CD38 expression by plasma cells in extramedullary multiple myeloma

Not available.

Advancing the PD-L1 CPS test in metastatic TNBC: Insights from pathologists and findings from a nationwide survey

Pembrolizumab has received approval as a first-line treatment for unresectable/metastatic triple-negative breast cancer (mTNBC) with a PD-L1 combined positive score (CPS) of ≥ 10. However, assessing CPS in mTNBC poses challenges. Firstly, it represents a novel analysis for breast pathologists. Secondly, the heterogeneity of PD-L1 expression in mTNBC further complicates the assessment. Lastly, the lack of standardized assays and staining platforms adds to the complexity. In KEYNOTE trials, PD-L1 expression was evaluated using the IHC 22C3 pharmDx kit as a companion diagnostic test. However, both the 22C3 pharmDx and VENTANA PD-L1 (SP263) assays are validated for CPS assessment. Consequently, assay-platform choice, staining conditions, and scoring methods can significantly impact the testing outcomes. This consensus paper aims to discuss the intricacies of PD-L1 CPS testing in mTNBC and provide practical recommendations for pathologists. Additionally, we present findings from a nationwide Italian survey elucidating the state-of-the-art in PD-L1 CPS testing in mTNBC.

[Covid-19 emergency and telemedicine: multifamily psychoeducational intervention in a forensic setting.]

AIM

The aim is to describe remote multifamily psychoeducational intervention led by REMS "Castore" team (an Italian health care facility for offenders who suffer from mental disorders and socially dangerous) in ASL Roma 5, a local health authority, during covid-19 emergency.

METHODS

The applied theoretical models have been the integrated psychoeducational intervention by I. Falloon and the multifamily psychoeducational intervention based on problem solving by F. Veltro. The multifamily psychoeducational intervention was attempted by inpatients' relatives from June to August 2020 with 8 weekly meetings of 90' each led by two psychiatric rehabilitation therapists and healthcare experts. Six families were involved in the study and its members were assessed by questionnaire on family problems, Brief-COPE and general health questionnaire tests. Users were assessed by Level of Expressed Emotion Scale test for their expressed emotion.

RESULTS

Data analysis highlighted the general low level of subjective and objective burden for family members in association with a high perception of that support provided by REMS. Furthermore, the study has shown those coping approaches oriented to the research of practical solutions, acceptance of events and assertive communication.

DISCUSSION

The low subjective and objective burden may be attributed to implicit security conditions in REMS and the absence of tasks mainly carried out by experts. Those coping styles oriented to more practical than emotional approaches suggest an emotional hyper control or stigma perception leading to isolation and loneliness.

CONCLUSIONS

The multifamily psychoeducational intervention has allowed a trustworthy relationship with REMS. Considering that the families involved in the study have never benefited by other psychoeducational interventions before, their early involvement appears to be a potential tool for preventing and managing crisis as well as minimizing recidivism.

Non-suicidal self-injury and impulsivity: Study of inibithory control in adolescent population

Introduction

Non-suicidal self-injury (NSSI) is a clinical condition defined as intentional, self-inflicted act causing pain or superficial damage without suicidal intents (12-35% of the adolescent community). Several findings show a high correlation between NSSI and impairments in the impulsivity control.

Objectives

The goal of our study is to evaluate the role of impulsivity in NSSI adolescents, relatively to the inhibitory control, in order to investigate if it can represent a neurocognitive risk factor underlying maladaptive behaviours and which psychopathological dimensions can be associated with this neurobiological process.

Methods

30 NNSI inpatients (age range: 12 to 18 years), drug-free, were compared with an age-matched control group, using two behavioural paradigms for the study of inhibitory control: the Stop Signal task and the emotive go/Nogo. Psychopathological traits were evaluated by self-report questionnaires for impulsivity dimensions, suicidality and self-injurious acts. Statistical analyses were performed with SPSS program (p =0.05).

Results

NSSI patients did not present impairments in the global inhibitory control but they had longer movement times in both paradigms and faster reaction times in the Go/no-go behavioural paradigm. Therefore, NSSI patients tended to be impulsive at an early stage of movement (rapid TR) and have to slow down in a second phase (TM slow) in order to have time to rework the cognitive processes underlying movement.

Conclusions

The impulsivity dimension is a complex construct that involves multiple interconnected factors. The study of neuro-cognitive and psychopathological aspects and how they are interconnected is necessary to draw new perspectives on the etiopathogenesis of NNSI.

Bovine pestivirus is a new alternative virus for multiple myeloma oncolytic virotherapy

BACKGROUND

The oncolytic viruses have shown promising results for the treatment of multiple myeloma. However, the use of human viruses is limited by the patients' antiviral immune response. In this study, we investigated an alternative oncolytic strategy using non-human pathogen viruses as the bovine viral diarrhea virus (BVDV) that were able to interact with CD46.

