[Quick guide to communicate important news to terminally ill patients]

The aim of this work is to be able to publish the information concerning communication with cancer patients as recommended in England. The observation and the study protocol during the stay abroad have been given the opportunity to stylize specific information on the methodology of communication of important information to terminally ill patients. It seems readily apparent as they characterized by both technical precision and sensivity to emotions and descriptions for the individual patient. How is shared by all chronic pain is predominantly complex emotion, a mix of additions and perceived physical and emotional pain - emotional. Because accurate information is beneficial to the patient and that really is not turned, so to speak, a "bullet" it is necessary that you have created, over time, a concrete "therapeutic alliance" between body physician, patient and possibly family. This arises, for sure, even at first accepted the patient during the clinical visit attentive to detail, is renewed in the definition of the common objective to be achieved, so analgesia and it is expressed in the certainty that the physician provides all the resources realistically available. It is then up to the sensitivity of the operator, doctor and/or nurse, described in the "take charge" find, from time to time, the words and manners, verbal and nonverbal, to respond fully to questions of the patient same.

MDM2 309 and TP53 Arg72Pro single nucleotide polymorphisms (SNPs) and clinical outcome in advanced lung cancer patients

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Background: The TP53 Arg72Pro (rs1042522:C>G) and MDM2 SNP309 (rs2279744:T>G) SNPs of the DNA damage response pathway have been shown to affect lung cancer risk. We aimed to investigate their relationship with the clinical outcome of chemotherapy (CT). Methods: We prospectively recruited 426 consecutive patients with advanced disease (352 NSCLC and 74 SCLC, 57% metastatic) referred for chemotherapy at our institution from July 2002 to January 2006: 82% male, median age at diagnosis 63 years, 56% current and 11% never smokers, 81% receiving combined platinum CT. Median follow up time was 10.5 months. Controls were 254 medical students. We designed specific TP53 and MDM2 primers for typing both SNPs using the Pyrosequencing assay. Results: Patients genotype frequencies were: TP53 Arg/Arg 51%, Arg/Pro 40%, Pro/Pro 8%, (61%, 35%, 4% among controls, p=0.02), MDM2 T/T 37%, T/G 46%, G/G 17%, (31%, 55%, 14% among controls, p=0.07). Both groups were in Hardy-Weinberg equilibrium. At multivariable analysis adjusted for gender, smoking status, type of chemotherapy, disease stage, and side effects, survival was significantly associated with performance status (PS) [HR 1.54 (1.2–2.0)], histology [SCLC vs. NSCLC - HR 1.51(1.1–2.1)] and objective response [yes vs. no HR 0.56 (0.4–0.7)] but with neither SNP; in contrast, grade 3–4 toxicity and objective response were concomitantly associated with the SNPs of TP53 [Pro carriers vs. Arg/Arg HR 1.40 (1.1–1.8) and 1.44 (1.0–2.0)] and MDM2 [GG vs. TT 0.57 (0.4–0.9) and 0.61 (0.4–0.97)]. These findings are in agreement with the notion that MDM2 GG homozygous cells express higher levels of mdm2, thus attenuating the p53 pathway, but don’t easily fit with the alleged greater apoptotic potential of p53 Arg72. We also observed significant associations of toxicity with platinum therapy, of objective response with histology and of both outcomes with PS (not shown). Conclusion: The study provides preliminary evidence that germ-line TP53 and MDM2 SNPs affect toxicity and objective response to CT in lung cancer patients, probably depending on a variable DNA damage response but not survival time that may mainly result from the tumor aggressiveness and somatic mutational status.

[Table: see text]

Prognostic Role of Protease-Activated Receptors 1 and 4 in Resected Stage IB Non-Small-Cell Lung Cancer

BACKGROUND

Protease-activated receptor (PAR)-1 and PAR-4 are involved in extracellular matrix invasion and angiogenesis.

PATIENTS AND METHODS

A series of 60 resected stage IB non-small-cell lung cancers (NSCLCs), including 30 adenocarcinomas (ADCs) and 30 squamous cell carcinomas (SCCs), were processed by immunohistochemistry with antibodies to PAR-1, PAR-4, vascular endothelial growth factor (VEGF), and CD34.

