Management of patients with severe asthma: results from a survey among allergists and clinical immunologists of the Central Italy Inter-Regional Section of SIAAIC.

BACKGROUND: Asthma, and severe asthma in particular, is often managed within a specialized field with allergists and clinical immunologists playing a leading role. In this respect, the National Scientific Society SIAAIC (Società Italiana di Allergologia, Asma ed Immunologia Clinica), structured in Regional and Inter-Regional sections, interviewed a large number of specialists involved in the management of this respiratory disease. METHODS: A survey entitled "Management of patients with asthma and severe asthma" based on 17 questions was conducted through the SIAAIC newsletter in 2019 thanks to the collaboration between GlaxoSmithKline S.p.A. and the Inter-Regional Section of SIAAIC of Central Italy. RESULTS: Fifty-nine allergists and clinical immunologists participated to the survey, and 40 of them completed the entire questionnaire. Almost all of the specialists (88%) reported that asthma control was achieved in above 50% of their patients, even if only one third (32%) actually used validated clinical tools such as asthma control test (ACT). Poor adherence to inhaled therapy was recognized as the main cause of asthma control failure by 60% of respondents, and 2-5 min on average is dedicated to the patient inhaler technique training by two-thirds of the experts (65%). Maintenance and as-needed therapy (SMART/MART) is considered an appropriate approach in only a minority of the patients (25%) by one half of the respondents (52%). A high number of exacerbations despite the maximum inhalation therapy were recognized as highly suspicious of severe asthma. Patients eligible for biological therapies are 3-5% of the patients, and almost all the responders (95%) agreed that patients affected by severe asthma need to be managed in specialized centers with dedicated settings. Biological drugs are generally prescribed after 3-6 months from the initial access to the center, and once started, the follow-up is initially programmed monthly, and then every 3-6 months after the first year of treatment (96% of responders). After phenotyping and severity assessment, comorbidities (urticaria, chronic rhinosinusitis with or without nasal polyps, vasculitis, etc.) are the drivers of choice among the different biological drugs. In the management of severe asthma, general practitioners (GPs) should play a central role in selecting patients and referring them to specialized centers while Scientific Societies should train GPs to appropriately recognize difficult asthma and promote public disease awareness campaigns. CONCLUSIONS: This survey which collects the point of view of allergists and clinical immunologists from Central Italy highlights that asthma control is still not measured with validated instruments. There is a general consensus that severe asthma should be managed only in dedicated centers and to this aim it is essential to encourage patient selection from a primary care setting and develop disease awareness campaigns for patients.

Migrants and allergy: a new view of the atopic march.

Summary: Atopy is the result of the influence of environmental factors on genetically predisposed individuals. Migration flows represent an interesting model to study the possible reciprocal roles of genes and environment. In this review the following issues influencing the development of allergic sensitization and/or atopic disorders in migrants will be rooted out: 1) ethnicity, genetic polymorphisms and risk of atopy; 2) double faceted effects of parasitic infestations; 3) biodiversity loss and industrial progress. Moreover, an extensive revision of the literature about the relationship between the migratory status and allergy development is provided.

"Slow" myosins in vertebrate skeletal muscle. An immunofluorescence study.

Specific antisera were raised in rabbits against column-purified myosins from a slow avian muscle, the chicken anterior latissimus dorsi (ALD), and a slow-twitch mammalian muscle, the guinea pig soleus (SOL). The antisera were labeled with fluorescein and applied to sections of muscles from various vertebrae species. Two distinct categories of the slow fibers were identified on the basis of their differential reactivity with the two antisera. Fibers stained by anti-ALD appear to correspond in distribution and histochemical properties to physiologically slow-tonic fibers, i.e., fibers that display multiple innervation and respond to stimulation with prolonged contractures. In mammals, only a minority of fibers in extraocular muscles and the nuclear bag fibers of muscle spindles were brightly labeled by this antiserum. In contrast, fibers labeled by anti-SOL in mammalian muscle appear to correspond in distribution and histochemical properties to physiologically slow-twitch fibers. Anti-SOL was also found to stain a population of fibers in reptiles, amphibians, and fishes that did not react, or reacted poorly, with anti-ALD; in avian muscle, only a minor proportion of the slow fibers were labeled by anti-Sol. these findings point to the existence of two antigenically distinct, though partly cross-reacting, types of "slow" myosin in vertebrate muscle.