METHODS

We treated several human myeloma cell lines and non-myeloma cell lines with BVDV to evaluate the expression of CD46 and to study the effect on cell viability by flow cytometry. The possible synergistic effect of bortezomib in combination with BVDV was also tested. Moreover, we infected the bone marrow mononuclear cells obtained from myeloma patients and we checked the BVDV effect on different cell populations, defined by CD138, CD14, CD3, CD19, and CD56 expression evaluated by flow cytometry. Finally, the in vivo BVDV effect was tested in NOD-SCID mice injected subcutaneously with myeloma cell lines.

RESULTS

Human myeloma cells were selectively sensitive to BVDV treatment with an increase of cell death and, consequently, of apoptotic markers. Consistently, bone marrow mononuclear cells isolated from myeloma patients treated with BVDV, showed a significant selective decrease of the percentage of viable CD138+ cells. Interestingly, bortezomib pre-treatment significantly increased the cytotoxic effect of BVDV in myeloma cell lines with a synergistic effect. Finally, the in vitro data were confirmed in an in vivo myeloma mouse model showing that BVDV treatment significantly reduced the tumoral burden compared to the vehicle.

CONCLUSIONS

Overall, our data indicate, for the first time, a direct oncolytic effect of the BVDV in human myeloma cells suggesting its possible use as novel alternative anti-myeloma virotherapy strategy.

Management of a periductal stromal tumor in a young woman: Our breast unit experience

Periductal stromal tumor (PDST) is a rare biphasic tumor of the breast that exhibits low-grade malignancy and intermediate behavior. It is characterized by proliferation of atypical spindle cells surrounding benign mammary ducts and infiltrating adjacent adipose tissue. PDST is distinguished from phyllodes tumor by its lack of leaf-like architecture; however, it is still unclear whether PDST is a separate entity or a certain spectrum of phyllodes tumor. Phyllodes tumors constitute a group of rare epithelial lesions of the breast which mainly develops at around 40-50 years. The histologic characteristics to be considered are many and often heterogeneous in the same lesion which makes interpretation in needle biopsy material difficult. Most phyllodes tumors have a benign nature, with a high rate of postsurgical recurrence. In the malignant form, metastases are described by distant hematogenous route; its indolent behavior implies a tight surgical management with precise excision of the lesion even if there is not, however, a unanimous consent on the parameters of accuracy of the margins.

Self-healing CD30- T-clonal proliferation of the tongue: report of an extremely rare case

Background

The etiology of traumatic ulcerative granulomas with stromal eosinophilia (TUGSE) is not clear, traumatic irritation having advocated as the most likely cause. TUGSEs are typically self-limiting slow-healing lesions of the oral mucosa with unclear pathogenesis, commonly manifesting as a rapidly developing, long-lasting ulcer.

Case presentation

Here we report a controversial case of a self-healing lesion of the tongue in a 57 year-old woman. A clonal T-cell proliferation and CD30 negative immunohistochemical (IHC) profile could be documented.

Discussion and conclusion

In view of the very peculiar clinical and histological features, a retrospective diagnosis of a TUGSE with scarce eosinophilic infiltrate (possibly in regression), displaying CD30- T-clonal proliferation was eventually rendered.

The patient did not report signs of recurrence after a 3-year follow-up period.

Prevalence and phenotype of the c.1529C>T SPG7 variant in adult-onset cerebellar ataxia in Italy

BACKGROUND AND PURPOSE

Hereditary ataxias are heterogeneous groups of neurodegenerative disorders, characterized by cerebellar syndromes associated with dysarthria, oculomotor and corticospinal signs, neuropathy and cognitive impairment. Recent reports have suggested mutations in the SPG7 gene, causing the most common form of autosomal recessive spastic paraplegia (MIM#607259), as a main cause of ataxias. The majority of described patients were homozygotes or compound heterozygotes for the c.1529C>T (p.Ala510Val) change. We screened a cohort of 895 Italian patients with ataxia for p.Ala510Val in order to define the prevalence and genotype-phenotype correlation of this variant.

METHODS

We set up a rapid assay for c.1529C>T using restriction enzyme analysis after polymerase chain reaction amplification. We confirmed the diagnosis with Sanger sequencing.

RESULTS

We identified eight homozygotes and 13 compound heterozygotes, including two novel variants affecting splicing. Mutated patients showed a pure cerebellar ataxia at onset, evolving in mild spastic ataxia (alternatively) associated with dysarthria (~80% of patients), urinary urgency (~30%) and pyramidal signs (~70%). Comparing homozygotes and compound heterozygotes, we noted a difference in age at onset and Scale for the Assessment and Rating of Ataxia score between the two groups, supporting an earlier and more severe phenotype in compound heterozygotes versus homozygotes.

CONCLUSIONS

The SPG7 c.1529C>T (p.Ala510Val) mutants accounted for 2.3% of cerebellar ataxia cases in Italy, suggesting that this variant should be considered as a priority test in the presence of late-onset pure ataxia. Moreover, the heterozygous/homozygous genotype appeared to predict the onset of clinical manifestation and disease progression.

Clinical characteristics of juvenile idiopathic arthritis in an area of central Italy: a population-based study

BACKGROUND

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children and an important cause of short and long-term disability. In a recent systematic review of population based studies, the epidemiology of JIA is variable worldwide with incidence rates ranging between 1.6 and 23.0/100,000, and prevalence rates between 3.8 and 400.0/100,000. We investigate the incidence and describe the characteristics of juvenile idiopathic arthritis in the pediatric population of the central Italy, in the period 2000-2009.

