Liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) methods for the therapeutic drug monitoring of cytotoxic anticancer drugs: An update

In the era of precision medicine, there is increasing evidence that conventional cytotoxic agents may be suitable candidates for therapeutic drug monitoring (TDM)- guided drug dosage adjustments and patient's tailored personalization of non-selective chemotherapies. To that end, many liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) assays have been developed for the quantification of conventional cytotoxic anticancer chemotherapies, that have been comprehensively and critically reviewed. The use of stable isotopically labelled internal standards (IS) of cytotoxic drugs was strikingly uncommon, accounting for only 48 % of the methods found, although their use could possible to suitably circumvent patients' samples matrix effects variability. Furthermore, this approach would increase the reliability of cytotoxic drug quantification in highly multi-mediated cancer patients with complex fluctuating pathophysiological and clinical conditions. LC-MS/MS assays can accommodate multiplexed analyses of cytotoxic drugs with optimal selectivity and specificity as well as short analytical times and, when using stable-isotopically labelled IS for quantification, provide concentrations measurements with a high degree of certainty. However, there are still organisational, pharmacological, and medical constraints to tackle before TDM of cytotoxic drugs can be more largely adopted in the clinics for contributing to our ever-lasting quest to improve cancer treatment outcomes.

Targeted therapies and checkpoint inhibitors in sarcoma

Sarcomas are defined as a group of mesenchymal malignancies with over 100 heterogeneous subtypes. As a rare and difficult to diagnose entity, micrometastasis is already present at the time of diagnosis in many cases. Current treatment practice of sarcomas consists mainly of surgery, (neo)adjuvant chemo- and/or radiotherapy. Although the past decade has shown that particular genetic abnormalities can promote the development of sarcomas, such as translocations, gain-of-function mutations, amplifications or tumor suppressor gene losses, these insights have not led to established alternative treatment strategies so far. Novel therapeutic concepts with immunotherapy at its forefront have experienced some remarkable success in different solid tumors while their impact in sarcoma remains limited. In this review, the most common immunotherapy strategies in sarcomas, such as immune checkpoint inhibitors, targeted therapy and cytokine therapy are concisely discussed. The programmed cell death (PD)-1/PD-1L axis and apoptosis-inducing cytokines, such as TNF-related apoptosis-inducing ligand (TRAIL), have not yielded the same success like in other solid tumors. However, in certain sarcoma subtypes, e.g. liposarcoma or undifferentiated pleomorphic sarcoma, encouraging results in some cases when employing immune checkpoint inhibitors in combination with other treatment options were found. Moreover, newer strategies such as the targeted therapy against the ancient cytokine macrophage migration inhibitory factor (MIF) may represent an interesting approach worth investigation in the future.

Hemispheric functional segregation facilitates target detection during sustained visuospatial attention

Visuospatial attention is strongly lateralized, with the right hemisphere commonly exhibiting stronger activation and connectivity patterns than the left hemisphere during attentive processes. However, whether such asymmetry influences inter‐hemispheric information transfer and behavioral performance is not known. Here we used a region of interest (ROI) and network‐based approach to determine steady‐state fMRI functional connectivity (FC) in the whole cerebral cortex during a leftward/rightward covert visuospatial attention task. We found that the global FC topology between either ROIs or networks was independent on the attended side. The side of attention significantly modulated FC strength between brain networks, with leftward attention primarily involving the connections of the right visual network with dorsal and ventral attention networks in both the left and right hemisphere. High hemispheric functional segregation significantly correlated with faster target detection response times (i.e., better performance). Our findings suggest that the dominance of the right hemisphere in visuospatial attention is associated with an hemispheric functional segregation that is beneficial for behavioral performance.

Cortical laminar resting-state signal fluctuations scale with the hypercapnic blood oxygenation level-dependent response

Calibrated functional magnetic resonance imaging can remove unwanted sources of signal variability in the blood oxygenation level‐dependent (BOLD) response. This is achieved by scaling, using information from a perfusion‐sensitive scan during a purely vascular challenge, typically induced by a gas manipulation or a breath‐hold task. In this work, we seek for a validation of the use of the resting‐state fluctuation amplitude (RSFA) as a scaling factor to remove vascular contributions from the BOLD response. Given the peculiarity of depth‐dependent vascularization in gray matter, BOLD and vascular space occupancy (VASO) data were acquired at submillimeter resolution and averaged across cortical laminae. RSFA from the primary motor cortex was, thus, compared to the amplitude of hypercapnia‐induced signal changes (tSD_hc) and with the M factor of the Davis model on a laminar level. High linear correlations were observed for RSFA and tSD_hc (R² = 0.92 ± 0.06) and somewhat reduced for RSFA and M (R² = 0.62 ± 0.19). Laminar profiles of RSFA‐normalized BOLD signal changes yielded good agreement with corresponding VASO profiles. Overall, this suggests that RSFA contains strong vascular components and is also modulated by baseline quantities contained in the M factor. We conclude that RSFA may replace the scaling factor tSD_hc for normalizing the laminar BOLD response.

