Serum Levels of Epithelial-Derived Cytokines as Interleukin-25 and Thymic Stromal Lymphopoietin after a Single Dose of Mepolizumab in Patients with Severe Non-Allergic Eosinophilic Asthma: A Short Report

The bronchial epithelium has continuous contact with environmental agents initiating and maintaining airway type 2 inflammation in asthma. However, there is a lack of data on whether reduced airway eosinophilic inflammation can affect the production of epithelial-derived mediators, such as interleukin-25 (IL-25) and thymic stromal lymphopoietin (TSLP). The aim of this study was to investigate the changes in serum levels of IL-25 and TSLP after a single dose of mepolizumab, a humanized monoclonal antibody to interleukin-5 (IL-5), in patients with severe non-allergic eosinophilic asthma (SNEA). We examined 9 SNEA patients before and four weeks after administration of 100 mg mepolizumab subcutaneously. The fractional exhaled nitric oxide (FeNO) level was analysed using an electrochemical assay (NIOX VERO®, Circassia, UK). Serum IL-25 and TSLP levels were measured by ELISA. Four weeks after the single dose of mepolizumab, blood eosinophil count significantly decreased from 0.55 ± 0.20 × 109/l to 0.14 ± 0.04 × 109/l (p = 0.01) and FEV1 increased from 2.1 ± 0.5 l (65.4 ± 8.8% of predicted) to 2.6 ± 0.4 l (76.4 ± 9.1% of predicted) (p = 0.04), while FeNO level has not changed (32.3 ± 8.4 vs 42.9 ± 12.6 ppb). Serum IL-25 level significantly decreased from 48.0 ± 17.2 pg/mL to 34.8 ± 17.1 pg/mL (p = 0.02) with same tendency in TSLP level: from 359.8 ± 71.3 pg/mL to 275.6 ± 47.8 pg/mL (p = 0.02). It has also been noticed a significant relation between changes in the blood eosinophil count and serum IL-25 level (r = 0.81, p = 0.008), as well as between changes in serum IL-25 and TSLP levels (r = 0.93, p = 0.004) after a single dose of mepolizumab. Thus, anti-IL-5 treatment with mepolizumab might diminish the production of bronchial epithelial-derived cytokines IL-25 and TSLP in patients with SNEA which is potentially related to reduced eosinophilic inflammation. This trial is registered in ClinicalTrial.gov with identifier NCT03388359.

Expression of eosinophil β chain-signaling cytokines receptors, outer-membrane integrins, and type 2 inflammation biomarkers in severe non-allergic eosinophilic asthma

Background

Severe non-allergic eosinophilic asthma (SNEA) is a rare asthma phenotype associated with severe clinical course, frequent exacerbations, and resistance to therapy, including high steroid doses. The key feature is type 2 inflammation with predominant airway eosinophilia. Eosinophil maturation, activation, survivability, and recruitment are mainly induced by interleukin (IL)-3, IL-5 and granulocyte–macrophage colony-stimulating factor (GM-CSF) through their receptors on eosinophil surface and related with integrins activation states. The aim of the study was to estimate the expression of eosinophil β chain-signaling cytokines receptors, outer-membrane integrins, and serum-derived type 2 inflammation biomarkers in SNEA.

Methods

We examined 8 stable SNEA patients with high inhaled steroid doses, 12 steroid-free patients with non-severe allergic asthma (AA), 12 healthy subjects (HS). Blood eosinophils were isolated using Ficol gradient centrifugation and magnetic separation. Eosinophils were lysed, and mRNA was isolated. Gene expressions of IL-5Rα, IL-3Rα, GM-CSFRα, and α4β1, αMβ2 integrins were analyzed using quantitative real-time reverse transcription polymerase chain reaction. Type 2 inflammation activity was evaluated measuring exhaled nitric oxide concentration (FeNO) collected with the electrochemical sensing device. Serum IL-5, IL-3, GM-CSF, periostin, chemokine ligand (CCL) 17 and eotaxin concentrations were assessed by enzyme-linked immunosorbent assay.

