead to severe tooth destruction. The treatments cost are very high thus prevention by information on the bad effects of sugar on diet and the baby bottle are of great interest.

[Study of fear of dental treatments in pediatrics in Sénegal]

Fear and anxiety of dental treatment have been recognized as a major source of a problems in pediatric dentistry. They can prevent dental procedure and lead to avoidance an dental phobia. A variaty of studies, using psychometric methods have been carried out worldwide to evaluate these behavious. In Senegal, no study of this nature has been done yet. The aim of this study was to evaluate fear and anxiety related to dental care in senegaleese pediatric children living in Dakar. We have used the children's Fear survey Schedule Dental Sb scale (CFSS-DS) in 415 senegalese children of both sex with a age anking from 7 to 15 years. The results showed a mean score of 33.222 +/- 11.162. Girls revealed a significant higher score (35.122 +/- 11.692) than boys (29.168 +/- 9.704) (p < 0.05). These mean score increase with age in both boys than girl. In addition, more than 43.5% of the children have never consulted a dentist previously and 28% among them showed fear of the dentist. 17% of the children who have dental experiences showed fear of the dentist. This study has showed that senegalease children revealed fear of the dental care even those who have never been to a dentist. It also point out the problem of the origine of dental fear in children.

[Evaluation of oral health and access to care in senegalese children with Down syndrome: preliminary study]

Down syndrom is the most frequent genetic disease discribed for viable (live born) children and the commonest cause of mental deficiency in developed countries. It is an autosomal chromosomic anomaly resulting from trisomy of all or part of chromosome 21 and is characterizd by general and mental deficiencies and a typical facial phenotype. The aims of this study are:--to evaluate the general and oral health of a senegalese group of children with Down syndrome and their siblings the closest in age,--to assess their access to care. We used the OADS (Oral Assessment Down Syndrome) questionnaire in 25 senegalese children with Down syndrome living in Dakar and 17 od their siblings the closest in age. Their ages range from 4 to 20 years old in both groups. Our results revealed that senegalese children with Down syndrome have more general and oral health problems compared to their siblings the closest in age but they were more likely to have difficulty finding both medical and dental services. This study pointed out the need for special care services with trained people for a better management of these specific patients.

[The health of the child during eruption of the deciduous teeth]

Teething is a physiological process that may be marked by local regional or general physiopathologies. We have studied these disorders in a sample of 499 children whom we followed from the age of 5 until the age of 30 months. The study consisted in a clinical endobuccal examination. Each month we recorded the order and the eruption date of the tooth or teeth and the disturbances that arise during the process or after, if any. We expose the results of this study in this paper. We collected local and general disturbances during the primary teeth eruption period. We considered that in certain conditions these disturbances could be to the eruption process. Teething is certainly a natural process, however considering its traumatic impact on the young child, we should not reject the aetiology in the justification of the disturbances observed in this process and seek another one which might not be valid.

[Dental cellulitis in children. Realities and perspectives in Senegal]

Cellulitises originated from teeth are frequent in developing countries. Theyare noted as well as in child as in adult. In child, causal tooth may be primary or permanent. In a prospective trial carried at Hôpital d'Enfants Albert Royer CHU-Fann, where we studied the frequency of cellulitises among the children, the main patterns of dental affections and the causal teeth involved and, in the same way, the management and prevention of these diseases in child. We noted that: 56.52% of the cases of cellulitises recorded interest the child of pediatric dentistry age and that 87.5% of the cellulitises cases are due to a primary tooth (primary molar overall) and first permanent molar necrosis. Management and prevention of cellulitises are based on: the respect of the therapeutic protocol, dental hygiene education and systematization of setting of dental caries preventive clinical procedures like SEALANTS and stainless steel crowns as well as in primaryand permanent dentition with as main target the primary molars and the first permanent molar or 6 years age tooth.

[Clinical study of alveolites and their treatment in multiple practice]

The alvéolite is an post-extractionnel accident, very frequent, unforeseeable, characterized by a deterioration of the physiological process of formation of the clot and occurring as well at the healthy subject at the degenerate. The objective of this work is to make an exploratory study on the cases of alvéolites which have occurred in three structures of odontological care in Dakar between October 2000 and June 2001. We studied the clinical and therapeutic aspects alveolites among 55 patients having undergone 168 extractions. On the whole 68 cases of alveolites were indexed including 18 suppurées forms and 50 dry forms. The alveolite was occured among 44 women and 11 men and the section of age which most touched ranges between 20 and 29 ans (51 %). The evoked factors etiologic are multiples(taken oral contraceptives, use of vasoconstricteurs. technical of extraction etc?). The treatment is local by type of antiseptic paste and general with base of antibiotic, antiseptic and anti-inflammatory. We don't have real coding of the treatment. The prevention remains the best attitude and consists with: - To carry out the acte operational with a rigorous asepsis - To avoid the inopportune instrumental traumatisms - To Irrigate the bone in permnance during the utilisation of rotary instruments.