RESULTS

Protease-activated receptor-1 was expressed in 37 cases (62%) and PAR-4 in 39 (65%). Adenocarcinomas were significantly more positive than SCC for PAR-1 (17 vs. 8 cases) and PAR-4 (10 vs. 5 cases). Vascular endothelial growth factor was expressed in 42 cases (70%): 22 ADC and 20 SCC. A significant correlation emerged between PAR-1 and/or PAR-4 expression and VEGF but not with microvessel density. Median follow-up was 38 months; actuarial 5-year survival was 43%. At univariate analysis, 3-year survival was shorter in patients expressing PAR-4 versus negative cases (29% vs. 60%; P = 0.002). In 46 patients expressing PAR-1 and/or PAR-4, 3-year survival was 30% versus 68% in 14 patients with no PAR expression (P = 0.002). A trend toward shorter 3-year survival was seen in PAR-1-positive versus PAR-1-negative cases (34% vs. 46%; P = 0.06). Multivariate analysis identified expression of PAR-1 and/or PAR-4 as an independent prognostic factor for reduced survival in resected stage IB NSCLC.

CONCLUSION

Expression of PAR-1 and PAR-4 in early-stage NSCLC could be included in a molecular algorithm for the selection of patients eligible for adjuvant studies.

Tachykinin activation of human monocytes from patients with interstitial lung disease, healthy smokers or healthy volunteers

Three types of tachykinin receptors, NK(1), NK(2)and NK(3), have been described to preferentially interact with substance P (SP), neurokinin A (NKA) and neurokinin B (NKB) respectively. Experimental evidence indicates that SP and NKA modulate the activity of inflammatory and immune cells, including mononuclear ones, and points to their involvement in lung pathophysiology. We previously reported that NK(1)and NK(2)receptors are present on monocytes (MO) isolated from healthy donors or rheumatoid patients - a greater sensitivity to NK(2)receptor stimulation was observed in the latter condition. This study evaluated the effects of SP and NKA, as well as NK(1)and NK(2)selective agonists and antagonists, on MO obtained from healthy volunteers, healthy smokers or patients with interstitial lung diseases (e.g. sarcoidosis and idiopathic pulmonary fibrosis). Superoxide anion (O(2)(-)) production was chosen as a parameter of cell activation. SP and NKA dose-dependently evoked O(2)(-)production from MO in all the conditions evaluated, their effects being competitively antagonized by selective antagonists (CP 96 345 and MEN 10 627, respectively). When selective NK(1)and NK(2)agonists were used, [Sar(9)Met(O(2))(11)]SP, a selective NK(1)agonist, induced a more than doubled O(2)production in MO obtained from patients with interstitial lung diseases as compared to healthy volunteers, whereas MO isolated from healthy volunteers were more sensitive to NK(2)receptor stimulation.

Tachykinin activation of human alveolar macrophages in tobacco smoke and sarcoidosis: a phenotypical and functional study

Substance P (SP) and neurokinin A (NKA), which exert bronchoconstrictor effects on human airways, are known to interact with inflammatory and immune cells, including monocyte macrophages. We have evaluated the effects of SP, NKA and the NK2 selective agonist [beta-Ala8]-NKA(4-10) on alveolar macrophages (AM) isolated from 4 healthy smokers and 4 non-smoker active pulmonary sarcoid patients. An accumulation of activated mononuclear phagocytes, as well as elevated angiotensin-converting enzyme (ACE) activity, has been evidenced in both clinical conditions. The phenotype of AMs in the studied subjects was characterized by an elevated expression of CD68+, HLA-DR+ and CD14+, CD14+ being significantly less in sarcoidosis as compared to smokers. SP, NKA and the NK2 selective agonist evoked superoxide anion (O2-) production in AMs obtained from sarcoid patients or healthy smokers. While SP acted in a non-dose-dependent manner in both conditions, NKA and [beta-Ala8]-NKA(4-10) evoked a dose-dependent respiratory burst (ED50 = 0.25 and 0.26 nM, respectively) in smokers, but not in sarcoidosis. The more marked phenotypical expression correlated well with the ability of NK2 receptors to activate AMs in smoker subjects.

Activated and memory alveolar T-lymphocytes in idiopathic eosinophilic pneumonia

To investigate the possible involvement of T-lymphocytes in the immunopathogenesis of idiopathic eosinophilic pneumonia (IEP), we have evaluated the phenotypic characteristics both of peripheral blood and alveolar lymphocytes in six patients with symptomatic IEP, and in 24 healthy nonsmokers as controls, by employing bronchoalveolar lavage (BAL), monoclonal antibodies, and flow-cytometry. In IEP, total and differential cell counts showed a mild alveolitis with an increase of eosinophil percentage and number; the alveolar lymphocyte count was also increased. In BAL, the total number both of CD4+ and CD8+ lymphocytes was significantly raised; CD4+ cells expressed early (CD25) activation antigens. The analysis of CD45R0, CD45RA and CD62L coexpression in IEP patients, when compared to healthy controls, revealed an accumulation of alveolar CD4+ cells showing phenotypic repertoire usually expressed by memory T-cells (CD45R0+, CD45RA-, CD62L-). CD8+ alveolar lymphocytes did not show any significant increase of activation antigen coexpression. Circulating lymphocytes were not significantly increased and showed only a significantly higher CD25 expression. These data suggest that a pivotal role is played by activated and memory CD4+ alveolar lymphocytes in IEP patients.

