Genetic counselling in ALS: facts, uncertainties and clinical suggestions

The clinical approach to patients with amyotrophic lateral sclerosis (ALS) has been largely modified by the identification of novel genes, the detection of gene mutations in apparently sporadic patients, and the discovery of the strict genetic and clinical relation between ALS and frontotemporal dementia (FTD). As a consequence, clinicians are increasingly facing the dilemma on how to handle genetic counselling and testing both for ALS patients and their relatives. On the basis of existing literature on genetics of ALS and of other late-onset life-threatening disorders, we propose clinical suggestions to enable neurologists to provide optimal clinical and genetic counselling to patients and families. Genetic testing should be offered to ALS patients who have a first-degree or second-degree relative with ALS, FTD or both, and should be discussed with, but not offered to, all other ALS patients, with special emphasis on its major uncertainties. Presently, genetic testing should not be proposed to asymptomatic at-risk subjects, unless they request it or are enrolled in research programmes. Genetic counselling in ALS should take into account the uncertainties about the pathogenicity and penetrance of some genetic mutations; the possible presence of mutations of different genes in the same individual; the poor genotypic/phenotypic correlation in most ALS genes; and the phenotypic pleiotropy of some genes. Though psychological, social and ethical implications of genetic testing are still relatively unexplored in ALS, we recommend multidisciplinary counselling that addresses all relevant issues, including disclosure of tests results to family members and the risk for genetic discrimination.

Effect of endothelin inhibition on lung fibroblasts on patients with systemic sclerosis

AIM

The aim of the study was to investigate the effect of selective ETRA Sitaxsentan on viability and differentiation into myofibroblasts of lung fibroblasts derived from SSc-ILD patients and the ability of this drug to modify the lung fibroblast synthesis of VEGF, type I collagen and fibronectin.

METHODS

Primary human lung fibroblast cultures were obtained from BAL of SSc-ILD patients. Cell cultures were exposed for 48 h to crescent concentrations of Sitaxsentan (10 -6M to 10 -4M). In these experimental conditions we evaluated cell viability through crystal violet staining, the production and mRNA expression of VEGF, fibronectin and type I collagen respectively through ELISA and real-Time PCR. Further, we detected alpha-Smooth Muscle Actin (α-SMA) through immunocytochemical assay.

RESULTS

The lowest concentration of sitaxsentan (10-6M) did not affect fibroblasts viability; conversely at higher concentrations, sitaxsentan induced a significant inhibition of cell viability. Synthesis and mRNA expression of VEGF, type 1 collagen and fibronectin were significantly reduced in treated lung fibroblasts compared to the untreated ones, in a dose-dependent manner. At higher concentrations, Sitaxsentan reduced the expression of α-SMA.

CONCLUSION

The results of this study show that sitaxentan is able in vitro to reduce both cell viability than production of VEGF and extra-cellular matrix components in SSc lung fibroblasts, confirming the anti-fibrotic potential of ETRA in SSc. The decreased expression of α-SMA in treated cells indicate that sitaxsentan may inhibit the fibroblast differentiation toward a myo-fibroblast phenotype and further support the hypothesis that the selective ETRAs may be beneficial in patients with SSc-ILD as anti fibrotic agents.

Behavioral, neuropsychiatric and cognitive disorders in Parkinson's disease patients with and without motor complications

BACKGROUND

Parkinson's disease (PD), commonly defined as a hypokinetic movement disorder, is hampered by the appearance of motor complications (MC), including dyskinesias and motor fluctuations, and non-motor symptoms such as behavioral, neuropsychiatric and cognitive disorders, which, in the last years, are gaining increasing attention. The factors affecting MC and these non-motor symptoms are still largely unknown and their interactions are not yet fully evaluated.

OBJECTIVE

To identify the presence of behavioral, neuropsychiatric and cognitive disorders in PD patients with and without MC and to evaluate their association with MC.

METHODS

Consecutive PD patients received a comprehensive structured clinical evaluation including pharmacologic treatment, MC and non-motor symptoms such as reward-seeking behaviors, neuropsychiatric symptoms (depression, anxiety, psychoses and hallucinations) and dementia.

RESULTS

349 patients were included in this analysis. Patient with MC showed enhanced frequency of dementia (p < 0.001), anxiety, depression and psychoses (p < 0.01). A higher frequency of impulse control disorders was detected in patients with dyskinesias (22.2% - p < 0.001) and motor complications (12.2% - p < 0.05). Dyskinesias were significantly more present in patients with hypersexuality (p < 0.05) and compulsive shopping (p < 0.001), while they were not significantly associated with pathological gambling and binge eating. Patients with dyskinesias also had significantly higher frequency of dopamine dysregulation syndrome, hallucinations and delusions (p < 0.001), with the exception of delusional jealousy.