Myosin types and fiber types in cardiac muscle. I. Ventricular myocardium.

Antisera against bovine atrial myosin were raised in rabbits, purified by affinity chromatography, and absorbed with insolubilized ventricular myosin. Specific anti-bovine atrial myosin (anti-bAm) antibodies reacted selectively with atrial myosin heavy chains, as determined by enzyme immunoassay combined with SDS-gel electrophoresis. In direct and indirect immunofluorescence assay, anti-bAm was found to stain all atrial muscle fibers and a minor proportion of ventricular muscle fibers in the right ventricle of the bovine heart. In contrast, almost all muscle fibers in the left ventricle were unreactive. Purkinje fibers showed variable reactivity. In the rabbit heart, all atrial muscle fibers were stained by anti-bAm, whereas ventricular fibers showed a variable response in both the right and left ventricle, with a tendency for reactive fibers to be more numerous in the right ventricle and in subepicardial regions. Diversification of fiber types with respect to anti-bAm reactivity was found to occur during late stages of postnatal development in the rabbit heart and to be influenced by thyroid hormone. All ventricular muscle fibers became strongly reactive after thyroxine treatment, whereas they became unreactive or poorly reactive after propylthiouracil treatment. These findings are consistent with the existence of different ventricular isomyosins whose relative proportions can vary according to the thyroid state. Variations in ventricular isomyosin composition can account for the changes in myosin Ca2+-activated ATPase activity previously observed in cardiac muscle from hyper- and hypothyroid animals and may be responsible for the changes in the velocity of contraction of ventricular myocardium that occur under these conditions. The differential distribution of ventricular isomyosins in the normal heart suggests that fiber types with different contractile properties may coexist in the ventricular myocardium.

Carnitine palmityl transferase deficiency: clinical variability, carrier detection, and autosomal-recessive inheritance.

A 21-year-old man had recurrent myoglobinuria; his 28-year-old sister had symptoms of fatigability. During prolonged fasting, serum free fatty acid rose in both siblings, but only the sister produced ketone bodies and had elevated creatine phosphokinase activity. Carnitine palmityl transferase (CPT) activity was less than 30% of normal in muscle and platelets. Liver biopsy disclosed a low level of the enzyme in the brother. The parents had intermediate levels of the enzyme in platelets. CPT deficiency seems to have an autosomal-recessive pattern of inheritance and a variable phenotypic expression.

"Fast" isomyosins and fiber types in mammalian skeletal muscle.

Immunohistochemical procedures have been used to correlate antigenic differences among fast isomyosins with their specific localization in particular types of rat muscle fibers. Antisera were produced in rabbits against myosins isolated from guinea pig fast-white (tensor fasciae latae) and fast-red (masseter) muscles. After sequential cross-adsorptions on insolubilized heterologous myosins, antibodies mainly directed against heavy chain determinants were obtained. In indirect immunofluorescence assays, these antibodies selectively stained fast-white (type IIB) and fast-red (type IIA) fibers, respectively. Slow-twitch (type I) fibers, which were reactive with antibodies against soleus muscle myosin, were unreactive with anti-fast-myocin antibodies. In addition to these major types of fibers, with unique immunoreactivity, two groups of fibers with double reactivity were identified: 1) fibers reactive with anti-slow-twitch and anti-fast-red antibodies (corresponding to IIC fibers with enzyme histochemistry) and 2) fibers reactive with anti-fast-red and anti-fast-white antibodies. We propose to identify these fibers with the symbols I in equilibrium with IIA and IIA in equilibrium with IIB, respectively, as they may be considered as intermediate and/or transitional stages between the major fiber types. No fibers were reactive with both anti-slow-twitch and anti-fast-white antibodies. Therefore, muscle fibers may change in a sequential manner, from I leads to IIA leads to IIB or in the reverse direction, suggesting an obligatory sequence of gene activation.

Immunohistochemical identification of slow-tonic fibers in human extrinsic eye muscles.

A fluorescent antiserum against myosin from chicken anterior latissimus dorsi muscle, which stains specifically the multiply innervated slow fibers of birds and amphibians, was applied to frozen sections of human extraocular muscles. A proportion of fibers in oculorotatory muscles were labeled by the antiserum. In contrast, no labeled extrafusal fiber was present in the levator palpebrae or in other body muscles. Serial study of sections stained for acetylcholinesterase and myosin ATPase showed that the labeled fibers in human oculorotatory muscles are multiply innervated and display acid-stable myosin ATPase activity.