Oro-dental and craniofacial anomalies in LEOPARD syndrome

'LEOPARD syndrome' is a syndrome affecting many systems or organs. The main anomalies are summarized in the acronym LEOPARD in which each letter corresponds to the damage of a given organ. In the presented case, there are oro-dental and craniofacial anomalies. The relationship between the LEOPARD syndrome and the given anomalies and the possibilities of the management and the follow-up of the diseased are studied. The clinical case presented is a 4-year-old boy with LEOPARD syndrome showing retardation of dental development, delayed development and possible agenesis of permanent teeth, and craniofacial anomalies (osseous hypodevelopment). The bibliographical study shows that LEOPARD syndrome is due to damage of the neural crest cells. Thus, the dental and craniofacial anomalies arise since neural crest cells participate in the formation of the teeth and some craniofacial bones. Therefore, dental and craniofacial anomalies might be expected in some cases of the disease. The therapeutic management of the lesions, and the follow-up of the patient would be done by a multidisciplinary team.

[Chronology and date of eruption of primary teeth in Senegal]

Chronology and eruption dates of primary teeth are parameters of importance in different medical scientific fields. We carried a longitudinal clinical study to determine these parameters in a local Senegalese population. The study interests a sample of 573 Senegalese Negro children of the two sexes and its aims are to situate these parameters formally and in space in on hand, and to be able to justify; in comparison to these parameters, the disturbances which accompany often the phenomenon of dental eruption in the other hand. We have results relating to chronology and eruption date of the 20 primary teeth of each of the children. Our study strengthens data already known but it reveals also other data as well as important. Other studies are however necessary to set a good board of chronology and eruption date of primary teeth in the Senegalese population.

[Complications of injuries to the deciduous teeth. Clinical and radiographic evaluation. Perspectives on management and prevention. Apropos of 4 cases]

The traumatisms of primary teeth have often sequels thereabouts grave on the germs of their successional permanent teeth. They have many causes but they are above all frequent during the child's walking trial. We have carried out a clinical and radiographic study of some cases. The study has ascertained the fact that the diversity of the sequels and their gravity depend on the age of the occurring of the traumatism, the intensity and the direction of the shock. The therapeutic and preventive management of these traumatisms and their possible sequels use a pluridisciplinary protocol based on the strict application of indicated treatments, the clinical and radiographic regular follow up and the adoption of a rigorous preventive attitude by the parents during the target period of walking trial.

[Application of phytotherapy in odontology: the case of Euphorbia balsamifera. Endodontic clinical trial]

Phytotherapy is a medicinal and ancestral practice in Africa. It deals with all the fields of human pathology. We wanted to ascertain the efficacy of some plants used in odontology as Euphorbia balsamifera traditionally used as antalgic treatment of acute dental pulpitis. The latex of the plant was caught and treated as to get enough stable paste. We used that paste in the same conditions we use arsenical nerve caustics, a pulpal devitalizer widely used in dental offices. The study carried out on 37 teeth has shown that latex of Euphorbia balsamifera is an effective pulpal devitalizing in contact with the pulp. Its lifetime action was comparable to that of the pulpal nerve caustics. The active principles are not known, however the product seems attractive as a pulpal devitalizing agent.

[Surgical dentistry and geriatrics in Senegal]

INTRODUCTION

Geriatric medicine is developing more and more as a specialism. Odontology is not behindhand. That is why, even in an African setting, when life expectancy is still not as high as in the West, we are finding ourselves treating older and older patients.

MATERIALS AND METHODS

During the course of the academic year 1989-1990, we treated 40 patients of both sexes, of different ethnic and social backgrounds aged from 55-89 years. Besides age, the patients had all undergone endo-buccal surgery, with the exception of parodontology surgery. According to sex: The forty patients comprised 27 men and 13 women. These figures are interesting and we will return to them during the discussion. According to age: The ages of our patients ranged from 55-89 years, with an average of 72. The distribution of age brackets shows a strong percentage (52.5%) of patients between 55 and 64 years of age. According to oral stage: In general, our patients neglect oral hygiene: 67.5% presented at least tartaric gingivitis. This negligence was evident in more men than women. According to general state: More than half the sample had at least one general pathological disorder. They ranged from cardio-vascular ailments, to differing digestive disorders, to neurological and endocrinal pathologics.

METHODOLOGY

The data was collected using the following 3 methods which slowly built up: questionnaire clinical examination the operation

RESULTS

The dividing-up of the different operations: we realised a total of 71 operations, this being an average 1.77 per patient. Distribution of pathological ailments according to type and nature: About 55% of our patients had a general pathology. Cardio-vascular ailments took first place with a frequency of 52.16%, followed by digestive problems with 26.08% neurological syndromes with 13.04% and ailments with endocrinal origins with a rate of 8.69%. Incidents during operation: incidents linked to the anaesthetic, incidents linked to the operation itself, post-operative incidents, healing.

DISCUSSION

Age: The most representative age-band was between 55 and 64 years (with a six ration of 1:5). Multiple extractions: Apart from a defective oral state, these extractions are always motivated by the need for prosthesis. All the patients were missing at least one tooth, confirming the thesis of Dubois, according to which "the repercussion of oral ageing appears in all its simplicity in either partial or total toothlessness".