DISCUSSION

We found a higher frequency of behavioral, neuropsychiatric and cognitive disorders in patients with MC. The lack of detection of dyskinesias in several PD patients with pathological gambling in our study represents a very interesting issue. While binge eating mainly seems to be related to the use of dopamine agonists, the significant lack of association between dyskinesias and delusional jealousy suggests the hypothesis of a possible underlying psychopathological predisposition rather than a mere pharmacologic effect in PD patients with these behavioral complications.

TRAP1, a novel antiapoptotic gene responsible for multidrug resistance in human colorectal carcinoma cells

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Background: TRAP1 has been recently described as a component of a mitochondrial pathway selectively up- regulated in tumor cells which antagonizes the proapoptotic activity of cyclophilin D and is responsible for maintenance of mitochondria integrity, thus favoring cell survival. Interestingly, novel TRAP1 antagonists cause sudden collapse of mitochondrial function and selective tumor cell death, suggesting that this pathway may represent a novel molecular target to improve anticancer therapy. Furthermore, we recently observed that TRAP1 is significantly up-regulated in osteosarcoma cells adapted to growth in mild oxidizing conditions and this correlates with a phenotype more resistant to H2O2-induced DNA damage and apoptosis. This evidence prompted us to investigate the role of TRAP1 as being responsible for multi-drug resistance in human colorectal cancer. Methods and Results: The evaluation of TRAP1 expression by immunoblot and quantitative RT-PCR analysis in a series of 26 human colorectal carcinomas allowed us to observe up-regulation in 17/26 tumors. Accordingly, TRAP1 protein levels were increased in HT-29 colorectal carcinoma cells resistant to 5-fluorouracil, oxaliplatin and irinotecan. Interestingly, HT-29 colorectal carcinoma and Saos-2 osteosarcoma cells transfected with TRAP1 gene exhibited a phenotype resistant to 5-fluorouracil-, oxaliplatin- and irinotecan-induced apoptosis, evaluated by MTT incorporation analysis and annexin V staining. Consistently, the transfection of a dominant negative N-terminal deletion mutant of TRAP1 as well as the inhibition of TRAP1 activity by the TRAP1 ATPase antagonist, shepherdin, increased the sensitivity to apoptosis induced by 5-fluorouracil, oxaliplatin and irinotecan in wild type HT-29 colorectal carcinoma cells and in HT-29 cells resistant to the single agents. Conclusions: These results suggest that the increased expression of TRAP1 in human colorectal carcinomas could be part of a pro-survival pathway responsible for multidrug resistance. Thus, targeting TRAP1 may represent a novel strategy to improve the efficacy of anticancer agents in colorectal cancer.

No significant financial relationships to disclose.

Tumor necrosis factor-associated protein 1 (TRAP-1) protects cells from oxidative stress and apoptosis

TRAP-1 is a mitochondrial heat shock protein (HSP), recently identified in Saos-2 osteosarcoma cells adapted to mild oxidative stress induced by diethylmaleate (DEM). TRAP-1 mRNA expression is increased in DEM-adapted cells as well as in tumor cells resistant to 5-fluorouracil and to platin derivatives. Since a strong decrease of TRAP-1 protein levels, upon cisplatin treatment, is observed only in controls but not in the DEM-adapted counterpart, a possible role for this protein in the development of resistant phenotypes could be hypothesized. To characterize the protective role of TRAP-1 against oxidative stress and apoptosis, stable transfectants were generated and characterized for their response to different stress types. These stable clones expressing constitutively high TRAP-1 levels: (i) are more resistant to H2O2-induced DNA damage and to apoptosis by cisplatin; (ii) contain higher reduced glutathione (GSH) levels than control cells; and (iii) do not release the apoptosis-inducing factor into the nucleus upon cisplatin treatment. Furthermore, high TRAP-1 levels interfere with caspase 3 activation. These results confirm the anti-apoptotic role of TRAP-1, and suggest that increased expression of this mitochondrial HSP in DEM-adapted and chemoresistant cells could be part of a pro-survival signaling pathway aimed to evade toxic effects of oxidants and anticancer drugs.