Results

Eosinophils from SNEA patients demonstrated significantly increased gene expression of IL-3Rα, IL-5Rα and GM-CSFRα as well as α4, β1 and αM integrin subunits compared with the AA group. The highest IL-5 serum concentration was in the SNEA group; it significantly differed compared with AA and HS. GM-CSF serum levels were similar in the SNEA and AA groups and were significantly lower in the HS group. No differences in serum IL-3 concentration were found among all groups. Furthermore, serum levels of eotaxin, CCL17 and FeNO, but not periostin, differed in all groups, with the highest levels in SNEA patients.

Conclusions

Eosinophil demonstrated higher expression of IL-3, IL-5, GM-CSF α-chain receptors and α4, β1, αM integrins subunits in SNEA compared with the AA group. Additionally, SNEA patients had increased serum levels of IL-5, eotaxin and CCL-17.

Trial registration

ClinicalTrials.gov Identifier NCT03388359.

Prognostic Value of Left Ventricular Function and Mechanics in Pulmonary Hypertension: A Pilot Cardiovascular Magnetic Resonance Feature Tracking Study

Background and objective: Cardiovascular magnetic resonance (CMR) - based feature tracking (FT) can detect left ventricular (LV) strain abnormalities in pulmonary hypertension (PH) patients, but little is known about the prognostic value of LV function and mechanics in PH patients. The aim of this study was to evaluate LV systolic function by conventional CMR and LV global strains by CMR-based FT analysis in precapillary PH patients, thereby defining the prognostic value of LV function and mechanics. Methods: We prospectively enrolled 43 patients with precapillary PH (mean pulmonary artery pressure (mPAP) 55.91 ± 15.87 mmHg, pulmonary arterial wedge pressure (PAWP) ≤15 mmHg) referred to CMR for PH evaluation. Using FT software, the LV global longitudinal strain (GLS) and global circumferential strain (GCS), also right ventricular (RV) GLS were analyzed. Results: Patients were classified into two groups according to survival (survival/non-survival). LV GLS was significantly reduced in the non-survival group (−12.4% [−19.0–(−7.8)] vs. −18.4% [−22.5–(−15.5)], p = 0.009). By ROC curve analysis, LV GLS > −14.2% (CI: 3.229 to 37.301, p < 0.001) was found to be robust predictor of mortality in PH patients. Univariable analysis using the Cox model showed that severely reduced LV GLS > −14.2%, with good sensitivity (77.8%) and high specificity (93.5%) indicated an increase of the risk of death by 11-fold. LV GLS significantly correlated in PH patients with RV ESVI (r = 0.322, p = 0.035), RV EF (r = 0.444, p < 0.003). Conclusions: LV systolic function and LV global longitudinal strain measurements using CMR-FT correlates with RV dysfunction and is associated with poor clinical outcomes in precapillary PH patients.

Diagnostic Yield of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration Cytological Smears and Cell Blocks: A Single-Institution Experience

Background and Objective: Endobronchial ultrasound (EBUS) is a minimally invasive endobronchial technique, which uses ultrasound along with a bronchoscope to visualize the airway wall and structures that are adjacent to it. Indications for endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are samplings of mediastinal, hilar lymph nodes, and tumors adjacent to airway walls. EBUS-TBNA has been used in our clinic since 2009. The aim of the study is to evaluate the sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy of cytological and histological specimens, and the safety of EBUS-TBNA in an unselected patient population that has been referred to our hospital. Materials and Methods: We have retrospectively analyzed the medical documentation of 215 patients who had EBUS-TBNA performed in our clinic from April 2009 to February 2014. Results: There were 215 patients who underwent EBUS-TBNA. A total of 296 lymph nodes were sampled. EBUS-TBNA was diagnostic in 176 (81.9%) cases of cytological, 147 (68.4%) cases of histological, and 191 (88.9%) cases of the combined evaluation. In the lung cancer patients, EBUS-TBNA cytology had a sensitivity of 72.9% and histology of 72.9%, and in the sarcoidosis group, it had a cytology of 55.8% and histology of 64.5%. As all positive cytology and histology specimens were assumed to be true positive, specificity and positive predictive value (PPV) were 100%. The sensitivity and diagnostic accuracy was significantly higher when cytology and histology specimens were combined, compared with cytology or histology results evaluated separately (p < 0.05) (for lung cancer 84.1% and for sarcoidosis 78.8%). The sensitivity and diagnostic accuracy of EBUS-TBNA procedures increased significantly over time, with increased experience. There were no complications with EBUS-TBNA in our clinical practice. Conclusions: EBUS-TBNA had a high diagnostic yield and was safe in the diagnosis of lung cancer and sarcoidosis. It was most informative when cytology and histology were combined. The informative value of EBUS-TBNA histology increased with our experience.