CONCLUSION

Elderly Senegalese patients present serious oral problems since extraction comprises the main part of surgical odontological operations. A better way of dealing with these subjects, weakened by old age and general pathology, is desirable.

[Complete removable dentures and the elderly at I.O.S., Dakar]

INTRODUCTION

At I.O.S. Dakar, we have taken an essential interest in elderly persons with functional disorders, aesthetic and psychological. We have fixed the following objectives: to evaluate the importance of the elderly person in our surgery to define the major characteristics of this category of patient to single out the specific aspects of the restorative denture to make our teaching programmes more relevant.

MATERIALS AND METHODS

Two complementary axes: a retrospective statistical descriptive study carried out on the records of patients at P.A.C. of I.O.S. during the previous three academic years of patients at P.A.C. of I.O.S. during the previous three academic years 1986-87, 88-89, 89-90. an analysis of the records based on the following variables: age, sex, place of living, occupation, type of complete attached dentures additionally, certain particular aspects of these patients have been studied.

SELECTION CRITERIA

We have studied patients over 55 years of age who have either a single or bimaxillary replacement.

VARIABLES STUDIED

two types of denture: unimaxillary CAD and bimaxillary CAD our patients were classed as: urban--living in Dakar and Gorée rural--coming from surrounding villages suburban--those coming from Pikine, Parcelles Assainies, Rufisque. for occupation: first sector--agriculture, fishing second sector--industrial or conversion workers third sector--service workers or tradesmen, housewives, pensioners, others. RESULTS AND COMMENTARY: the sex ratio is closely akin to that of the general population the majority of patients live in Dakar these are mainly housewives, retired people who could regularly attend our consultations and stay the course of our treatment, prosthetic restorations are complete attached bimaxillary dentures (79.14%). Clinical specifications: On a local clinical level, the total toothlessness of the elderly presents as: a muscular hypotomy, a loss of the vertical dimension of occlusion, a marked increase in nasal and oral fissures, a stiffening of the articular structures, a great reduction of osteo-mucus in the residual edges, a spreading of the tongue which invades the oral cavity, a loss of occlusive memory, Bearing on therapy and teaching: good clinical observation, constant reference to the medical services, appropriate surgery prior to denture fitting.

CONCLUSION

This study shows us that at I.O.S. Dakar, persons over 55 coming to consult us are most often city dwellars and often housewives or retired people. The major purpose of these visits is functional. The minute failure rate encountered over these three years has led us to believe that prosthesis enjoys high esteem thanks to the raised criteria of competence, of knowledge and of the patience of the whole team.

[Clinical use of the Sonic Air MM 1500 and the Meca Sonic 1400 in canal preparation in endodontics]

INTRODUCTION

The preparation for canalisation has remained manual for a long time, technically constrictive and lasting for a long time. The application of ultrasound in Endontony allows us to tackle more calmly the canal course of the teath. The aim of this work is to make a qualitative comparison of the endosonic technique and the manual technique with reference to cases treated in the Dentisterie Opératoire clinic in Dakar.

MATERIAL AND METHOD

40 teeth of a complex canal anatomy and or in the posterior position in the buccal cavity were submitted to either a manual canalisation preparation or endosconic followed by monconic canal filling with a paste: 3 inc oxyde eugenol and iodoform. OPERATING FORMULA: Preparatory X rays: Allow us to evaluate the length of the work or the operating length after catheterisation: LO--length PRO, APEX RADIO-IMM LO--operating length PRO - occlusive point of reference The parietal support technique: The "synergetic" effect of ultrasonic oscillations of cavitation and of micro-acoustic currents associated with the action of the irrigation solution allow us to obtain canal incision.

INSTRUMENTS

the pneumatic Sonic Air MM 1500; the Meca Sonic MMR 1400 coupled to a standard ISO motor; SHAPERS and Meca Shapers. Activated by shaper or Méca Shaper. Classic monoconic canal filling: Wadding paste + zinc oxyde paste-iodoform eugenol. X rays for orthocentric monitoring. RESULTS--DISCUSSION: In 60% of the cases treated, the patients presented with a complete dentition. The third inferior molar was in almost all the cases, the cause of the patient seeking a dental consultation. By endosonic treatment-conservation of teeth which would otherwise have been destined for extraction; biopulectomy or instituted pulpectomy for cases of desdodontite, endosconic amplication and canal sealing after the cooling of the inflammation. Duration of treatment: 2 sessions for gangrenous cases or desmodondite and one session for biopulpectomy or pulpectomy, with 4 sessions in 10% of the cases. Operation times: Saving of time of 40-50%. If a second session was necessary, 15-20 minutes was sufficient. Incidents or accidents during or after the operation: breakage of instruments, post-operative inflammatory reaction.

CONCLUSION

better distribution of the irrigation solution, lessening of the risk of infection, better quality of the state of the canal surface, reduction in operating time, precision and reliability, conservation of teeth which would otherwise have been extracted, as many of the elements which encourages the appreciation of ultrasound in endodonty.