Surgery of the lateral skull base: a 50-year endeavour

Disregarding the widely used division of skull base into anterior and lateral, since the skull base should be conceived as a single anatomic structure, it was to our convenience to group all those approaches that run from the antero-lateral, pure lateral and postero-lateral side of the skull base as “Surgery of the lateral skull base”. “50 years of endeavour” points to the great effort which has been made over the last decades, when more and more difficult surgeries were performed by reducing morbidity. The principle of lateral skull base surgery, “remove skull base bone to approach the base itself and the adjacent sites of the endo-esocranium”, was then combined with function preservation and with tailoring surgery to the pathology. The concept that histology dictates the extent of resection, balancing the intrinsic morbidity of each approach was the object of the first section of the present report. The main surgical approaches were described in the second section and were conceived not as a step-by-step description of technique, but as the highlighthening of the surgical principles. The third section was centered on open issues related to the tumor and its treatment. The topic of vestibular schwannoma was investigated with the current debate on observation, hearing preservation surgery, hearing rehabilitation, radiotherapy and the recent efforts to detect biological markers able to predict tumor growth. Jugular foramen paragangliomas were treated in the frame of radical or partial surgery, radiotherapy, partial “tailored” surgery and observation. Surgery on meningioma was debated from the point of view of the neurosurgeon and of the otologist. Endolymphatic sac tumors and malignant tumors of the external auditory canal were also treated, as well as chordomas, chondrosarcomas and petrous bone cholesteatomas. Finally, the fourth section focused on free-choice topics which were assigned to aknowledged experts. The aim of this work was attempting to report the state of the art of the lateral skull base surgery after 50 years of hard work and, above all, to raise questions on those issues which still need an answer, as to allow progress in knowledge through sharing of various experiences. At the end of the reading, if more doubts remain rather than certainties, the aim of this work will probably be achieved.

P14.46 SUBEPENDYMAL GIANT CELLS ASTROCYTOMA (SEGA) IN TUBEROUS SCLEROSIS COMPLEX (TSC): A SERIES OF 31 PATIENTS

Background

Subependymal Giant Cells Astrocytomas (SEGAs) are characteristic of Tuberous Sclerosis Complex (TSC). They are usually benign tumors but may rapidly grow and cause hydrocephalus and raised intracranial pressure. Surgery is mandatory for large and symptomatic SEGAs

METHODS

31 patients harboring SEGAs in TSC were admitted for surgery. The main indications for surgery were tumor size and location, tumoral growth and cystization/hemorrhage, and hydrocephalus. In presence of symptomatic hydrocephalus firts surgery aimed to reduce intracranial pressure

RESULTS

Forty-four surgeries were performed in 31 patients achieving Gross Total and Subtotal Removal in 36 and 8 patients respectively. Recurrences occurred in 11 patients; nine of them were reoperated while two were administered therapy with m-TOR pathway inhibitors. Surgical morbidity and mortality accounted for 22.7% and 2.3% respectively; hydrocephalus was the main complication. After an average follow-up of 5 years, 90% of patients had no evidence of the disease and most (93,3%) had a good clinical status after surgery; 12 out of 30 patients (40%) had a VP-shunt for hydrocephalus

Conclusions

GTR is feasible and represents the treatment of choice of SEGAs in TSC. Therapy with m-TOR pathway inhibitors is to be considered in selected patients and especially in recurrences of SEGAs

P08.03 Separation and divorce after the diagnosis of child’s brain tumor

BACKGROUND

The diagnosis of a child’s brain tumor is a terrible situation for every member of the family. Numerous are the case of separations and divorces in Italy after a diagnosis of a child’s cancer. In particular, it happens with parents of children affected with brain tumor, being the most frequent solid tumor and the first cause of a tumor child’s death. The crisis related to the discovery of a tumor consists of four phases: shock, reaction, processing and re-orientation. It can happen that the diagnosis, experienced as a traumatic experience, can unite the family members as well as separate them. If there is already a process of family disintegration, a trauma can be a cause for breakup. The aim of our study was to investigate the possible correlation between brain tumor diagnosis in children and parental separations/divorces.