Factors associated with sputum culture conversion in patients with pulmonary tuberculosis

OBJECTIVE

The aim of this study was to determine what factors are associated with sputum culture conversion after 1 month of tuberculosis (TB) treatment.

MATERIALS AND METHODS

A total of 52 patients with new drug susceptible pulmonary TB were included in the study. Patients completed St. George respiratory questionnaire (SGRQ), they were asked about smoking, alcohol use, living conditions and education. Body mass index (BMI) measurements, laboratory tests (C reactive protein [CRP], vitamin D, albumin) were performed, and chest X-ray was done. After 1 month of treatment sputum culture was repeated.

RESULTS

Culture conversion after 1 month of treatment was found in 38.5% cases. None of investigated social factors appeared to have an effect on conversion, but worse overall health status (as reported in SGRQ) and longer duration of tobacco smoking were detected in the "no conversion" group. Concentrations of albumin, CRP, X-ray score and the time it took Mycobacterium tuberculosis culture to grow also differed. Patients who scored 30 or more on SGRQ were more than 7 times as likely to have no conversion. However, the most important factor predicting sputum culture conversion was sputum smear grade at the beginning of treatment: patients with grade of 2+ or more had more than 20-fold higher relative risk for no conversion. Using receiver operating characteristic curve analysis, we also developed a risk score for no conversion.

CONCLUSIONS

The most important factors in predicting sputum culture conversion after 1 month of treatment were grades of acid-fast bacilli in sputum smears at time of diagnosis and scores of SGRQ.

Distribution of M1 and M2 macrophages in tumor islets and stroma in relation to prognosis of non-small cell lung cancer

BACKGROUND

Non-small cell lung cancer (NSCLC) remains the most common cause of cancer related death worldwide. Tumor-infiltrating macrophages are believed to play an important role in growth, progression, and metastasis of tumors. In NSCLC, the role of macrophages remains controversial; therefore, we aimed to evaluate the distribution of macrophages (M1 and M2) in tumor islets and stroma and to analyze their relations to patients' survival.

METHODS

Lung tissue specimens from 80 NSCLC patients who underwent surgical resection for NSCLC (pathological stage I-III) and 16 control group subjects who underwent surgery because of recurrent spontaneous pneumothorax were analyzed. Immunohistochemical double staining of CD68/iNOS (markers for M1 macrophages) and CD68/CD163 (markers for M2 macrophages) was performed and evaluated in a blinded manner. The numbers of M1 and M2 macrophages in tumor islets and stroma were counted manually.

RESULTS

Predominant infiltration of M1 and M2 macrophages was observed in the tumor stroma compared with the tumor islets. M2 macrophages predominated over M1 macrophages in the tumor tissue. Tumor islets-infiltrating M1 macrophages and the number of total tumor-infiltrating M2 macrophages were independent predictors of patients survival: high infiltration of M1 macrophages in tumor islets was associated with increased overall survival in NSCLC (P < 0.05); high infiltration of total M2 macrophages in tumor (islets and stroma) was associated with reduced overall survival in NSCLC (P < 0.05).

CONCLUSIONS

This study demonstrated that high infiltration of M1 macrophages in the tumor islets and low infiltration of total tumor-infiltrating M2 macrophages were associated with improved NSCLC patients' survival.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01955343 , registered on September 27, 2013.

