Nantes 2015

Nantes 23rd to the 26th September 2015

I think it is safe to say that the presentations this year were on the whole much more technical and cutting edge than at recent conferences. This was a mixed blessing, leaving some of the audience feeling that their medical knowledge was really outdated, but bringing to the participants new and extremely interesting new information.

Michael KELLY gave us an update on his joint presentation with Patrice METAYER in Biarritz on the differences between the (medico-)legal systems in France and England. They have now undertaken a detailed review of the work and it is to be published in a medico-legal journal this autumn.

We then heard Prof S BRULEY DES VARANNES on modern thinking about irritable bowel syndrome. He showed that the incidence is high in western countries, and demonstrated that the effect on quality of life was comparable to diseases such as diabetes.

His thesis is that leaky gut is a very important causal factor, whether this is post-infective or otherwise. Biopsies show increased mast cells, close to the intestinal wall nerve-endings, giving a plausible mechanism for pain and for alterations in gut motility.

He introduced the concept of FODMAPS: Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols. Dietary manipulation to   reduce these is difficult and requires specially trained dietitian input.

 John BEAVAN gave a fascinating insight into doping in cycling from the early days of the Tour de France up to Lance Armstrong and later. Dop is a word adopted from Zulu, and the first reports of performance altering substances dates back to 1897. It was such a normal part of cycling life and lore that by 1930 there was a published warning that the race organisers were unable to provide dope, and competitors should provide their own. The first laws were only introduced in 1965, and early testing in the TdF was in 1966. Deaths were common, Tommy Simpson being the first in the modern era to be seen to die as a result of doping when he became dehydrated on Mt Ventoux. Lance Armstrong was known about for many years, but always managed to escape censure, presumably because he was only an index case and there would have been a cascade of bans were he to have been pursued.

Matthew Day presented a report on the botulism outbreak in injecting drug users in west-central Scotland in 2014-5. The index case was not diagnosed immediately, but once the diagnosis was made a high index of suspicion led to rapid diagnosis and treatment for other cases. In total 40 cases were treated, the majority requiring intensive care as well as surgical drainage of abscesses. Half were ventilated, and a small number of deaths were recorded.

James McDONALD gave us an insight into the use of social media in medicine. We need to recognise the different functions of open and closed networks, and to ensure that sensitive data are not put into the public sphere. I was not surprised that Linkedin has a high coverage. The main problem is avoiding being signed up! Twitter is much less commonly used professionally. Age is less relevant than would first be thought, but English as a first language remains an indicator of use of networks. It appears that the uptake of social media among doctors has got to 50%. The guidelines for professional use, such as those by RCGP are not always being followed closely, particularly around self-identification of doctors giving advice on-line.

 Martin PUNTER presented the various presentations of cerebral venous thrombosis. It is responsible for less than 1% of strokes and is commoner in women than men, and in younger women, thought to be because of hormonal factors, particularly oral contraceptives. Most presentations are early, but some are very delayed. CT scans give a less defined appearance than in infarct; CT venography and MRI are particularly helpful in confirmation. The basis of treatment is supportive, but specific neurological interventions to relieve increased IC pressure (lumbar puncture or acetazolamide, for example) may be needed. Anticoagulation is standard.Complications include coning (engagement); chronic headache; intracranial hypertension; visual problems; epilepsy; AV fistula; and pulmonary embolism from the intracerebral thrombus.        

Carol BARTON told us about Henry March Webb, surgeon of the mid 19th century. He         observed and carefully recorded operations in Paris hospitals, then set out on a world-wide journey, largely within the army. He was with the 51st Regiment of Foot in Malta, then in        St Lucia for 3 years. Subsequent postings were Ceylon and St Helena, a link with Napoleon’s exile. His meticulous diary allows an insight into the diseases and surgical adventures in the late pre-anaesthetic era.