Intercellular adhesion molecule-1 is upregulated on peripheral blood T lymphocyte subsets in dual asthmatic responders

To examine the role of adhesion molecules in T cell recruitment and activation during allergen-induced late asthmatic response (LAR), we evaluated the expression of lymphocyte function-associated antigen-1 alpha (LFA-1 alpha) and intercellular adhesion molecule-1 (ICAM-1) on peripheral blood T lymphocyte subsets from atopic asthmatic patients and their changes following allergen inhalation challenge. 12 atopic asthmatic patients were studied. Six patients showed only a single early response after allergen challenge, and six developed a dual response. At baseline, dual responders (DR) had a significantly higher expression of ICAM-1 on CD4+ and CD8+ T lymphocytes as compared with both single early responders (P < 0.005 and P < 0.02, respectively) and controls (P < 0.001, both comparisons). Allergen challenge was followed by a decrease of CD8+ ICAM-1+ T lymphocytes in all DR (P < 0.05) and of CD4+ ICAM-1+ T lymphocytes in four out of six DR, at the time of the LAR. At the same time, a significant rise in serum levels of the soluble form of ICAM-1 was observed in DR. These results suggest that peripheral blood immunoregulatory T lymphocytes are in a higher state of activation in DR as compared with early responders. The upregulation of ICAM-1 on these cells may be important in enhancing airway inflammation in patients with LAR.

Adenosine deaminase activity and fibronectin levels in bronchoalveolar lavage fluid in sarcoidosis and tuberculosis

We have studied Adenosine Deaminase (ADA) activity and Fibronectin (FN) levels in Bronchoalveolar Lavage Fluid (BALF) from 50 patients with Sarcoidosis (15 active, 35 non active) and from 24 patients with Pulmonary Tuberculosis in order to evaluate relationships between both ADA and FN in BALF and alveolitis data. BALF ADA activity increases in active sarcoidosis as well as in tuberculosis, as a result of activation, differentiation and proliferation of blood-derived mononuclear alveolar cells. In sarcoidosis this hypothesis is supported by the significant positive correlation observed between ADA activity and both the number of alveolar CD4+ lymphocytes and the number of alveolar lymphocytes bearing activation antigens (CD25 and VLA-1). BALF FN levels increase, showing highest values in active sarcoidosis. ADA and FN elevation in BALF from active sarcoidosis patients could be suggested as additional markers of disease activity. Highest BALF ADA/Albumin ratio observed in pulmonary tuberculosis patients suggests an increased local production and differentiates pulmonary tuberculosis from active sarcoidosis. Increased FN/Albumin ratio observed in non active sarcoidosis appears to be related to a similar mechanism during the reparative process following granulomatous inflammation.

Alveolar immune mediators in HIV-related pneumonia. Different role of IL-2 and IL-1 in inducing lung damage

In order to elucidate the role played by alveolar cytokines in the pathogenesis of HIV-related lung damage, levels of interleukin (IL) 1 beta, IL-2, IL-6, tumor necrosis factor (TNF)-alpha, and interferon (Ifn) were assessed on supernatant of bronchoalveolar lavage fluid from 30 consecutive HIV-1 seropositive (HIVAb+) patients with clinical and radiologic evidence of pneumonia, from 20 HIV- seronegative (HIVAb-) patients with pulmonary sarcoidosis, and from 10 HIVAb- healthy control subjects. Cytokine levels were expressed as picogram (IL-1, TNF), nanogram (IL-6), and international unit (IL-2, Ifn) per milligram of albumin per deciliter. Total and differential cell counts, cytofluorimetric enumeration of CD3+, CD3+/DR+, CD4+, CD8+, and CD8+/CD16+ cells, as well as microbiologic investigations for opportunistic agents were performed on lavage pellets. HIV-related pneumonia was characterized by higher mean alveolar level of IL-2 (12 +/- 5 IU), and by more elevated mean counts of T cells (109 +/- 16), activated T cells (60 +/- 12), and CD8+ cells (90 +/- 13)/microliters if compared with both active sarcoidosis and control subjects, where respective values of 0.2 +/- 0.1 and 0.3 +/- 0.2 IU IL-2/mgAlb/dl, of 52 +/- 11 and 7 +/- 2 T cells, of 20 +/- 5 and 1.2 +/- 0.3 activated T cells, and of 11 +/- 2 and 3 +/- 0.6 CD8+ cells per microliter were found. HIV-infected patients with opportunistic lung infections (OIs) showed the highest mean IL-2 level (21 +/- 4 IU), and higher counts of both CD8+ (117 +/- 20) and CD8+/CD16+ (36 +/- 7) cells per microliter if compared with patients without evidence of OIs (respectively, 62 +/- 13 CD8+ and 18 +/- 3 CD8+/CD16+ cells per microliter). By contrast, extremely high IL-1 levels (1,463 +/- 760 pg), and IL-2 levels similar to control subjects (3.4 +/- 1.2 IU), were found in the absence of OIs. Different mechanisms depending respectively on IL-2-mediated cytotoxic cell recruitment and activation, or IL-1-mediated tissue injury may account for HIV-related lung damage, depending on the presence or absence of opportunistic agents.