Impact of advanced medical therapy for the outcome of an adult patient with Eisenmenger syndrome

Eisenmenger syndrome (ES) is the most severe form of pulmonary arterial hypertension (PAH) associated with congenital heart disease. It is an extremely devastating condition with a serious impact on patients' life. Classical therapy of ES remains directed to avoid complications, such as erythrocytosis, treatment of congestive heart failure, prevention of infection, and secondary haematological abnormalities such as iron deficiency and coagulation disorders. However, the only effective treatment is heart–lung transplantation; still, morbidity and mortality after transplantation remain substantially high. Furthermore, waiting lists for heart–lung transplantation are long. Recent studies examining the use of advanced medical treatment in patients with ES have shown that it may have beneficial effects in patients with ES; however, additional studies need to be done to confirm its efficacy and appropriate clinical use. A 41-year-old female admitted to the Hospital of Lithuanian University of Health Sciences due to progressive dyspnea on minimal effort, heart failure symptoms leading to NYHA functional class III-IV. After clinical and instrumental investigations, ES secondary to unrepaired patent ductus arteriosus with severe PAH was diagnosed. Treatment with sildenafil was initiated together with the standard pharmacological therapy, and the patient was added to the waiting list for the heart and lung transplantation. After 24 months of stable condition, her clinical status deteriorated, and combination therapy (sildenafil and ambrisentan) was initiated. Clinical symptoms and exercise capacity improved, and she has been stable for 4 years thereafter. Our experience of the management of an adult patient with ES showed the benefits of treatment with advanced therapy with pulmonary vasodilators that improved the patient's quality of life and delayed the need for heart and lung transplantation.

Distribution of CD4(+) and CD8(+) T cells in tumor islets and stroma from patients with non-small cell lung cancer in association with COPD and smoking

BACKGROUND AND OBJECTIVE

The immune system plays an important role in non-small cell lung cancer (NSCLC) and chronic obstructive pulmonary disease (COPD). The aim of this study was to evaluate the infiltration patterns of CD4(+) and CD8(+) T cells in NSCLC and to analyze their relation to COPD, smoking status and other clinicopathologic variables.

MATERIALS AND METHODS

Lung tissue specimens from 50 patients who underwent surgery for NSCLC (stages I-III) and 10 control group subjects were analyzed immunohistochemically.

RESULTS

NSCLC patients had a greater number of CD4(+) and CD8(+) T cells infiltrating the lung tissue than the control group (P=0.001) with predominant infiltration in the tumor stroma. We found a significant association between the number of total and tumor stroma-infiltrating CD4(+) and CD8(+) T cells, and smoking status (P<0.05). There were more CD8(+) T cells in the tumor stroma and fewer in the tumor islets in NSCLC patients with COPD as compared to NSCLC patients without COPD (P<0.05). However, there was no such association between CD4(+) T cells and COPD status. A high level of CD8(+) T cell infiltration in the tumor stroma was independently associated with the coexistence of COPD in multivariate analysis (P<0.05).

CONCLUSIONS

According to our data, COPD but not smoking seems to be associated with higher infiltration of CD8(+) T cells in the tumor stroma of patients with NSCLC. It allows us to hypothesize that NSCLC patients with coexisting COPD may have a more favorable outcome due to anticancer properties of stromal CD8(+) T cells.

Efficacy of radiofrequency treatment of the soft palate for patients with mild to moderate obstructive sleep apnea hypopnea syndrome: treatment protocol with nine lesions to the soft palate

PURPOSE

The study aimed at assessing the efficacy and safety of a radiofrequency treatment (RFT) protocol with nine lesions to the soft palate in the treatment of mild to moderate obstructive sleep apnea hypopnea syndrome (OSAHS).

METHODS

Twenty-eight mild to moderate OSAHS patients underwent two sessions of RFT (CelonLab ENT system) at the palatal level within the interval from 6 to 8 weeks. Nine lesions (power setting of 10 W) were made per session. The baseline and posttreatment polysomnography and clinical tests battery consisting of visual analogue scales (VAS), Sleep Apnea Quality of Life Index (SAQLI), Beck Depression Inventory--second edition (BDI-II), and Epworth sleepiness scale (ESS) were applied to assess the RFT outcomes.

RESULTS

Mild to moderate OSAHS patients demonstrated statistically significantly reduced posttreatment mean VAS values for most of the OSAHS-related complaints. A significant improvement in sleepiness (ESS score 6.7 ± 3.7 vs 8.5 ± 4.1, p < 0.01), depressivity (BDI-II score 7.5 ± 6.5 vs 13.1 ± 11.7, p < 0.01), and health-related quality of life (SAQLI score 5.3 ± 0.8 vs 4.7 ± 0.9, p < 0.01) was observed after the RFT. The mean AHI decreased from 13.7 ± 5.9 to 8.3 ± 4.9 points (p < 0.01) in the entire group of patients. According to Sher's criteria of success, 17 out of 28 (60.7 %) patients improved after RFT. No major complications were noted with RFT.