Engraftment capacity of mesenchymal cells following hematopoietic stem cell transplantation in patients receiving reduced-intensity conditioning regimen

The engraftment ability of mesenchymal cells was investigated in 26 patients receiving allogeneic transplantation from HLA-identical siblings with reduced-intensity conditioning (RIC). The stem cell source was bone marrow (BM) in eight patients and G-CSF-mobilized peripheral blood hematopoietic cells in 18 cases. A total of 32 patients engrafted very quickly and the chimerism evaluation (both on myeloid and on lymphoid subsets) showed that they were full donor by day 60. At the time of the study they were in complete hematological remission and displayed a full donor hematopoiesis. Two patients showed early disease progression while one did not engraft. Forty-eight out-marrow samples harvested from the 26 patients generated a marrow stromal layer adequate for the chimerism evaluation. Monocyte-macrophage contamination of marrow stromal layers was always reduced below 2% by repeated trypsinizations and treatment with the leucyl-leucine (leu-leu) methyl ester. The chimerism evaluation was performed by PCR analysis of STRs microsatellites and the amelogenin locus, by using capillary electrophoresis (CE) and by FISH analysis in case of the sex mismatch. In eight patients, a partial donor origin of stromal cells was shown (7-86% cells of donor). The source of hematopoietic cells was BM in three patients and mobilized peripheral blood in the other five.

Analysis of 80 bilateral hip replacement surgeries performed in a single session. Feasibility study

Patients affected with bilateral coxarthrosis often present with clinical and radiographic findings that are similar on both sides. The experience with 80 patients submitted to bilateral hip replacement in a single session demonstrated the usefulness and the reduction in costs in relation to hospitalization and rehabilitation. Indications and contraindications must be taken seriously.

Computerized single-breath nitrogen washout: predicted values in a rural French community

Comparative manual and computer measurements of the alveolar N2 slope and closing volumes have indicated systematic differences. When a computerized system is used in field surveys, predicted values are to be obtained under the same conditions. Therefore, we measured the alveolar nitrogen slope (phase III, PIII), closing volume (CV), and closing capacity (CC) from single-breath N2 washout maneuvers in 158 healthy subjects (68 females), ages 21 to 64 years, from a rural community living in a nonpolluted area of northeast France. PIII, the CV to vital capacity ratio (CV:VC, %), and the CC to the total lung capacity ratio (CC:TLC, %) were regressed against age, height, weight, and the body mass index (BMI, kg/m2) and prediction equations with 95% confidence intervals were computed. PIII increased with age in both sexes and tended to decrease with height in males (r = -0.19, p = .08). The CV:VC and CC:TLC ratios depended on age and, in males, increased with the BMI. Despite accepting a 15% difference between the test VC and the spirometric VC, only 46.3% of asymptomatic nonsmokers produced a valid single-breath nitrogen washout (SBN2) test. This high failure rate limits the usefulness of the test for epidemiologic purposes when older populations "naive" to pulmonary function testing are studied under field-survey conditions.

Rehabitation of allograft with bone dehydrated with solvents in reconstruction after removal of bone tumors: MRI evaluation

It was the purpose of this study to analyze the behavior of Tutoplast bone allograf to fill cavities produced by the removal of benigning bone tumors of those with local malignancy. X-ray and MR images obtained during follow-up demonstrated an increase in the signal in all of the sequences within the graft, indicating complete rehabitation of the grafted area.

Age and bronchial hyperresponsiveness are associated with failure to perform the single breath N2 test in a rural female population

Because some authors have reported high rates of failure in performing the single breath N2 (SBN2) test in rural areas, the present study aimed at evaluating its acceptability in a female population, unfamiliar with lung function testing, in a rural area of northeastern France. Two hundred ninety-eight women from a rural area volunteered for a preventive medicine examination (91.6% of those invited); four of them were excluded for clinical reasons, and six (2%) were unable to perform spirometry. The protocol included completion of a questionnaire, spirometry with a bronchial reactivity test, skin prick test, and the SBN2 test utilizing a computerized assembly. Although failures caused by the apparatus were few (n = 7, 2.4%) 96 of 281 women (34.1%) were unable to produce two valid SBN2 tests in a series of six attempts. Compared with the group who succeeded in the test (n = 185), women who failed were older and had a higher prevalence of bronchial hyperresponsiveness. Logistic regression confirmed the independent association of these two variables with an inability to perform. We conclude that in a female population completely unfamiliar with lung function testing the SBN2 test has a high rate of failure associated with higher age and the presence of bronchial hyperresponsiveness.