MATERIAL AND METHODS

We considered 427 patients afferent from 2012 to 2018 to the Neuro-Oncology Unit of the Meyer Children’s Hospital. Brain tumors are the 55–60% of all the tumors of our hospital, with an extra-regionality greater than 65%. The data analysis was conducted through information obtained directly from the families during follow-up visits or by telephone interviews.

RESULTS

Consistent with literature data in our series, the most frequent brain tumors were low-grade gliomas medulloblastomas, high-grade gliomas, ependymomas, midline diffuse gliomas, craniopharyngiomas, germ cell tumors and other rare pediatric tumors. The population was divided in 16 females and 18 males from different Italian regions: 65% from Central Italy, 23% from the South and Islands, 12% from the North. Data analysis showed 34 cases of separation and/or divorce, equal to 7% of our whole population, during treatment and more frequently at the end of treatment or after death. The median age of the 34 patients at the diagnosis of brain tumor was 9.5 years (range 1–19 years), with a higher percentage of cases of separations (41%) for parents of patients aged 10 years-14 years; 7 were the cases of separation and/or divorce when the diagnosis of brain tumor was made around 12–48 months after the child birth.

CONCLUSION

The diagnosis of a child’s brain tumor can generate stress in the family leading to different reactions, such as conflicts between parents or a real family crisis. The results of our study suggest a possible correlation between the diagnosis of a child’s brain tumor and the cases of separation and/or divorce. High risk medulloblastomas and high-grade gliomas that are likely to have a shorter path due to the unfavorable prognosis of the disease, appear to be the pathologies more often related to situations of family disputes. However, further investigations are necessary to verify the trend emerged from our study respect to the normal population.

P04.08 The role of SCN1A in glioblastomas and mixed neuronal glial tumors of pediatric age

BACKGROUND

Low and high grade gliomas, are the most common pediatric central nervous system (CNS) tumors and they show an extremely broad range of clinical behavior. Pediatric glioma is distinct from its adult counterpart with different genetic/epigenetic profile and biological features. Recently, several studies have shown the involvement of voltage-gated Na+ channels (VGSC) in different types of cancer, including gliomas. VGSC are multimeric transmembrane complexes, responsible for membrane depolarization in excitable cells playing an important role also in cell proliferation, migration, apoptosis and differentiation. VGSC are therapeutic targets in cardiovascular and neurological disorders and, in cancers, they could be a novel target for the development of promising anticancer therapy

MATERIAL AND METHODS

Firstly, we explored the genetic background of 9 pediatric glioblastomas (1–9 pGBMs), through whole-exome sequencing (WES) using HiSeq1000 platform (Illumina) with paired-end approach. On the basis of our results, we extended our study in another group of 16 epileptogenic mixed neuronal-glial tumors of pediatric age, (WHO grade I and II), through an amplicon approach (TSCA) using MiniSeq System platform (Illumina)

RESULTS

We identified variants in SCN1A gene in 3/9 pGBMs: case 3 had c.5782C>G in tumor and blood; case 5 showed c.2278G>T and two mosaic variants (c.5933C>T, 22% and c.4942C>T, 14%); case 6 showed c.667G>T variant only in tumor, and not in other non tumoral tissues (blood, urine and buccal swab). No variants in SCN1A were identified in a group of 16 pediatric mixed gliomas

CONCLUSION

In this study, we explore the genetic background of two groups of pediatric neuroepithelial brain tumors, through Next generation sequencing approach. We identified only in pGBMs variants in SCN1A gene that encoded for VGSCs and is involved in a spectrum of early-onset epileptic encephalopathies. None of our mutated patients showed history of epilepsy. Now, it is not clear the significance of these variants in pGBMs but interestingly, these variants are present in pGBM and not in mixed gliomas. Further studies on a big cohort of patients are needed to establish if they could play a role in pGBMs aggressiveness, migration and progression. Moreover, VGSCs could be a pharmacological target in pGBMs treatment

P14.43 Histone H3F3A and HIST1H3B K27M mutations in pediatric high-grade gliomas: the Florentine experience

Background

Pediatric high- grade gliomas (HGGs) represent a malignancy with a poor survival. The genetic analysis of these entities has identified useful mutations for an improved prognostic framing. The research of mutations in all H3 histone variants (HIST1H3B and H3F3A) could be usefull to define tumors with different prognosis and phenotypes inasmuch they seems to drive two distinct oncogenic programmes.

MATERIALS E METHODS

We performed a retrospective analysis of pediatric HGGs. We evaluated the type of histone H3 mutated and we performed a meta-analysis comparing our results with literature data.