Peroneal muscular atrophy with ataxia and partial myoclonic epilepsy.

Two brothers, 17 and 11 years old, presented with pes cavus, absence of deep tendon reflexes, péripheral vibratory sensory loss, ataxia, tremor, nystagmus, dysarthria and partial myoclonic epilepsy. Electromyography showed severe slowing of motor conduction velocity in the lower extremities and increased distal latencies. A peroneal nerve biopsy showed absence of myelin sheath in most fibres resulting in numerous demyelinated nerve fibres. The father and seven uncles on the paternal side had pes cavus, hammer toes and moderate vibratory peripheral sensory loss. Three of seven siblings had slow motor conduction velocities on EMG. None had EEG abnormalities. Epilepsy started at an early age in both patients with myoclonic jerks of the right arm especially during sleep. EEG recordings were characterized by focal or diffuse epileptiform discharges. In the elder brother a partial motor epileptic status occurred with adversive seizures involving the right side of the body. He died of a broncopneumonia after 3 days of this epileptic status. Histopathological examination showed a severe demyelination of dentato-rubral pathways in the cerebellum and a partial degeneration of Goll and Burdach's tracts in the cervical spinal cord. The nosological classification of this syndrome is discussed and an autosomal dominant inheritance with incomplete penetrance or variable expressivity is suggested.

Morphogenesis of rat muscle spindles after nerve lesion during early postnatal development.

The influence of innervation on muscle spindle morphogenesis has been investigated in rat hind-limb muscles by sectioning the sciatic nerve, with suture of the stumps, at various postnatal stages. After nerve section at 4 or 7 days of age a proportion of spindles survived during the denervation phase and developed, during the subsequent reinnervation phase, into atypical structures. The reinnervated spindles were recognized by the presence of a limiting capsule but lacked the characteristic distinction of equatorial and polar regions. The intrafusal fibres were fewer than normal and were indistinguishable in size and fine structure from extrafusal fibres; they had a single motor endplate and lacked sensory nerve terminals. In reinnervated muscles of animals operated at 13 and 22 days of age there was a progressive tendency towards a restoration of normal spindle structure and innervation. These findings indicate that muscle spindle morphogenesis is profoundly altered by nerve lesion at early development stages, apparently as a result of inadequate sensory reinnervation. This study also shows that the differentiation of intrafusal fibres is dictated by their specific pattern of innervation and is not intrinsically predetermined.

[Types of fibers in skeletal muscles of mammals: histochemical and ultrastructural characteristics in relation to their contractile properties]. / Tipi di fibre nei muscoli scheletrici dei mammiferi: caratteristiche istochimiche e ultrastrutturali in rapporto alle proprieta' contrattili

A tentative correlation of histochemical and ultrastructural features with physiological properties in mammalian skeletal muscle fibers is presented. In particular, the characteristic metabolic and structural profile of fast-twitch red fibers is described and evidence is presented for the presence of such fibers in limb muscles and masticatory muscles of the rat. The existence of interspecies and even intraspecies variation in the histochemical correlates of the different fiber categories is emphasized and the significance of intermediate fiber types is discussed.

Myomuscular junctions in re-innervated rat skeletal muscle.

Re-innervated extensor digitorum longus, soleus and plantaris muscles of the rat were studied after denervation performed at various postnatal ages. The muscle fibres, which normally run from tendon to tendon as independent units, were found to be very frequently connected by myomuscular junctions, both in the form of terminal insertions of one fibre into another and of lateral bridges which may join two or more muscle fibres at one or more levels. Positive reaction for AChE activity was demonstrated at the level of the junctions. Incubation for myosin ATPase activity showed that myomuscular junctions are only found between fibres of the same histochemical type, which in re-innervated muscles are usually aggregated in 'type groupings'. Ultrastructural features were similar in both forms of myomuscular junctions. The appearance is that of an interdigitation of muscle projections from neighbouring fibres, each projection being covered by a basement membrane with attached collagen fibrils. The finger-like projections at their endings contain vesicles and elongated cisternae filled with granular dense material. It is postulated that the synchronous activity of neighbouring fibres within the compact motor units of reinnervated muscles is a causal factor initiating the formation of myomuscular junctions.

Abnormal myomuscular junctions and AChE in a congenital neuromuscular disease.