CONCLUSIONS

RFT protocol with nine lesions to the soft palate seems to be an effective and safe treatment modality associated with low morbidity in selected mild to moderate OSAHS patients.

Local and systemic neutrophilic inflammation in patients with lung cancer and chronic obstructive pulmonary disease

Background

Recent investigations suggest that neutrophils play an important role in the immune response to lung cancer as well as chronic obstructive pulmonary disease (COPD). The aim of this study was to evaluate the amount of neutrophils and markers of their activity in lung cancer and COPD and in coexistence of these two diseases.

Methods

In total, 267 persons were included in the study: 139 patients with lung cancer, 55 patients with lung cancer and COPD, 40 patients with COPD, and 33 healthy subjects. Peripheral blood and BAL fluid samples were obtained for cell count analysis and determination of NE, MPO levels and ROS production. NE and MPO levels in the serum and BAL fluid were determined by ELISA. ROS production was analyzed by flow cytometer.

Results

The percentage, cell count of neutrophils and neutrophil to lymphocyte ratio in the peripheral blood were significantly higher in lung cancer patients with or without COPD compared to COPD patients or healthy individuals (P < 0.05). The percentage and cell count of neutrophils in BAL fluid were significantly lower in patients with lung cancer with or without COPD than in patients with COPD (P < 0.05). However, BAL fluid and serum levels of both NE and MPO were significantly higher in patients with lung cancer than COPD patients or healthy individuals (P < 0.05). Neutrophils produced higher amounts of ROS in patients with lung cancer with or without COPD compared with COPD patients or healthy individuals (P < 0.05).

Conclusions

The results from this study demonstrate higher degree of local and systemic neutrophilic inflammation in patients with lung cancer (with or without COPD) than in patients with COPD.

Controlled trial of combined radiofrequency-assisted uvulopalatoplasty in the treatment of snoring and mild to moderate OSAS (pilot study)

PURPOSE

The aim of this study was to assess the efficacy of radiofrequency treatment (RFT) of the soft palate and combined radiofrequency-assisted uvulopalatoplasty (RF-UPP) in the treatment of snoring and mild to moderate obstructive sleep apnea/hypopnea syndrome (OSAHS).

METHODS

In the study group consisting of 32 snoring and mild to moderate OSAHS patients with excessive soft tissue of the soft palate or uvula, 13 patients underwent RFT of the soft palate and 19 patients underwent combined RF-UPP. The baseline and posttreatment polysomnography and clinical test battery consisting of Visual Analogue Scales (VAS), Lithuanian version of Sleep Apnea Quality of Life Index (SAQLI-LT), Spielberg's Trait-State Anxiety Inventory, Beck Depression Inventory-second edition (BDI-II), and Epworth Sleepiness Scale were applied to assess the treatment outcomes.

RESULTS

After a short-term follow-up of 2 to 3 months, the group of the RFT patients showed improvement in mean VAS snoring and SAQLI-LT scores, while the group of RF-UPP patients showed statistically significantly improvement in mean apnea-hypopnea index (AHI) (12.51 ± 7.66 vs. 7.88 ± 6.05, p < 0.05, β = 0.107), SAQLI-LT, and BDI-II scores. The group of RF-UPP patients had superior and statistically significant improvement compared to the RFT alone patients with regard to mean AHI (effect size 4.63 ± 4.65 vs. 0.95 ± 4.83, p < 0.05) and SAQLI-LT (effect size 0.75 ± 0.59 vs. 0.33 ± 0.40, p < 0.05) scores.

CONCLUSIONS

Combined RF-UPP showed to be effective in the treatment of snoring and mild to moderate OSAS overcoming the RFT alone.