RESULTS

We evaluated 41 cases of pediatric HGGs (median age of patients: 7 years old, range: 0–32):): 32 anaplastic astrocytoma (78,5%), 9 glioblastoma multiforme (25,9%), We have researched the K27M mutations in the distinct histone H3 variants (i.e. HIST1H3B and H3F3A). The mutation H3F3A K27M was found in 6 patients instead HIST1H3B K27 mutations was found in a single patient with GBM. All the patients with H3F3A K27M mutation had a progression disease but without statistical correlation (p:0,07). They had a worse prognosis with a median overall survival of 15,5 months (p: 0.0014) versus wild type patients (not reached). H3.3K27M mutation status is a significant predictor of OS with a hazard ratio of 4.499 (p = 0.0001). The patient with HIST1H3B K27 mutation died after first line of therapy.

Conclusions

Due to the low incidence of the mutation HIST1H3B in our series we can’t define the difference with two variants. However, the research of K27M mutation in HGGs has diagnostic and prognostic role. The role of histone H3 mutated could predict the outcome in HGGs patients and it could give us more informations compared to the clinic and radiological characteristic of the tumors.

End-to-side innervated sensate radial forearm flap in the hand: A 5-year follow-up

Optimal functional reconstruction of the palmar surface of the hand requires good sensibility especially for the thumb and the radial side of the fingers. We report the long-term results of a distally based radial forearm flap (RFF) used for soft tissue coverage in the palm, index and middle finger and an end-to-side neurorrhaphy between the lateral antebrachial cutaneous nerve (LACN) and the proper palmar digital nerve of the middle finger to restore sensation. At 5 years' follow-up, the patient's sensory recovery was assessed through static and moving two-point discrimination, light touch sensation, pain perception, hot and cold temperature perception, an electrophysiological study and sweat test. An S3+ sensory recovery on the British Medical Research Council scale, as modified by Mackinnon and Dellon, was noted together with a good perception in the palm compared to decreased perception in the volar surface of the proximal phalanx. These findings prove that the RFF can provide good functional coverage of the palm together with good sensitivity by end-to-side reinnervation.

High-Resolution CBV-fMRI Allows Mapping of Laminar Activity and Connectivity of Cortical Input and Output in Human M1

Layer-dependent fMRI allows measurements of information flow in cortical circuits, as afferent and efferent connections terminate in different cortical layers. However, it is unknown to what level human fMRI is specific and sensitive enough to reveal directional functional activity across layers. To answer this question, we developed acquisition and analysis methods for blood-oxygen-level-dependent (BOLD) and cerebral-blood-volume (CBV)-based laminar fMRI and used these to discriminate four different tasks in the human motor cortex (M1). In agreement with anatomical data from animal studies, we found evidence for somatosensory and premotor input in superficial layers of M1 and for cortico-spinal motor output in deep layers. Laminar resting-state fMRI showed directional functional connectivity of M1 with somatosensory and premotor areas. Our findings demonstrate that CBV-fMRI can be used to investigate cortical activity in humans with unprecedented detail, allowing investigations of information flow between brain regions and outperforming conventional BOLD results that are often buried under vascular biases.

The levels of vancomycin in the blood and the wound after the local treatment of bone and soft-tissue infection with antibiotic-loaded calcium sulphate as carrier material

AIMS

Calcium sulphate (CaSO₄) is a resorbable material that can be used simultaneously as filler of a dead space and as a carrier for the local application of antibiotics. Our aim was to describe the systemic exposure and the wound fluid concentrations of vancomycin in patients treated with vancomycin-loaded CaSO₄ as an adjunct to the routine therapy of bone and joint infections.

PATIENTS AND METHODS

A total of 680 post-operative blood and 233 wound fluid samples were available for analysis from 94 implantations performed in 87 patients for various infective indications. Up to 6 g of vancomycin were used. Non-compartmental pharmacokinetic analysis was performed on the data from 37 patients treated for an infection of the hip.

RESULTS

The overall systemic exposure remained within a safe range, even in patients with post-operative renal failure, none requiring removal of the pellets. Local concentrations were approximately ten times higher than with polymethylmethacrylate (PMMA) as a carrier, but remained below reported cell toxicity thresholds. Decreasing concentrations in wound fluid were observed over several weeks, but remained above the common minimum inhibitory concentrations for Staphylococcus up to three months post-operatively.

CONCLUSION

This study provides the first pharmacokinetic description of the local application of vancomycin with CaSO₄ as a carrier, documenting slow release, systemic safety and a release profile far more interesting than from PMMA. In particular, considering in vitro data, concentrations of vancomycin active against staphylococcal biofilm were seen for several weeks. Cite this article: Bone Joint J 2017;99-B:1537-44.