We studied a patient with a congenital neuromuscular disease clinically characterized by ophthalmoplegia, slight limb muscle weakness, and normal electromyography. In the muscle biopsy, there were frequent examples of interdigitation of areas of muscle and extracellular spaces giving a fragmented appearance to muscle fibers. These structures resemble myomuscular junctions; acetylcholinesterase activity was present in the vicinity of these structures and on the muscle cell surface.

The fate of newly formed satellite cells during compensatory muscle hypertrophy.

Compensatory hypertrophy was induced in the rat extensor digitorum longus muscle by extirpation of the synergistic tibialis anterior. Injections of 3H-thymidine (2 muCi/g body weight) was given at 24, 48, and 72 h after the operation. In animals killed immediately after the last injection both satellite cell nuclei and true muscle nuclei were labeled, whereas in animals killed 4 weeks later only true muscle nuclei were labeled. The results are interpreted as indicating incorporation of newly formed satellite cells into the fibers during compensatory hypertrophy.

The organization of titin (connectin) and nebulin in the sarcomeres: an immunocytolocalization study.

Monospecific polyclonal antibodies against two exceptionally large proteins, titin (a-T) and nebulin (a-N) isolated from rabbit skeletal muscles, were raised in guinea pig. Using an immuno-pre-embedding method, we have localized at the ultrastructural level of resolution the reactivity sites in skinned muscle fibres. At resting length a-T and a-N antibodies recognize epitopes which only partially overlap. a-T antibodies decorate mostly the A band with at least four clearly distinguished lines of reaction and one line in the I band, all near the A/I limit; a-N antibodies bind to the same region, but with wider areas of reaction in both A and I bands. To study whether the localization of these reaction sites varies according to the sarcomere length, skinned rabbit psoas fibres were incubated at sarcomere lengths ranging from maximum shortening to overstretching. The results indicate that lines decorated by a-T move away from the Z disc when the sarcomere is lengthened. With respect to the M line, the behaviour was biphasic. When the sarcomere was stretched up to about 2.8 microns, the decorated lines maintain almost the same distance from the M line. When the sarcomere is stretched beyond 2.8 microns, all a-T epitopes move away from the M line and the molecule behaves elastically. At resting length the a-N decoration appears to be localized on three large adjacent bands at the I, A/I and A level. The a-N line of reaction at the edge of the A band moves away from the Z discs as the sarcomere lengthens, while a second line which seems to be localized at the tip of the thin filament moves away from M line when the sarcomere lengthens. In non-overlapping sarcomeres a-N antibodies decorate only the tip of the thin filaments. Our results indicate that titin forms a polar filament connecting the M line to the Z line. In short sarcomeres, the filament seems to have some connections with structures of the A band, since titin epitopes do not move during stretching. These connections are lost at longer sarcomere lengths. On the other hand, our results suggest that nebulin is probably not a constituent of the titin filament.

Morphological and functional characterization of the endosarcomeric elastic filament.

The elastic filament was studied in chemically skinned fibers from rabbit psoas muscle by electron microscopy and resting tension measurements. Extraction of skinned fibers with 40 mM sodium pyrophosphate caused a selective removal of about two-thirds of the thick filaments and formed a gap between the remaining portion of the A band and the I band. Very thin filaments were seen in the gap and were decorated by anti-titin antibody. The resting tension of these fibers was comparable to that of unextracted control fibers. When the M band was completely extracted by a solution containing 0.6 M NaCl, the resting tension completely disappeared at sarcomere lengths from 2.8 to approximately 3.4 microns. These results suggest that the elastic force of short sarcomeres is endowed in the titin filaments and that these filaments are anchored to some structures of the Z and M lines. Other filaments were found in the gap between the two I bands of NaCl-extracted sarcomeres. These filaments differed from titin filaments by a larger diameter and the anchoring points. They may represent the sarcomeric structures responsible for the resting tension of extracted fibers stretched at sarcomere lengths longer than 3.4 microns.

Immunoelectron microscopic epitope locations of titin in rabbit heart muscle.

The location of cardiac titin epitopes in the sarcomere of rabbit cardiac, atrial and ventricular muscle was studied by using polyclonal antibodies against skeletal muscle titin. The results show that incubation with the antibody leads to the appearance of four electron-dense stripes in the A band of both atrial and ventricular cardiac muscle. The location and intensity of these stripes were identical to those observed in skeletal muscle. In conclusion we demonstrate that titins from skeletal and cardiac muscles share some common antigenic determinants.