METHODS

A retrospective study was conducted in the Marche region to identify patients with a diagnosis of juvenile idiopathic arthritis according to ILAR criteria, between January 1, 2000 and December 31, 2009. JIA was classified according to the ILAR criteria, that is, arthritis of unknown etiology that persisted for > 6 weeks with onset before the age of 16 years. The pooled global ascertainment of cases was estimated by capture-recapture methods and two independent information sources of ascertainment of new cases of JIA were considered.

RESULTS

We studied 151 patients (56 males, 37.1% and 95 females, 62.9%) meeting the ILAR criteria of juvenile idiopathic arthritis. Mean age at presentation was 6.8 ± 3.7 years for males and 6.0 ± 4.0 years for females (p=0.22). The overall incidence rate was 6.34 per 100,000/year (C.I. 6.26-7.35) and the total incidence rate increase from 2000-2009 was 8.16%. Oligoarthritis was the most common onset type (n=98, 65.0%) with 62.5% of ANA-positive patients in at least two determinations.

CONCLUSIONS

Our results indicate that juvenile idiopathic arthritis incidence rates in Italy are comparable to previous data from southern Europe, with a higher frequency of oligoarthritis. To the best of our knowledge, this is the first population-based epidemiological study carried out in Italy focusing on the incidence of juvenile idiopathic arthritis.

Neurofibromatosis type I and multiple myeloma coexistence: A possible link?

The association between Neurofibromatosis type I (NF1) and multiple myeloma (MM), a plasma cell, dyscrasia is very rare. Here we put to the attention of the scientific community two new cases. The first one is a patient with active MM whereas the second with smoldering MM. Both patients present typical features of NF1 but skeletal alterations were present only in the second case including dysplasia, marked scoliosis and osteoporosis. MM osteolytic lesions were absent in both patients. In addition to the clinical diagnosis of NF1, a molecular testing for NF1 gene mutations has been performed finding that patient one was heterozygous for the c.6855C>A (Tyr2285Ter) mutation, while patient two was heterozygous for the c.7838dupC (Lys2614GlufsTer20) mutation. The two mutations were diagnosed both in genomic DNA from peripheral blood and from MM cells. The potential link between NF1 mutation and the increased risk of MM is discussed in the report.

Accuracy and Relative Value of Bone Marrow Aspiration in the Detection of Lymphoid Infiltration in non-Hodgkin Lymphoma

Aims and background

In hematologic malignancies, bone marrow aspiration is considered complementary to bone marrow biopsy for the detection of tumor infiltration. The present study evaluated the accuracy of bone marrow aspiration and the relative contributions of bone marrow aspiration and bone marrow biopsy in detecting bone marrow involvement by non-Hodgkin lymphomas.

Methods and study design

We compared 51 simultaneous marrow aspirates and core biopsies from non-Hodgkin lymphoma patients for sensitivity, specificity, concordance, quality and clinical relevance.

Results

The agreement level of bone marrow biopsy and bone marrow aspiration was 80%, and the overall sensitivity and specificity for bone marrow aspiration were 69% and 86%, respectively. When considering only the indolent non-Hodgkin lymphoma samples, the sensitivity of bone marrow aspiration was 82% and the specificity was 85%, whereas the sensitivity and specificity were 40% and 86%, respectively, in the aggressive non-Hodgkin lymphoma specimens. Five cases (10%) were reported in which bone marrow biopsy did not detect lymphoid infiltration even though the bone marrow aspiration was positive. In one of these, lymphoid infiltration was documented by a second bone marrow biopsy performed thereafter.

Conclusions

The data from the current study show that bone marrow aspiration is a useful procedure with which to detect bone marrow infiltration by lymphoma. Although it cannot be a substitute for examination of the marrow by core biopsy, the utility of adding an aspirate to bone marrow biopsy is supported by its earlier and easier availability for bone marrow examination, the larger amounts of marrow that can be examined with both procedures, and the percentage, although small, of potentially true-positive bone marrow aspirates with negative biopsies.

Concomitant KIT/BRAF and PDGFRA/BRAF mutations are rare events in gastrointestinal stromal tumors

AIM

The BRAF mutation is a rare pathogenetic alternative to KIT/PDGFRA mutation in GIST and causes Imatinib resistance. A recent description of KIT and BRAF mutations co-occurring in an untreated GIST has challenged the concept of their being mutually exclusive and may account for ab initio resistance to Imatinib, even in the presence of Imatinib-sensitive KIT mutations. BRAF sequencing is generally limited to KIT/PDGFRA wild-type cases. Hence, the frequency of concomitant mutations may be underestimated.

METHODS

We screened for KIT (exon 9, 11, 13, 17), PDGFRA (exon 12,14, 18) and BRAF (exon 15) mutations a series of 407 GIST. Additionally, we evaluated the BRAF V600E mutation-specific antibody, VE1, as a surrogate for V600E mutation, on a series of 313 GIST (24 on whole sections, 288 cases on tissue array), including 6 cases molecularly ascertained to carry the BRAF V600E mutation.