[Necrotizing Fasciitis: A comprehensive review]

Even though necrotizing fasciitis is considered a rare disease, the spreading of the predisposing factors such as diabetes and chronic diseases, contribute to increase the incidence of this infection. Thus, how to diagnose and treat this clinical pathology, which represents an emerging need. This infection could be fatal for patients if not early diagnosed and treated and it represents a challenge both for the clinicians both for the surgeons. From this consideration was born the idea to write this review article in order to furnish to the readers a helpful tool in the management of this disease starting from its clinical and epidemiological features leading to the diagnosis, both clinical and radiological, and concluding with the treatment both medical both surgical .This article reviews literature on PubMed/MEDLINE with key words "necrotizing", "fasciitis" and "necrotizing fasciitis" from 1967 to 2014, considering all the aspects of the disease. The authors attempt to draw comparisons to their own experience managing this condition to give an Italian perspective to the condition.

Dosage optimization of treatments using population pharmacokinetic modeling and simulation

Pharmacokinetic variability in drug levels represent for some drugs a major determinant of treatment success, since sub-therapeutic concentrations might lead to toxic reactions, treatment discontinuation or inefficacy. This is true for most antiretroviral drugs, which exhibit high inter-patient variability in their pharmacokinetics that has been partially explained by some genetic and non-genetic factors. The population pharmacokinetic approach represents a very useful tool for the description of the dose-concentration relationship, the quantification of variability in the target population of patients and the identification of influencing factors. It can thus be used to make predictions and dosage adjustment optimization based on Bayesian therapeutic drug monitoring (TDM). This approach has been used to characterize the pharmacokinetics of nevirapine (NVP) in 137 HIV-positive patients followed within the frame of a TDM program. Among tested covariates, body weight, co-administration of a cytochrome (CYP) 3A4 inducer or boosted atazanavir as well as elevated aspartate transaminases showed an effect on NVP elimination. In addition, genetic polymorphism in the CYP2B6 was associated with reduced NVP clearance. Altogether, these factors could explain 26% in NVP variability. Model-based simulations were used to compare the adequacy of different dosage regimens in relation to the therapeutic target associated with treatment efficacy. In conclusion, the population approach is very useful to characterize the pharmacokinetic profile of drugs in a population of interest. The quantification and the identification of the sources of variability is a rational approach to making optimal dosage decision for certain drugs administered chronically.

A simple model to assess nitrogen and phosphorus contamination in ungauged surface drainage networks: application to the Massaciuccoli Lake Catchment, Italy

Modeling is a common practice to evaluate factors affecting water quality in environmental systems impaired by point and nonpoint losses of N and P. Nevertheless, in situations with inadequate information, such as ungauged basins, a balance between model complexity and data availability is necessary. In this paper, we applied a simplified analytical model to an artificially drained floodplain in central-western Italy to evaluate the importance of different nutrient sources and in-stream retention processes and to identify critical source areas. We first considered only a set of chemical concentrations in water measured from February through May 2008 and from November 2008 through February 2009. We then broadened available data to include water discharge and hydraulic-head measurements to construct a hydrogeological model using MODFLOW-2000 and to evaluate the reliability of the simplified method. The simplified model provided acceptable estimates of discharge (ranging from 0.03-0.75 m s) and diffuse nutrient inputs from water table discharge and in-stream retention phenomena. Estimates of PO-P and total P retention (ranging from 1.0 to 0.6 μg m s and from 1.18 to 0.95 μg m s for PO-P and total P, respectively) were consistent with the range of variability in literature data. In contrast, the higher temporal variability of nitrate concentrations decreased model accuracy, suggesting the need for more intensive monitoring. The model also separated the dynamics of different reaches of the drainage network and identified zones considered critical source areas and buffer zones where pollutant transport is reduced.

Representation of HIV/Aids and Mental Health Co-Morbidity in Medical and Social Sciences Literature

Introduction:

Aim of this article is to explore the ways in which, over the last 25 years, knowledge about HIV/Aids and Mental Health co-morbidity has been represented within medical and social sciences literature.

Methods:

The study has been conducted on the texts of 1101 published manuscripts abstracts within from 1984 to 2008, referring to 379 different journals and retrieved on PUBMED database. It was used the following database search string: ("mental health"[Title/Abstract]) or ("mental illness"[Title/Abstract]) AND (("aids"[Title/Abstract]) or ("hiv"[Title/Abstract]))). A Computer Aided Text Analysis was conducted with dedicated software: T-Lab (Lancia) using Cluster Analysis.