Familial membranous nephropathy

Numerous HLA studies suggest that genetic factors play an important role in the development of membranous nephropathy (MN). We studied seven patients with idiopathic MN, from three unrelated families of Italian ancestry. Complement phenotype analysis and restriction fragment length polymorphism (RFLP) typing of HLA class II and of the switch region genes were done in family members. In the first family, the father, one son, and one daughter had MN; another daughter had clinical glomerulonephritis. The three members with MN shared one HLA haplotype carrying DR beta 11; in the two siblings with the disease, the second HLA haplotype carried the DR beta 3.2 allele. In families 2 and 3, two brothers had MN: in family 2, they differed in at least one haplotype; in family 3, they differed in both haplotypes. Only family 3 was informative with regard to the RFLP of the switch region genes: the two siblings were identical for both Ig heavy chain haplotypes. No clinical, laboratory or morphologic features consistent with a secondary form of the disease were found. Familial clustering of MN suggests a genetically transmitted mechanism.

The single-breath nitrogen test in coal miners: factors associated with failure to perform

The single-breath nitrogen washout (SBN2) test was used, along with spirometry, in the baseline examination of a longitudinal study in a cohort of active coal miners from North-eastern France. The procedure was computerized, allowing the technician to coach and encourage the subject, and excluding computation errors. While all miners performed satisfactory spirometry, a significant number were unable to meet the National Heart and Lung Institute recommendation concerning a 10% agreement of vital capacities. When the limits were set at +/-12%, 57 miners (24.2%) were still classified as failing to perform. When compared to those who succeeded, those failing proved to be significantly older, had more cumulated dust exposure, a higher prevalence of chronic cough and sputum, and a trend for more micronodulation on the chest radiographs. The ventilatory function did not differ between the two groups. These results confirm previous data on spirometric test failure concerning older age and respiratory symptoms, extending them to the SBN2 test. The present study further indicates that dust exposure and roentgenologic pneumoconiosis nodulation are associated with failure to perform the SBN2 test.

Cholesterol atheromatous embolism: an increasingly recognized cause of acute renal failure

BACKGROUND

Cholesterol atheromatous embolism is a systemic disease resulting from cholesterol crystal embolization to many organs, including the kidney. Vascular surgery, vascular radiology investigations and anticoagulation have been identified as inciting factors.

METHODS

Fifteen patients with extensive atherosclerosis, presenting with simultaneous occurrence of acute renal failure and peripheral ischaemic changes were diagnosed as having acute renal failure due to cholesterol atheromatous embolism.

RESULTS

The patients, 12 men and three women, had an average age of 65 years. In one patient, spontaneous occurrence of the disease was observed. An inciting factor was identified in 14 patients: aortography in 10, aortic surgery in two, and thrombolysis in two. Clinical course of acute renal failure was quite variable. Four patients required dialysis; 11 were conservatively managed. All patients had concomitant skin lesions, including digital mottling, cyanosis and gangrene of the toes, and livedo reticularis of the lower limb and abdomen. Eosinophilia was the most common laboratory abnormality. The diagnosis of cholesterol atheromatous embolism was confirmed by tissue examination in eight; in three it was based on the finding of retinal cholesterol emboli; in four patients it was made on clinical grounds. Seven patients died within 36 months. Death was most commonly from cardiac causes.

CONCLUSIONS

Since the population at risk for cholesterol embolism is growing and the disease is iatrogenic in origin, we should expect to detect cholesterol embolism with greater frequency as cause of acute renal failure in the future.

Influence of protein catabolic rate on nutritional status, morbidity and mortality in elderly uraemic patients on chronic haemodialysis: a prospective 3-year follow-up study

It has been recently reported that elderly chronic haemodialysis (CHD) patients have a reduced protein catabolic rate (PCRn) in spite of an adequate Kt/V. However until now the long-term consequences of this fact on the nutritional status, morbidity, and mortality were not known. This prospective study evaluates, over a period of 3 years, the effect of the reduced PCRn on some nutritional parameters, morbidity mortality in CHD patients older than 65 years with adequate and stable Kt/V. Over the period 1990-1993 we evaluated 42 CHD patients over 65 years (mean +/- SD 72 +/- 5 years). PCRn, total serum proteins, serum albumin concentration, body weight, body mass index (BMI) and serum transferrin were determined at the start of the study and followed yearly until the end of observation. The incidence of hospitalization/patient-year, the mortality rate and the causes of death were also recorded. All the patients were managed to maintain a Kt/V > 0.9 throughout the study. Twenty-two patients (Group A), mean age 70 +/- 4 years, completed the entire period of observation. Their Kt/V was 1.10 +/- 0.12, PCRn was 0.95 +/- 0.12 g/kg/day, and serum albumin concentration was 40.2 +/- 1.5 g/l, and these did not change significantly. The other parameters also remained stable over time. Twenty patients (Group B) died. Their mean age was 74 +/- 6 years. This group's Kt/V was 1.11 +/- 0.15, PCRn was 0.94 +/- 0.18 g/kg/day, and serum albumin concentration was 39 +/- 3.1 g/l, and there were no significant variations between the start and the end of observation for all the parameters studied.(ABSTRACT TRUNCATED AT 250 WORDS)