RESULTS

No concomitant KIT/BRAF or PDGFRA/BRAF mutations were detected. BRAF mutation was detected only in one case, wild-type for KIT/PDGFRA. All the 6 BRAF-mutant cases stained positive with the VE1 antibody. A weak VE1 expression was observed in 14/287 (4.9%) BRAF wild-type cases, as observed also in 2/6 BRAF-mutant cases. Overall in our series, sensitivity and specificity of the VE1 antobody were 100% and 95.1%, respectively.

CONCLUSION

The concomitance of BRAF mutation with either KIT or PDGFRA mutation is rare in GIST. In these tumors, moderate/strong VE1 immunoreactivity is a valuable surrogate for molecular analysis. Instead, genotyping is warranted in the presence of weak VE1 staining.

Copy number variants analysis in a cohort of isolated and syndromic developmental delay/intellectual disability reveals novel genomic disorders, position effects and candidate disease genes

BACKGROUND

Array-comparative genomic hybridization (array-CGH) is a widely used technique to detect copy number variants (CNVs) associated with developmental delay/intellectual disability (DD/ID).

AIMS

Identification of genomic disorders in DD/ID.

MATERIALS AND METHODS

We performed a comprehensive array-CGH investigation of 1,015 consecutive cases with DD/ID and combined literature mining, genetic evidence, evolutionary constraint scores, and functional information in order to assess the pathogenicity of the CNVs.

RESULTS

We identified non-benign CNVs in 29% of patients. Amongst the pathogenic variants (11%), detected with a yield consistent with the literature, we found rare genomic disorders and CNVs spanning known disease genes. We further identified and discussed 51 cases with likely pathogenic CNVs spanning novel candidate genes, including genes encoding synaptic components and/or proteins involved in corticogenesis. Additionally, we identified two deletions spanning potential Topological Associated Domain (TAD) boundaries probably affecting the regulatory landscape.

DISCUSSION AND CONCLUSION

We show how phenotypic and genetic analyses of array-CGH data allow unraveling complex cases, identifying rare disease genes, and revealing unexpected position effects.

Expression of CD38 in myeloma bone niche: A rational basis for the use of anti-CD38 immunotherapy to inhibit osteoclast formation

It is known that multiple myeloma (MM) cells express CD38 and that a recently developed human anti-CD38 monoclonal antibody Daratumumab mediates myeloma killing. However, the expression of CD38 and other functionally related ectoenzymes within the MM bone niche and the potential effects of Daratumumab on bone cells are still unknown. This study firstly defines by flow cytometry and immunohistochemistry the expression of CD38 by bone marrow cells in a cohort of patients with MM and indolent monoclonal gammopathies. Results indicate that only plasma cells expressed CD38 at high level within the bone niche. In addition, the flow cytometry analysis shows that CD38 was also expressed by monocytes and early osteoclast progenitors but not by osteoblasts and mature osteoclasts. Indeed, CD38 was lost during in vitro osteoclastogenesis. Consistently, we found that Daratumumab reacted with CD38 expressed on monocytes and its binding inhibited in vitro osteoclastogenesis and bone resorption activity from bone marrow total mononuclear cells of MM patients, targeting early osteoclast progenitors. The inhibitory effect was not observed from purified CD14⁺ cells, suggesting an indirect inhibitory effect of Daratumumab. Interestingly, all-trans retinoic acid treatment increased the inhibitory effect of Daratumumab on osteoclast formation.

These observations provide a rationale for the use of an anti-CD38 antibody-based approach as treatment for multiple myeloma-induced osteoclastogenesis.

RPL5 on 1p22.1 is recurrently deleted in multiple myeloma and its expression is linked to bortezomib response

Chromosomal region 1p22 is deleted in ≥20% of multiple myeloma (MM) patients, suggesting the presence of an unidentified tumor suppressor. Using high-resolution genomic profiling, we delimit a 58 kb minimal deleted region (MDR) on 1p22.1 encompassing two genes: ectopic viral integration site 5 (EVI5) and ribosomal protein L5 (RPL5). Low mRNA expression of EVI5 and RPL5 was associated with worse survival in diagnostic cases. Patients with 1p22 deletion had lower mRNA expression of EVI5 and RPL5, however, 1p22 deletion status is a bad predictor of RPL5 expression in some cases, suggesting that other mechanisms downregulate RPL5 expression. Interestingly, RPL5 but not EVI5 mRNA levels were significantly lower in relapsed patients responding to bortezomib and; both in newly diagnosed and relapsed patients, bortezomib treatment could overcome their bad prognosis by raising their progression-free survival to equal that of patients with high RPL5 expression. In conclusion, our genetic data restrict the MDR on 1p22 to EVI5 and RPL5 and although the role of these genes in promoting MM progression remains to be determined, we identify RPL5 mRNA expression as a biomarker for initial response to bortezomib in relapsed patients and subsequent survival benefit after long-term treatment in newly diagnosed and relapsed patients.