Efficacy and safety of erlotinib versus chemotherapy in second-line treatment of patients with advanced, non-small-cell lung cancer with poor prognosis (TITAN): a randomised multicentre, open-label, phase 3 study

BACKGROUND

Erlotinib, docetaxel, and pemetrexed are approved for the second-line treatment of non-small-cell lung cancer (NSCLC), but no head-to-head data from large clinical trials are available. We undertook the Tarceva In Treatment of Advanced NSCLC (TITAN) study to assess the efficacy and tolerability of second-line erlotinib versus chemotherapy in patients with refractory NSCLC.

METHODS

TITAN was an international, randomised multicentre, open-label, phase 3 study that was done at 77 sites in 24 countries. Chemotherapy-naive patients with locally advanced, recurrent, or metastatic NSCLC received up to four cycles of first-line platinum doublet chemotherapy, after which patients with disease progression during or immediately after chemotherapy were offered enrolment into TITAN. Enrolled patients were randomly assigned (1:1) by a minimisation method to ensure balanced stratification, to receive erlotinib 150 mg/day or chemotherapy (standard docetaxel or pemetrexed regimens, at the treating investigators' discretion), until unacceptable toxicity, disease progression, or death. Patients were stratified by disease stage, Eastern Cooperative Oncology Group performance status, smoking history, and region of residence. The primary endpoint was overall survival in the intention-to-treat population. TITAN was halted prematurely because of slow recruitment. This study is registered with ClinicalTrials.gov, number NCT00556322.

FINDINGS

Between April 10, 2006, and Feb 24, 2010, 2590 chemotherapy-naive patients were treated with first-line platinum doublet chemotherapy, of whom 424 had disease progression and were enrolled into TITAN. 203 patients were randomly assigned to receive erlotinib and 221 were assigned to receive chemotherapy. Median follow-up was 27·9 months (IQR 11·0-36·0) in the erlotinib group and 24·8 months (12·1-41·6) in the chemotherapy group. Median overall survival was 5·3 months (95% CI 4·0-6·0) with erlotinib and 5·5 months (4·4-7·1) with chemotherapy (hazard ratio [HR] 0·96, 95% CI 0·78-1·19; log-rank p=0·73). The adverse-event profile of each group was in line with previous studies. Rash (98/196 [50%] in the erlotinib group vs 10/213 [5%] in the chemotherapy group for all grades; nine [5%] vs none for grade 3 or 4) and diarrhoea (36 [18%] vs four [2%] for all grades; five [3%] vs none for grade 3 or 4) were the most common treatment-related adverse events with erlotinib, whereas alopecia (none vs 23 [11%] for all grades; none vs one [<1%] for grade 3/4) was the most common treatment-related adverse event with chemotherapy.

INTERPRETATION

No significant differences in efficacy were noted between patients treated with erlotinib and those treated with docetaxel or pemetrexed. Since the toxicity profiles of erlotinib and chemotherapy differ, second-line treatment decisions should take into account patient preference and specific toxicity risk profiles.

FUNDING

F Hoffmann-La Roche.

Pseudoaneurysm of brachiocephalic artery mimicking the mediastinal tumor

58 year-old male admitted to the Hospital of Lithuanian University of Health Sciences due to suspicion of mediastinal tumor for diagnostic endobronchial ultrasound procedure (EBUS). The main patient's complain was progressive dyspnea. Objective investigation revealed no major findings: normal breath sounds, heart rate – 96 bpm, blood pressure – 120/80 mmHg. Chest CT scan showed the mediastinal tumor of 3.8 × 3.5 cm. During bronchoscopy smooth intratracheal nodule of 5 mm was found. Superficial biopsy showed normal airway mucosa. During EBUS procedure no clear lymph node structure or blood flow was detected. It was decided to observe the patient clinically. One month later massive hemoptysis started. Urgent bronchoscopy revealed large right-sided mass and intratracheal wall dislocation due to the possible mediastinal tumor in the same location as the polyp in the previous investigation. Repeated chest CT scan showed increasing tumor of size 4.0 × 3.2 × 4.0 cm in the mediastinum and pseudoaneurysm of brachiocephalic artery was suspected. The diagnosis was later confirmed by aortography. The patient underwent successful aneurysmectomy.

The role of mutation status of the epidermal growth factor receptor gene in advanced non-small cell lung cancer

OBJECTIVE

The aim of this study was to examine the prevalence of epidermal growth factor receptor (EGFR) gene mutations among patients with advanced nonsquamous non-small cell lung cancer (NSCLC) treated in our institution and to evaluate the associations between EGFR mutations and clinicopathological characteristics.