Results:

Cluster Analysis allowed to identify five different main dimensions: 1:(27,68%) Health-care Service organizational development; 2: (22,10%) Mental health as empowering precursor of infection risks. 3: (8,58%) Quality of life; 4: (19,17%). Therapies and treatments’ research; 5: (22,46%) Psychological issues, emotions and distress correlated to seropositive patients and their caregivers. Figure 1 it is a way to outline the five clusters literature trends over the time of 25 years.

Conclusions:

Our review could help to identify particular areas in need of change, to provide a baseline against which to assess future changes and to provide data for use in research health planning and policy analysis.

[Radioprotection: doctrinaire references and medical surveillance]

The current statement of radioprotection, as formulated in the 60/90 ICRP Publication and confirmed in the recent 103/07 ICRP Publication, strengths the conceptual principle of the optimization, justification and limitation of doses, it analyses the risk and proposes the values of dose limitation, according to socio-medical considerations. The medical radioprotection's aim moved from the limitation of deterministic damages ("tissue reactions" according to ICRP 103/07) to the probability's reduction of stochastic effects appearance. The "tissue reaction problem" was solved maintaining the exposition limits under the threshold. All the Radiological Protection System is orientated toward the reduction of stochastic effects appearence based on epidemiological evidences (if findable) and caution: caution is represented by LNT (Linear No-Threshold Hypotesis). This hypothesis permits to apply criteria of risk's evaluation by mathematics intruments. Even if sometimes this hypothesis was scientifically criticized recently (ICRP 103/07) it's been considered valid for the prevention in the radiological protection sphere. The medical radioprotection is interested in worker's general state of health. This state of health should be compatible with specific work's conditions and permit to formulated a judgement of fitness. This compatibility (without contraindication) shall be kept and checked time by bringing about preventive measures and, in the same time, picking out the first signs of any pathologies. Therefore with the radioprotection we can talk about genetic individual susceptibility to neoplasia. Especially with the moleculer genetics we can recognize a quite big number of hereditary defects combined with family predisposition to cancer. The medical surveillance therefore has to be a prevention activity for each individual worker considering his ipersusceptibility, his specific working risk, his particular state of health, his habits, his family predisposition, his aspirations and his socio-cultural context.

Lrrk2 R1441C parkinsonism is clinically similar to sporadic Parkinson disease

OBJECTIVE

Leucine-rich repeat kinase 2 (LRRK2) mutations are the most common cause of Parkinson disease (PD). Several dominantly inherited pathogenic substitutions have been identified in different domains of the Lrrk2 protein. Herein, we characterize the clinical and genetic features associated with Lrrk2 p.R1441C.

METHODS

We identified 33 affected and 15 unaffected LRRK2 c.4321C>T (p.R1441C) mutation carriers through an international consortium originating from three continents. The age-specific cumulative incidence of PD was calculated by Kaplan-Meier analysis.

RESULTS

The clinical presentation of Lrrk2 p.R1441C carriers was similar to sporadic PD and Lrrk2 p.G2019S parkinsonism. The mean age at onset for parkinsonism was 60 years, range 30-79 years; fewer than 20% of the patients had symptoms before the age 50 years, while by 75 years >90% of them had developed symptoms. Haplotype analysis suggests four independent founders for the p.R1441C mutation.

CONCLUSIONS

The distribution in age at onset and clinical features in Lrrk2 p.R1441C patients are similar to idiopathic and Lrrk2 p.G2019S parkinsonism. Several independent founders of the p.R1441C substitution suggest this site is prone to recurrent mutagenesis.

Analysis and reliability of posturographic parameters in Parkinson patients at an early stage

Aim of this work was to evaluate Parkinsonian (PARK) patients at their initial stage of the disease by static posturography in order to study: the stability of posture system; the role of visual input; the influence of an acute administration of levodopa. This would allow the creation of a database that can be useful to follow the progression of the disease. Attention was also focused on the assessment of the reliability of quantitative posturographic parameters (PP); a large number of PP that can be derived using classical, structural, and nonlinear approaches have been considered. Particular attention has been given to this latter approach. The class of PD subjects examined in this work resulted to be very different from classical Parkinsonian subjects studied in literature.

Antinuclear antibodies giving the 'multiple nuclear dots' or the 'rim-like/membranous' patterns: diagnostic accuracy for primary biliary cirrhosis

BACKGROUND

Serum antinuclear antibodies giving the 'multiple nuclear dots' or the 'rim-like/membranous' patterns are frequently detected by indirect immunofluorescence on HEp-2 cells in patients with primary biliary cirrhosis.

AIM

To assess the accuracy of multiple nuclear dot and rim-like/membranous antinuclear antibodies for the diagnosis of primary biliary cirrhosis.