The Proteasome Inhibitor Bortezomib Maintains Osteocyte Viability in Multiple Myeloma Patients by Reducing Both Apoptosis and Autophagy: A New Function for Proteasome Inhibitors

Multiple myeloma (MM) is characterized by severely imbalanced bone remodeling. In this study, we investigated the potential effect of proteasome inhibitors (PIs), a class of drugs known to stimulate bone formation, on the mechanisms involved in osteocyte death induced by MM cells. First, we performed a histological analysis of osteocyte viability on bone biopsies on a cohort of 37 MM patients with symptomatic disease. A significantly higher number of viable osteocytes was detected in patients treated with a bortezomib (BOR)-based regimen compared with those treated without BOR. Interestingly, both osteocyte autophagy and apoptosis were affected in vivo by BOR treatment. Thereafter, we checked the in vitro effect of BOR to understand the mechanisms whereby BOR maintains osteocyte viability in bone from MM patients. We found that osteocyte and preosteocyte autophagic death was triggered during coculturing with MM cells. Our evaluation was conducted by analyzing either autophagy markers microtubule-associated protein light chain 3 beta (LC3B) and SQSTM1/sequestome 1 (p62) levels, or the cell ultrastructure by transmission electron microscopy. PIs were found to increase the basal levels of LC3 expression in the osteocytes while blunting the myeloma-induced osteocyte death. PIs also reduced the autophagic death of osteocytes induced by high-dose dexamethasone (DEX) and potentiated the anabolic effect of PTH(1-34). Our data identify osteocyte autophagy as a new potential target in MM bone disease and support the use of PIs to maintain osteocyte viability and improve bone integrity in MM patients.

Galaxy evolution. Evidence for mature bulges and an inside-out quenching phase 3 billion years after the Big Bang

Most present-day galaxies with stellar masses ≥10(11) solar masses show no ongoing star formation and are dense spheroids. Ten billion years ago, similarly massive galaxies were typically forming stars at rates of hundreds solar masses per year. It is debated how star formation ceased, on which time scales, and how this "quenching" relates to the emergence of dense spheroids. We measured stellar mass and star-formation rate surface density distributions in star-forming galaxies at redshift 2.2 with ~1-kiloparsec resolution. We find that, in the most massive galaxies, star formation is quenched from the inside out, on time scales less than 1 billion years in the inner regions, up to a few billion years in the outer disks. These galaxies sustain high star-formation activity at large radii, while hosting fully grown and already quenched bulges in their cores.

Antimicrobial Susceptibility, Biochemical and Genetic Profiles ofStaphylococcus haemolyticusStrains Isolated from the Bloodstream of Patients Hospitalized in Critical Care Units

Staphylococcus haemolyticus strains (n=20), responsible of blood stream infections, were consecutively isolated from patients hospitalized in two different wards at high risk of infection. Strains displayed high rate of resistance to oxacillin (90%). All strains but two with decreased susceptibility (MIC = 4 microg/mL), were sensitive to vancomycin. Ten strains were resistant to teicoplanin. Among the strains susceptible to glycopeptides, three displayed heteroresistance to vancomycin and seven to teicoplanin, when tested by Etest technique with 2 x McFarland inoculum. Biochemical reactions allowed to assign strains to eight biotypes, with 11 strains clustering under two main biotype A and biotype B. Pulsed-field-gel-electrophoresis (PFGE) identified 11 different PFGE-types. Seven strains grouping under the major PFGE-type 1 and three strains clustering in PFGE-type 2, closely correlated to biotype A and biotype B respectively. Seven teicoplanin-resistant isolates clustered in the PFGE-type 1, two in the PFGE-type 2 and one in PFGE-type 5. Therefore, teicoplanin-resistant strains were biochemically and genetically related and clonally distributed, despite different clones of S. haemolyticus circulated in the units during the study period.

Thyroid gland and pulmonary hypertension. What's the link?

Both hyperthyroidism and hypothyroidism produce changes in cardiac contractility, myocardial oxygen consumption, cardiac output, blood pressure, and systemic or pulmonary vascular resistance. In almost all cases these cardiovascular changes are reversible when the underlying thyroid disorder is recognized and treated. Pulmonary hypertension (PAH) has been associated with thyroid dysfunction, but primarily with hyperthyroidism. The vast majority of patients with this form of PAH are usually older with toxic multinodular goitre. Data currently available suggest a direct influence of TH on pulmonary vasculature. Possible mechanisms include: 1) enhanced catecholamine sensitivity, causing pulmonary vasoconstriction, a reduction in pulmonary vascular compliance and an increase in vascular resistance; 2) increased metabolism of intrinsic pulmonary vasodilating substances (prostacyclin, nitric oxide); 3) decreased or impaired metabolism of vascontrictors (serotonin, endothelin 1 and tromboxane). In some cases (Graves's and Hashimoto's disease) and an autoimmune process inducing endothelial damage may play a key role. Future studies should focus on discovering the immunogenetic overlap between autoimmune thyroid diseases and PAH: common human leukocyte antigen alleles, susceptibility loci and so on. Such an understanding of the genetic and immune factors may ultimately lead to novel effective approaches in the treatment of PAH. At present, thyroid function tests should be considered in the investigation of all patients with PAH.