John WARD presented another of his lost heroes, Pierre C A Louis, 1787-1872. In the course of his long life he was a major influence in the development of American medicine through the exposure of American doctors to his teaching in Paris. France did not recognise his contributions, as he espoused data collection over numerous patients to give patterns that could be valuable in subsequent cases. The prevailing attitude was that observation of the individual was paramount, and that lessons could only be drawn from the experience of the physician. He gave up a rich practice in Odessa to return to Paris to a much lower income   during a diphtheria epidemic. His work on the benefits or otherwise of cupping, bleeding and leaches was decried. They were so intrinsic to the standard disease models that questioning them, or even worse, testing them was anathema. However, he was able to compare bleeding for   pneumonia early or late in the process, showing that early bleeding was associated with faster recovery but a higher mortality.

On Friday, Prof Michel NEUNLIST from Nantes gave a fascinating but very technical lecture on the contribution of neuro-gastroenterology to the understanding and treatment of digestive disorders. He showed that the gut is a most complex neurological organ, using all the neurotransmitters that are present in the CNS, and suggesting that the CNS developed subsequently using the existing bowel mechanisms. The development of the GI nervous system from the neural plate is completed by 7 weeks of gestation.

He told us that the understanding of gut function is essential to all aspects of health, as           homeostasis requires a fully functioning GI tract with active feedback controls. Animal models show that leaky gut reduces life expectancy. Parkinsonism may have an aetiological basis in the gut neural pathways. The James Tudor Prize presentations were given this year by a mixed cohort of French and UK students. The quality of the presentations was excellent. The winner was Camille GODET who presented a clinical case of severe constipation on a child. It turned out to be caused by the   extremely rare autosomal dominant syndrome de Currarino, which has a teratoma eroding the sacrum causing the cauda equina-like symptoms.

  Prof Jean-Paul SOULILLOU gave the James Tudor Foundation Lecture. He is head of service in the Nephrology unit in Nantes. His subject was emerging bioreagents in targeted immunosuppression, so he started with the history of (successful) renal transplantation from 1963 onwards. From the beginning it was recognised that rejection had to be overcome if grafts were to survive, but the treatments were not initially very effective, nor safe. He gave us a masterclass on the development of polyclonal antibodies, and the subsequent development of targeted antibodies against more and more specific transmitter pathways on T cells. These have been refined over time as understanding of the mechanisms improved. Early versions had catastrophic side effects when inhibition of pathways causing cellular reactions to the foreign tissue, also blocked the inhibitory pathways – which use the same or similar transmitters –   causing major cascades. After many years, in monkey models there is now 100% survival when a combination of the new monoclonals is used in concert with traditional anti-rejection medication.

Saturday morning gave us Prof George KARAM on the history of transplantation since 1952 when a mother to son renal graft was performed. The first success was 2 years later in Boston between monozygotic twins. The differences in approach between France and UK were highlighted, with no permission for altruistic anonymous donation in France, and differences in the definition of the time that harvesting of organs can occur from dead donors. Immediate family members can offer organs if they are suitable, but most grafts are from donors who are either brain dead, have suffered circulatory (not cardiac for semantic reasons) arrest or controlled non-heart beating donors. France has an opt-out system, but it is often overridden by the family of the deceased. In France, 10,000 are on dialysis, with 3,000 renal grafts performed annually.

Luc ROTENBERG showed us that imaging of early breast cancer remains an art. Our idea that smooth lesions are benign and spiculated ones malignant is only correct to an extent, and     biopsy or excision remains essential in most cases. Morten RASMUSSEN from Copenhagen introduced us to the extraordinary world of metabolomics. Their research is aimed at very early pre-diagnosis of cancer (initially breast also) using a wide range of non-specific metabolic   markers, the majority standard biochemical tests done routinely. None in itself is discriminatory, but the combination of many seems to give a robust pattern that indicates a future cancer. It has only been tested in the relatively homogeneous Danish population to date so there is much more work to be done before it can be used diagnostically. The results so far are very interesting, with the sample study of 57,000 and using 176 variables, the group got 80% sensitivity and specificity 5 years ahead. Julia DINA presented on the pathogenicity of measles, and the WHO aim for eradication, now set for 2020, a long delay from earlier targets due to political instability in various countries. She reminded us that measles virus is related to rinderpest, now extinct, and that it is a very stable RNA virus.

 Zara BIELER rounded off the conference with a brief demonstration of the new and improved website and the possibility of its linkage to that of AFMB. She also encouraged us to use the AFMS’s other social media sites.