METHODS

Sera from 4371 consecutive patients referred to our laboratory were analysed under code for antinuclear antibodies testing by indirect immunofluorescence on HEp-2 cells.

RESULTS

Review of the clinical records of the 4371 patients allowed identification of 101 patients with antimitochondrial antibody-positive primary biliary cirrhosis and 22 with antimitochondrial antibody-negative variant. Multiple nuclear dot and/or rim-like/membranous patterns were found in 59 (1.3%) of the 4371 patients: 31 antimitochondrial antibody-positive primary biliary cirrhosis, 17 antimitochondrial antibody-negative primary biliary cirrhosis and 11 non-primary biliary cirrhosis. The specificity for primary biliary cirrhosis of both the antinuclear antibodies pattern was 99%. Positive predictive value and likelihood ratio for a positive test were 86% (95% CI: 72.7-94) and 221 (95% CI: 91.7-544) for multiple nuclear dot, 79% (95% CI: 62.2-90.1) and 132 (95% CI: 56.8-312.7) for rim-like/membranous, respectively.

CONCLUSIONS

Multiple nuclear dot and rim-like/membranous antinuclear antibodies are rare findings. Their positivity strongly suggests the diagnosis of primary biliary cirrhosis, irrespective of antimitochondrial antibody status. The high specificity for primary biliary cirrhosis makes them a useful diagnostic tool especially in antimitochondrial antibody-negative patients.

Autoimmune enteropathy and rheumatoid arthritis: a new association in the field of autoimmunity

We report the case of a 35-year-old woman with a diagnosis of coeliac disease at the age of 32 due to a severe malabsorption and flat mucosa without endomysial and tissue transglutaminase antibodies. The lack of clinical and histological improvement after 1 year of a gluten-free diet led to a diagnosis of refractory sprue. She had a good clinical response to steroids that were stopped after 3 months when she became pregnant. After delivery, she again started to complain of malabsorption with arthritis. Positivity for enterocyte autoantibodies together with a flat mucosa persistence allowed to identify a condition of autoimmune enteropathy; moreover, a rheumatological assessment gave evidence of an associated rheumatoid arthritis. Treatment by steroids and methotrexate brought to the remission of intestinal and articular symptoms together with an improvement of duodenal histology. This is the first description of an autoimmune enteropathy associated with rheumatoid arthritis. Autoimmune enteropathy should be always ruled out in patients with a villous atrophy unresponsive to a gluten-free diet, autoimmune manifestations and negativity of coeliac disease markers.

Antibodies to filamentous actin (F-actin) in type 1 autoimmune hepatitis

AIMS

To evaluate the diagnostic significance of anti-filamentous actin antibodies (A-FAA) assessed with a commercial ELISA in comparison with immunofluorescence reactivity and patterns of anti-smooth muscle antibodies (SMA); and to correlate A-FAA positivity with clinical, immunogenetic, laboratory, and histological features in patients with autoimmune hepatitis type 1 (AIH-1).

METHODS

We studied 78 consecutive untreated AIH-1 patients and 160 controls: 22 with autoimmune hepatitis type 2 (AIH-2), 51 with hepatitis C, 17 with coeliac disease (CD), 20 with primary biliary cirrhosis (PBC) and 50 blood donors. SMA was evaluated by indirect immunofluorescence (IIF) on frozen sections of rat tissues, and A-FAA with a modified commercial ELISA.

RESULTS

SMA was detected by IIF in 61 (78%) of 78 AIH-1 patients, of whom 47 (60%) had the SMA-T/G and 14 (18%) the SMA-V pattern. Of the pathological controls, 32 (20%) had the SMA-V pattern (25 with hepatitis C, 2 with AIH-2, 2 with PBC, 3 with CD). A-FAA were present in 55 AIH-1 patients (70.5%; 46 with SMA-T/G, 7 with SMA-V, and 2 SMA-negative), and in 10 controls (6%), of whom five had hepatitis C, two AIH-2, two PBC and one CD. The association between A-FAA and the SMA-T/G pattern was statistically significant (p<0.0001). A-FAA levels were higher in SMA-T/G positive than SMA-V positive AIH-1 patients and controls (p<0.0001). A-FAA positivity was significantly associated with higher gamma-globulin and IgG levels, but did not correlate with other considered parameters.

CONCLUSION

The modified A-FAA ELISA strictly correlates with the SMA-T/G pattern and is a reliable and operator independent assay for AIH-1. Detection of A-FAA, even if devoid of prognostic relevance, may be useful when interpretative doubts of standard IIF arise.