Continuous positive airway pressure treatment of sleepy patients with milder obstructive sleep apnea: results of the CPAP Apnea Trial North American Program (CATNAP) randomized clinical trial

RATIONALE

Twenty-eight percent of people with mild to moderate obstructive sleep apnea experience daytime sleepiness, which interferes with daily functioning. It remains unclear whether treatment with continuous positive airway pressure improves daytime function in these patients.

OBJECTIVES

To evaluate the efficacy of continuous positive airway pressure treatment to improve functional status in sleepy patients with mild and moderate obstructive sleep apnea.

METHODS

Patients with self-reported daytime sleepiness (Epworth Sleepiness Scale score >10) and an apnea-hypopnea index with 3% desaturation and from 5 to 30 events per hour were randomized to 8 weeks of active or sham continuous positive airway pressure treatment. After the 8-week intervention, participants in the sham arm received 8 weeks of active continuous positive airway pressure treatment.

MEASUREMENTS AND MAIN RESULTS

The Total score on the Functional Outcomes of Sleep Questionnaire was the primary outcome measure. The adjusted mean change in the Total score after the first 8-week intervention was 0.89 for the active group (n = 113) and -0.06 for the placebo group (n = 110) (P = 0.006). The group difference in mean change corresponded to an effect size of 0.41 (95% confidence interval, 0.14-0.67). The mean (SD) improvement in Functional Outcomes of Sleep Questionnaire Total score from the beginning to the end of the crossover phase (n = 91) was 1.73 ± 2.50 (t[90] = 6.59; P < 0.00001) with an effect size of 0.69.

CONCLUSIONS

Continuous positive airway pressure treatment improves the functional outcome of sleepy patients with mild and moderate obstructive sleep apnea.

A new type of Hypersensitivity Pneumonitis: salami brusher's disease

We observed five consecutive cases of Hypersensitivity Pneumonitis in subjects working in a salami factory. The workers had to clean the white mould growing on salami surface using a manual wire brush. The five patients (four female) had a mean age of 39 +/- 15 years; two were smokers. Three patients had an acute clinical presentation with fever, dyspnoea, dry cough, oxygen desaturation, and presented at the emergency department with suspected diagnosis of community acquired pneumonia. The mean latency for developing respiratory symptoms was 11.6 days. Pulmonary function test demonstrated a reduction in diffusing capacity (DLCO) in all 5 patients (60 +/- 15% of predicted value). Skin prick test was positive for Penicillium spp in 3 cases and for Cladosporium and Aspergillus spp in 2 others. Specific IgG antibodies against Penicillium spp were positive in 3 subjects; 2 were positive for Aspergillus Fumigatus. The prevailing radiological pattern was a ground glass appearance in the three patients with acute clinical onset and a centrilobular one in patients with subacute onset. All patients were advised to avoid exposure to the antigens. Follow-up visits including pulmonary function testing, and DLCO measurement were conducted at one, three and six months. HRCT was performed at six month. Four subjects had a complete radiological and clinical resolution after changing work. Only one patient was treated with oral steroids for severe dyspnoea and progressive reduction of DLCO, gaining a complete radiological and clinical stability at six months.

Invasive pulmonary aspergillosis in non-neutropenic patients: analysis of a 14-month prospective clinical experience

Invasive pulmonary aspergillosis (IPA) is one of the major causes of morbidity and mortality in severely immunocompromised patients, but recently several authors have reported the occurrence of IPA in liver cirrhosis, chronic obstructive pulmonary disease (COPD) patients, most of whom, but not all, were receiving steroid treatment, with a very high mortality rate. The detection of galactomannan performed in respiratory specimens is a new valuable test for the diagnosis of probable IPA, even in non-neutropenic high risk patients. Since the frequency and clinical impact of IPA in non-hematologic patients is not well known, it seemed rational to us to attempt a prospective study evaluating all patients hospitalized in a university hospital for whom an infectious Diseases consultation was required. This 14-month survey in our hospital, using recently recommended diagnostic criteria, seems to suggest an emerging role of IPA in these patients who may have a higher mortality rate than their neutropenic peers, and provides preliminary evidence that early diagnosis and prompt initiation of antifungal therapy may improve the ultimate outcome of their IPA.

Tuberculosis in kindergarten and primary school, Italy, 2008-2009

An outbreak of tuberculosis (TB) in Italy involved 19 schoolchildren with active TB and 43 with latent infection. The source of the outbreak was a school assistant born in Italy who had a family history of TB. This outbreak highlights the need for maintaining clinical and public health expertise in countries with low TB incidence.