[Alveolar macrophage subpopulations and circulating monocytes. Immunophenotypic study in healthy non-smokers]

Peripheral blood monocytes of 10 non-smoker normal subjects and the macrophages of their bronchoalveolar lavage fluid (BAL) were investigated with two commercially available monoclonal antibodies (MAC 387, CD14). Surface membrane monocyte cells show simultaneously both markers. Instead alveolar macrophage (MA) can be divided in three different phenotype groups by the expression of the two markers (MAC 387+/CD14-, MAC 387+/CD14+, MAC 387-/CD14+). Particularly, MA with MAC 387+/CD14+ phenotype are adherent cells and morphologically lack anthracosis. Their alveolar presence in non-smokers can be due to normal turnover of monocytes from blood into alveoli. By contrast MA with MAC 387+/CD14- phenotype are non-adherent cells without anthracosis. At last MA with MAC 387-/CD14+ phenotype are non-adherent cells but different amounts of anthracosis in their cytoplasm can be observed.

Lymphocyte subpopulations analysis in pleural fluid and peripheral blood in patients with lymphocytic pleural effusions

Lymphocyte subpopulations analysis by an 11-monoclonal antibody (MoAb) panel was carried out in pleural fluid and in peripheral blood in 30 patients affected by newly diagnosed, untreated pleural effusion of different etiology determinated with bacteriological, cytological or histological criteria. Lymphocytes were the predominant cell type, in pleural fluid, in neoplastic pleural effusions as well as in congestive heart failure pleural effusions and, especially, in tuberculous pleural effusions. Lymphocyte analysis in pleural fluid and in peripheral blood suggests the involvement of different mechanisms for the lymphocyte accumulation in the pleural space according to different etiologies. Tuberculous pleural effusions showed an evident CD4+ and TEC T5.9+ lymphocyte accumulation from peripheral blood. In these patients, cutaneous skin test response to purified protein derivative was strongly related to this situation. In neoplastic pleural effusions there was a lower percentage of CD4+ lymphocytes, reflecting circulating lymphocyte pool; however, in neoplastic pleural effusions, various lymphocyte patterns may be sometimes observed depending on different histologies. Passive lymphocyte accumulation seems to be the most important mechanism in congestive-heart-failure pleural effusions.

[Anesthesia for pleuroscopy. Importance of intubation with the Carlens tube for a selective diagnosis of emphysematous bullae in primary spontaneous pneumothorax]

A brief account of the origin of spontaneous pneumothorax and the indications for pleuroscopy in thoracopulmonary surgery is followed by an explanation of the advantages of this method in the selective detection of emphysematous bullae, their number and size, and the state of the lung parenchyma. The evaluation of these parameters is essential to the planning of oriented surgery. A general anaesthesia technique employing a Carlens tube in selective intubation is also illustrated. By permitting separate ventilation of the lungs this method allows a selective diagnosis to be made of emphysematous bullae (including microbullae), and prevents all forms of acute respiratory distress.

[Problems of anesthesia and resuscitation in the extraction of tracheo-bronchial foreign bodies in children]

After briefly considering the high incidence of foreign bodies found in the bronchi of children, and some characteristics connected with their nature, the early and late complications that may occur as a results are illustrated. Resuscitation and anaesthesia techniques are then described, stress being laid on the importance of the ketamine-TCT injection and local anaesthetic association. The latter has proved most effective in personal cases as it resolves the laryngotracheo-bronchial spasm responsible for asphyctic crisis and prevents any dangerous deepening of narcosis during bronchoscopic manoeuvres for the extraction of the foreign body.