MATERIALS AND METHODS

A total of 103 patients with NSCLC were examined from April 2010 to September 2011. The patients were screened for EGFR mutations in exons 19 and 21 using sequence analysis.

RESULTS

EGFR mutations were detected in 10 patients (9.71%): 23.1% of women and 5.2% of men (P<0.05), 31.8% of never-smokers and 4.7% of smokers (P<0.05), and 12.3% of patients with adenocarcinomas and 6.25% of patients with large cell carcinomas (P>0.05). Eight mutations (80.0%) were found in exon 21: 7 patients had the L858R mutation and 1 patient had the L861G mutation. Two mutations (20.0%) were found in exon 19: 1 patient had the L747-A748 deletion and 1 patient had the L747-A750insE deletion. The overall response rate was significantly greater in the EGFR mutation-positive group than in the EGFR mutation-negative or control groups (P<0.05). The median progression-free survival in the EGFR mutation-negative group and the control group that received systemic standard chemotherapy was 5.6 months (95% CI, 4.3 to 7.0) and 5.3 months (95% CI, 4.9 to 5.7), respectively, but it was not achieved in the EGFR mutation-positive group that received EGFR tyrosine kinase inhibitors (P<0.05).

CONCLUSIONS

The frequency of EGFR mutations in our patients with nonsquamous NSCLC was found to be similar to that reported in Europe. EGFR mutations were more frequent in women and never-smokers.

Comparison of C-reactive protein levels in patients with lung cancer and chronic obstructive pulmonary disease

OBJECTIVE

The aim of this study was to establish C-reactive protein (CRP) levels in serum of patients with lung cancer and chronic obstructive pulmonary disease (COPD) and evaluate the associations of CRP levels with clinicopathological characteristics.

MATERIALS AND METHODS

In total, 140 persons were included in the study: 43 patients with lung cancer, 34 patients with lung cancer and COPD, 42 patients with COPD, and 21 healthy subjects. CRP analysis was performed with a serum protein analyzer using commercially available high-sensitivity reagent kits.

RESULTS

The C-reactive protein levels were significantly higher in the lung cancer patients with or without COPD compared with the COPD patients or the control group (20.42±1.95 and 22.49±2.31 vs. 8.37±0.91 and 2.49±0.47 mg/L, respectively; P<0.01). The patients with advanced lung cancer had higher CRP levels compared with the patients suffering from early stage lung cancer (23.11±1.72 vs. 14.59±2.23 mg/L, P<0.01). The CRP levels were significantly higher in the patients with early stage lung cancer compared with the COPD patients (14.59±2.23 mg/L vs. 8.37±0.91 mg/L, P<0.05). No association was found between CRP and histology, lung function, and smoking status in the patients with lung cancer.

CONCLUSIONS

Chronic inflammation plays an important role in both diseases: lung cancer and COPD. However, it seems that inflammation is more pronounced in patients with lung cancer, as the CRP levels were significantly higher in these patients than other groups.

Sarcoidosis--moving to the new standard of diagnosis?

In this article, the most recent literature data regarding the diagnosis of sarcoidosis have been reviewed. The diagnosis of sarcoidosis can be reliably established when there is a compatible clinical/radiological picture together with pathologic evidence of noncaseating epithelioid cell granulomas. Pathologic specimens can be obtained by conventional bronchoscopy with endobronchial, transbronchial lung biopsy, bronchoalveolar lavage, and recently introduced endoscopic ultrasound techniques (endoscopic ultrasound-guided fine-needle aspiration, EUS-FNA, and endobronchial ultrasound-guided transbronchial needle aspiration, EBUS-TBNA) or surgical procedures such as thoracotomy, thoracoscopy, and mediastinoscopy. The place and value of EBUS-TBNA or EUS-FNA in diagnosis of sarcoidosis are discussed.

Late-onset nocturnal intractable seizure during sleep: what is the origin?