Variability of the computerized single-breath nitrogen washout test in healthy adults. Results from a field survey in a French rural area

Within-subject (difference between paired tests, or coefficient of variation [c. var.] of three consecutive measurements) and between-subjects (standard deviation of the mean group) variability were assessed for the variables derived from the single-breath nitrogen (SBN2) test in a group of healthy, asymptomatic subjects (n = 289) aged 20-64 years, from a rural area in North-East France. Duplicate measurements in 99 subjects showed excellent agreement between the two attempts (correlation coefficients between 0.94 and 0.98) for static lung volumes and the alveolar N2 slope (PIII); closing volumes (CV) were more variable (r = 0.77 for absolute value, 0.79 for % VC) while closing capacities (CC) were in intermediate position (r = 0.86 for absolute value, and 0.88 for % TLC). The variability of three consecutive measures in 190 subjects showed the coefficients of variation to be low for static volumes and closing capacity (2.4-7.4%) and higher for PIII (15.1%) and CV or CV/VC (18.2 and 17.8%). The analysis of variance did not detect significant differences between the three sets of measurements, with the exception of a progressive increase of vital capacity (VC), and decrease in residual volume (RV) from test 1 to test 3, the total lung capacity being the same. Variability was uninfluenced by age or sex, except a higher c. var. for female VC as compared to males (2.8 vs. 2.2%, P = 0.02) and a higher variability of TLC (2.9 vs. 2.3%, P = 0.03) and VC (2.8 vs. 1.9%, P = 0.003) in people older than 40 years as opposed to those younger than 40 years.

Nutritional status in long-term CAPD patients

We studied normalized urea nitrogen appearance (NUNA), normalized protein catabolic rate (NPCR), and normalized daily creatinine excretion (NDCE) in twenty-one patients (15 men, 6 women; mean age 63 +/- 9 years) on CAPD for more than 4 years (80 +/- 27 months). In the same patients we evaluated the changes in serum albumin and transferrin with time. After 74 +/- 26 months on CAPD, NUNA was 0.12 +/- 0.03 g/Kg IBW/day, NPCR = 1.09 +/- 0.19 g/Kg IBW/day; NDCE = 15.1 +/- 3.1 mg/Kg IBW/day; serum albumin = 3.8 +/- 0.2 g/dl. NUNA was correlated with NPCR (p < 0.001) and both were correlated with NDCE (p = 0.007 and p = 0.008). NPCR significantly decreased as patient age increased (p = 0.007) but was not correlated with time on CAPD, sex or serum albumin. Serum albumin did not change as age increased. Serum albumin and serum transferrin had not significantly changed after 4 years (after 8 years in a subgroup of eight patients). Finally, we compared these data to the initial data recorded for the same patients (mean interval: 64 +/- 21 months). NUNA, NPCR and NDCE did not change significantly. Changes in NPCR were directly related to changes in NDCE (p = 0.019). This study supports that long-term CAPD does not necessarily impair nutritional status and suggests that the oldest patients can maintain stable serum albumin concentrations on lower protein intake than younger ones.

[Pramiverine/metamizole - a spasmoanalgesic for routine therapy of symptoms in emergency/a clinical trial in patients with biliary colics (author's transl)]

The authors refer to a previous trial with the combination 4,4-diphenyl-N-isopropyl-cyclohexylamine-hydrochloride (pramiverine Sistalgin) and N-methyl-N-(2,3-dimethyl-5-oxo-1-phenyl-3-pyrazolin-4-yl)-aminomethanesulfonate (metamizole) (Sistalgin comp.) in patients with renoureteral lithiasis and report results obtained with the same spasmoanalgesic and a comparative preparation in patients with biliary colics. On the basis of parameters selected for the trial, the success of pramiverine/metamizole therapy in subjective and objective complaints induced by biliary stone diseases is considered positive.