EBV-associated leukoencephalopathy with late onset of central nervous system lymphoma in a kidney transplant recipient

Central nervous system (CNS) lymphoma is a rare posttransplant lymphoproliferative disorder (PTLD), which usually has a poor outcome. To date, no specific conditions predisposing to this complication have been identified. We here describe the case of a renal transplant patient who was initially diagnosed as having Epstein-Barr virus (EBV)-associated leukoencephalopathy and ultimately developed EBV-positive CNS lymphoma. The patient was a young lady who, 2 years after transplantation, presented with focal neurological and electroencephalographic abnormalities and diffuse white matter lesions on brain magnetic resonance imaging. EBV-DNA was detected in the cerebrospinal fluid (CSF) by polymerase chain reaction. After acyclovir therapy and immunosuppressive drug tapering, the symptoms and electroencephalographic abnormalities subsided, and EBV-DNA disappeared from the CSF. Ten years later, a bulky cerebral mass was found. After excision, a diagnosis of EBV-positive, Hodgkin-like monomorphic B-cell PTLD was made. This case illustrates the potential pathophysiological relationships between EBV infection, leukoencephalopathy and CNS lymphoma; although a long time elapsed from the initial neurological illness to CNS lymphoma, a link between these two conditions cannot be excluded. Therefore, a careful long-term follow-up of EBV-related encephalopathy is advisable.

Evaluation of sham-CPAP as a placebo in CPAP intervention studies

STUDY OBJECTIVES

To evaluate the use of sham-continuous positive airway pressure (CPAP) treatment as a placebo intervention.

DESIGN AND SETTING

Analysis of polysomnograms performed in fixed order without sham-CPAP and on the first night of the sham-CPAP intervention in participants in the CPAP Apnea Trial North American Program (CATNAP), a randomized, placebo controlled trial evaluating the effects of CPAP treatment on daytime function in adults with newly diagnosed mild to moderate obstructive sleep apnea (apnea hypopnea index (AHI) 5-30).

PARTICIPANTS

The first 104 CATNAP participants randomized to the sham-CPAP intervention arm.

MEASUREMENTS AND RESULTS

Compared to the polysomnographic measures without sham-CPAP, the study on the first night with sham-CPAP had statistically significant differences that suggested a decrease in sleep quality: decreased sleep efficiency, increased arousal index, increased time in stage 1 NREM sleep, and prolonged latency to REM sleep. However, all of these differences had a relatively small effect size. Compared to the polysomnogram without sham-CPAP, the number of hypopneas on the sham-CPAP polysomnogram was significantly increased and the number of apneas significantly decreased. Relatively minor differences in AHI with and without sham-CPAP were present and were dependent on the criteria used to score hypopneas.

CONCLUSION

Comparison of polysomnograms with and without sham-CPAP revealed differences that, although statistically significant, were small in magnitude and had relatively low effect sizes suggesting minimal clinical significance. The results support the use of sham-CPAP as a placebo intervention in trials evaluating the effects of CPAP treatment in patients with obstructive sleep apnea.

CLINICAL TRIAL INFORMATION

This paper was a secondary analysis of clinical trial data. CATNAP: CPAP Apnea Trial North American Program, the trial from which the data were obtained, is registered with clinicaltrial.gov. Registration #NCT00089752.

CC-chemokine ligand 20/macrophage inflammatory protein-3α and CC-chemokine receptor 6 are overexpressed in myeloma microenvironment related to osteolytic bone lesions

The expression of the chemokine CC-chemokine ligand 20 (CCL20)/macrophage inflammatory protein (MIP)-3alpha and its receptor CC-chemokine receptor 6 (CCR6) by multiple myeloma (MM) and microenvironment cells and their potential relationship with osteoclast (OC) formation and osteolytic bone lesions in MM patients was investigated in this study. First, we found that MM cells rarely produce CCL20/MIP-3alpha but up-regulate its production by bone marrow (BM) osteoprogenitor cells and osteoblasts in coculture with the involvement of soluble factors as interleukin-1beta and tumor necrosis factor alpha. MM cells also stimulate both CCL20/MIP-3alpha and CCR6 expression by OCs in coculture. Thereafter, we showed that CCL20/MIP-3alpha significantly increases both the number of multinucleated tartrate-resistant acid phosphatase-positive OCs and receptor activator of nuclear factor-kappaB-positive OC progenitor cells similar to CCL3/MIP-1alpha. Finally, we found that blocking anti-CCL20/MIP-3alpha and anti-CCR6 antibodies significantly inhibits MM-induced OC formation. In vitro data were further expanded in vivo analyzing a total number of 64 MM patients. Significantly higher CCL20/MIP-3alpha levels were detected in MM patients versus monoclonal gammopathy of uncertain significance (MGUS) subjects and in MM osteolytic patients versus nonosteolytic ones. Moreover, a significant increase of CCL20/MIP-3alpha-positive osteoblasts in osteolytic MM patients compared with nonosteolytic ones was observed. Interestingly, no significant difference in BM CCL20/MIP-3alpha expression and level was observed between MGUS and nonosteolytic MM patients. Our data indicate that CCL20/MIP-3alpha and its receptor CCR6 are up-regulated in the bone microenvironment by MM cells and contribute to OC formation and osteolytic bone lesions in MM patients.