A 54-year-old man was admitted to the Sleep Laboratory, Hospital of Kaunas University of Medicine, for assessment of nocturnal seizures of unknown origin during sleep. This patient complained of increasing daytime sleepiness, morning headaches. Before the admission to the Sleep Laboratory, the treatment with depakine and clonazepam had been prescribed. Despite the treatment, the frequency of nocturnal seizures and daytime sleepiness increased. Full night polysomnography was performed. Ten central apneas were registered during all night. Two central sleep apneas with deep desaturation followed by generalized tonic-clonic seizures were documented. First sleep apnea lasted for 180 seconds and was terminated by epileptic tonic-clonic seizures. The second central sleep apnea with oxygen desaturation of 65% was detected 20 minutes later. It lasted for 200 seconds and was also terminated by epileptic tonic-clonic seizures. The conclusion was drawn that the patient had epileptic seizures caused by central sleep apneas with deep oxygen desaturation. The treatment with nasal continuous positive airway pressure device was started. The seizures disappeared completely. Clonazepam was stopped. Depakine was gradually withdrawn during the two weeks. One-year follow-up showed very good compliance, no seizures, and diminished daytime sleepiness.

Psychometric properties of the Lithuanian version of Sleep Apnea Quality of Life Index (a pilot study)

OBJECTIVE

To arrange and test for its psychometric properties Lithuanian version of Sleep Apnea Quality of Life Index and assess quality of life among snoring and obstructive sleep apnea patients before and after the treatment.

MATERIAL AND METHODS

Cross-cultural adaptation of Lithuanian version of Calgary Sleep Apnea Quality of Life Index was accomplished according to generally accepted methodology. In total, 36 (29 males and 7 females) patients (mean age, 41.1+/-9.7 years) suffering from socially disturbing snoring and obstructive sleep apnea were included into the study. All patients underwent complete full-night polysomnography (mean apnea/hypopnea index, 12.7+/-11.2) and were treated with two sessions of radiofrequency tissue ablation at the palatal and tong base (if it was necessary) levels. Lithuanian version of the Calgary Sleep Apnea Quality of Life Index was presented before the treatment with radiofrequency tissue ablation and in the period of 2 to 3 months after the treatment. Thirty-five patients repeated the same questionnaire after three weeks to assess the reliability of scores.

RESULTS

The Cronbach's a coefficients of internal reliability were above the standard (0.7 for groups) in all subdomains and domains. Test-retest correlation coefficients for each domain (ranged from 0.92 to 0.94) were statistically significant (P<0.0001). Lithuanian version of the questionnaire was found to be responsive to clinical change. A statistically significant difference in the mean Sleep Apnea Quality of Life Index scores in the study group patients before and after the surgery was found in all daily functioning subdomains and social interactions domains.

CONCLUSIONS

Overall, the results of the present pilot study demonstrate that the Lithuanian version of Sleep Apnea Quality of Life Index is applicable for clinical purposes.

[Peculiarities of nocturnal oxygen saturation in obstructive sleep apnea]

The aim of the study was to determine which factors are important for desaturation depth during sleep in obstructive sleep apnea (OSA) and to establish impact of nocturnal oxygen desaturation on the daytime sleepiness. 190 consecutive patients were included in the study (135 men and 55 women, mean age 52.59+/-11.31 and 58.93+/-8.85 years, respectively). Desaturation level depended on body-mass index and correlation with Epworth sleepiness scale (ESS) was statistically significant but not high (p<0.5). In the univariate analysis assessing factors important for severe daytime sleepiness (ESS more than 10), age and obesity were not statistically significant. A probability of severe sleepiness increased in male patients (odds ratio 3.52), and when microarousal index was more than 30 (odds ratio 6.12), apnea-hypopnea index more than 35 (odds ratio 4.25), mean desaturation less than 90% (odds ratio 4.09), maximum desaturation less 80% (odds ratio 3.06), general desaturation index more than 36 per hour (odds ratio 2.86), desaturation index during non-REM sleep more than 38 per hour (odds ratio 3.2). In the multivariate analysis only arousal index more than 30 per hour increased a probability of severe sleepiness in patients with OSA (odds ratio 4.97).

CONCLUSIONS

Hypoxemia depth at night is an important factor for daytime sleepiness having obstructive sleep apnea, but the most important is microarousal index. Hypoxemia depth depends on initial saturation and patients' body-mass index.