Early-onset parkinsonism associated with PINK1 mutations: frequency, genotypes, and phenotypes

OBJECTIVE

To assess the prevalence, nature, and associated phenotypes of PINK1 gene mutations in a large series of patients with early-onset (<50 years) parkinsonism.

METHODS

The authors studied 134 patients (116 sporadic and 18 familial; 77% Italian) and 90 Italian controls. The whole PINK1 coding region was sequenced from genomic DNA; cDNA was analyzed in selected cases.

RESULTS

Homozygous pathogenic mutations were identified in 4 of 90 Italian sporadic cases, including the novel Gln456Stop mutation; single heterozygous truncating or missense mutations were found in another 4 Italian sporadic cases, including two novel mutations, Pro196Leu and Gln456Stop. Pathogenic mutations were not identified in the familial cases. Novel (Gln115Leu) and known polymorphisms were identified with similar frequency in cases and controls. In cases carrying single heterozygous mutation, cDNA analysis detected no additional mutations, and revealed a major pathogenic effect at mRNA level for the mutant C1366T/Gln456Stop allele. All patients with homozygous mutations had very early disease onset, slow progression, and excellent response to l-dopa, including, in some, symmetric onset, dystonia at onset, and sleep benefit, resembling parkin-related disease. Phenotype in patients with single heterozygous mutation was similar, but onset was later.

CONCLUSIONS

PINK1 homozygous mutations are a relevant cause of disease among Italian sporadic patients with early-onset parkinsonism. The role of mutations found in single heterozygous state is difficult to interpret. Our study suggests that, at least in some patients, these mutations are disease causing, in combination with additional, still unknown factors.

Hepatic steatosis in chronic hepatitis C: impact on response to anti-viral treatment with peg-interferon and ribavirin

BACKGROUND

There is increasing evidence that hepatic steatosis contributes to the progression of liver fibrosis, whereas its impact on the efficacy of anti-viral treatment is still under investigation.

AIM

To evaluate the effect of steatosis on the outcome of combined anti-viral treatment.

METHODS

We studied 102 consecutive naive patients with chronic hepatitis C receiving combined anti-viral therapy (peg-interferon alpha-2b and ribavirin).

RESULTS

Fifty (49%) of 102 patients had evidence of hepatic steatosis (29 grade 1, 16 grade 2 and 5 grade 3). Sustained virological response was similar in patients with and without steatosis (58% vs. 56%); moreover, the grade of steatosis did not affect the rate of sustained virological response (grade 1: 58%, grade 2: 56% and grade 3: 60%). Patients with steatosis had significantly higher serum levels of aspartate transaminase, alanine transaminase and gamma-glutamyltransferase (P = 0.007, 0.004 and 0.03, respectively), higher histological activity (P = 0.03), more advanced stage of fibrosis (P = 0.0394) and more often hepatitis C virus genotype 3 (P = 0.04).

CONCLUSIONS

Our findings suggest that hepatic steatosis in chronic hepatitis C, irrespective of its grade, is not a negative prognostic factor of response to combined anti-viral therapy, even when the histological and biochemical profile of the disease is more aggressive.

IGF-I stimulates proliferation of spontaneously immortalized human keratinocytes (HACAT) by autocrine/paracrine mechanisms

HaCaT keratinocytes are derived from adult human skin and although spontaneously immortalized, remain highly related to their normal counterparts. We observed that HaCaT cells can proliferate in serum-free medium (SFM), in contrast to normal human keratinocytes whose growth in vitro requires a feeder layer and/or the supplementation with hormones and growth factors. Since autocrine production of growth factors has been proposed as the pathway that cells may exploit to escape growth regulation, we have investigated whether this is occurring in HaCaT cultured in SFM. Either epidermal growth factor (EGF) or insulin-like growth factor-1 (IGF-I) was effective and dose-dependently stimulated HaCaT replication. The ability of these keratinocytes to express EGF and IGF-I and their receptors was investigated by northern blot and reverse transcriptase-polymerase chain reaction (RT-PCR). We report that HaCaT cells synthesize mRNAs for IGF-I, IGF-II, IGF-IR and EGF-R but not EGF mRNA. Immunoneutralization of IGF-I with specific monoclonal antibodies blocked spontaneous HaCaT proliferation in SFM, as did incubation with antibodies against IGF-IR. These data demonstrate that an autocrine/paracrine loop based on IGF-I may allow HaCaT keratinocytes to proliferate autonomously in culture in contrast to keratinocytes in primary culture. A similar mechanism may be involved in the development of hyperproliferative diseases of human skin and its functional disruption may represent the target for therapeutic approaches.