Multidrug-resistant Acinetobacter baumannii outbreak in an intensive care unit

Carbapenem-resistant Acinetobacter baumannii was isolated from 15 colonized or infected patients (carriers) between April and July 2004, in a teaching hospital ICU in Rome, Italy. All isolated strains were susceptible only to gentamicin, ampicillin-sulbactam and colistin and displayed the same Random Amplified Polymorphic DNA (RAPD) 1 pattern. Twelve out of 15 strains were susceptible to tigecycline, whereas the remaining three showed intermediate susceptibility. Although infection control measures were reinforced and carriers isolated in separate rooms, A. baumannii transmission continued. Therefore, finally A. baumannii carriers were moved to another available subintensive unit, which was re-equipped, and cared for by dedicated personnel, whereas only the non infected/colonized patients remained in the ICU. This study shows that during an outbreak by multiresistant A. baumannii it may be indispensable to geographically isolate not only patients but also dedicated staff.

The new tumor-suppressor gene inhibitor of growth family member 4 (ING4) regulates the production of proangiogenic molecules by myeloma cells and suppresses hypoxia-inducible factor-1 alpha (HIF-1alpha) activity: involvement in myeloma-induced angiogenesis

Angiogenesis has a critical role in the pathophysiology of multiple myeloma (MM); however, the molecular mechanisms underlying this process are not completely elucidated. The new tumor-suppressor gene inhibitor of growth family member 4 (ING4) has been recently implicated in solid tumors as a repressor of angiogenesis. In this study, we found that ING4 expression in MM cells was correlated with the expression of the proangiogenic molecules interleukin-8 (IL-8) and osteopontin (OPN). Moreover, we demonstrate that ING4 suppression in MM cells up-regulated IL-8 and OPN, increasing the hypoxia inducible factor-1alpha (HIF-1alpha) activity and its target gene NIP-3 expression in hypoxic condition. In turn, we show that the inhibition of HIF-1alpha by siRNA suppressed IL-8 and OPN production by MM cells under hypoxia. A direct interaction between ING4 and the HIF prolyl hydroxylase 2 (HPH-2) was also demonstrated. Finally, we show that ING4 suppression in MM cells significantly increased vessel formation in vitro, blunted by blocking IL-8 or OPN. These in vitro observations were confirmed in vivo by finding that MM patients with high IL-8 production and microvascular density (MVD) have significantly lower ING4 levels compared with those with low IL-8 and MVD. Our data indicate that ING4 exerts an inhibitory effect on the production of proangiogenic molecules and consequently on MM-induced angiogenesis.

Imaging of a small bowel cavernous hemangioma: report of a case with emphasis on the use of computed tomography and enteroclysis

Hemangiomas of the small bowel are rare benign tumors, that are dangerous since they may cause massive or occult gastrointestinal bleeding. We describe a case of a jejunum cavernous hemangioma detected by computed tomography (CT) and barium studies. An abdominal CT scan (with intravenous contrast agent) depicted a pronounced contrast enhanced lesion arising from the front wall of a loop of the proximal ileum. Enteroclysis revealed a small intramural nodular defect.

HEV prevalence in the general population and among workers at zoonotic risk in Latium Region

Hepatitis E Virus (HEV) infections are responsible for large waterborne outbreaks in developing countries. Sporadic cases in the developed world are mainly imported from endemic areas. HEV has been suggested to be a zoonotic infection, for which pigs may be the reservoir; specific swine strains of HEV have been identified. Humans are susceptible to infections with swine strains. The aim of this study was to analyse whether Italian pig farmers, veterinarians and abattoir workers are more exposed than persons with other occupations. A total of 92 workers at zoonotic risk and 3511 controls from the general population of two Latium cities, Rome and Rieti, were tested for IgG-HEV antibodies. No significant difference in anti-HEV prevalence was observed between the two groups. The prevalence of general population was 2.9% against 3.3% of pig breeders, while there was a statistically significant difference (p = .0004) between subjects recruited in Rome (prevalence 2.5%) and those recruited in Rieti (prevalence 5.5%). Moreover, in some subgroups of general population and in a subgroup of pig breeders, the prevalence was higher than that previously reported in Italy and in other European countries. The highest value (33%) was found in male housekeepers enrolled in Rome; an analogous value was found in the employees of abattoirs (33%). Further studies are needed to elucidate the transmission routes.

The proteasome inhibitor bortezomib affects osteoblast differentiation in vitro and in vivo in multiple myeloma patients

The proteasome inhibitor bortezomib may increase osteoblast-related markers in multiple myeloma (MM) patients; however, its potential osteoblastic stimulatory effect is not known. In this study, we show that bortezomib significantly induced a stimulatory effect on osteoblast markers in human mesenchymal cells without affecting the number of osteoblast progenitors in bone marrow cultures or the viability of mature osteoblasts. Consistently we found that bortezomib significantly increased the transcription factor Runx2/Cbfa1 activity in human osteoblast progenitors and osteoblasts without affecting nuclear and cytoplasmatic active beta-catenin levels. Consequently a stimulatory effect of bortezomib on bone nodule formation was also demonstrated in osteoblast progenitors. These in vitro observations were confirmed in vivo by the finding of a significant increase in the number of osteoblastic cells x mm(2) of bone tissue and in the number of Runx2/Cbfa1-positive osteoblastic cells that was observed in MM patients who responded to bortezomib. Our in vitro and in vivo observations support the hypothesis that a direct stimulatory effect on bone formation process could occur during bortezomib treatment.