Alpha1-antitrypsin deficiency in Greece: Focus on rare variants.

PURPOSE: A1Antitrypsin deficiency (AATD) pathogenic mutations are expanding beyond the PI*Z and PI*S to a multitude of rare variants. AIM: to investigate genotype and clinical profile of Greeks with AATD. METHODS: Symptomatic adult-patients with early-emphysema defined by fixed airway obstruction and computerized-tomography scan and lower than normal serum AAT levels were enrolled from reference centers all over Greece. Samples were analyzed in the AAT Laboratory, University of Marburg-Germany. RESULTS: Included are 45 adults, 38 homozygous or compound heterozygous for pathogenic variants and 7 heterozygous. Homozygous were 57.9% male, 65.8% ever-smokers, median (IQR) age 49.0(42.5-58.5) years, AAT-levels 0.20(0.08-0.26) g/L, FEV1(%predicted) 41.5(28.8-64.5). PI*Z, PI*Q0, and rare deficient allele's frequency was 51.3%, 32.9%,15.8%, respectively. PI*ZZ genotype was 36.8%, PI*Q0Q0 21.1%, PI*MdeficientMdeficient 7.9%, PI*ZQ0 18.4%, PI*Q0Mdeficient 5.3% and PI*Zrare-deficient 10.5%. Genotyping by Luminex detected: p.(Pro393Leu) associated with MHeerlen (M1Ala/M1Val); p.(Leu65Pro) with MProcida; p.(Lys241Ter) with Q0Bellingham; p.(Leu377Phefs*24) with Q0Mattawa (M1Val) and Q0Ourem (M3); p.(Phe76del) with MMalton (M2), MPalermo (M1Val), MNichinan (V) and Q0LaPalma (S); p.(Asp280Val) with PLowell (M1Val); PDuarte (M4), YBarcelona (p.Pro39His). Gene-sequencing (46.7%) detected Q0GraniteFalls, Q0Saint-Etienne, Q0Amersfoort(M1Ala), MWürzburg, NHartfordcity and one novel-variant (c.1A>G) named Q0Attikon.Heterozygous included PI*MQ0Amersfoort(M1Ala), PI*MMProcida, PI*Mp.(Asp280Val), PI*MOFeyzin. AAT-levels were significantly different between genotypes (p = 0.002). CONCLUSION: Genotyping AATD in Greece, a multiplicity of rare variants and a diversity of rare combinations, including unique ones were observed in two thirds of patients, expanding knowledge regarding European geographical trend in rare variants. Gene sequencing was necessary for genetic diagnosis. In the future the detection of rare genotypes may add to personalize preventive and therapeutic measures.

Mitochondrial neurogastrointestinal encephalomyopathy: Clinical and biochemical impact of allogeneic stem cell transplantation in a Greek patient with one novel TYMP mutation.

We describe the case of a Greek female patient with the Classic form of the ultra- rare and fatal autosomal recessive disorder Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) and the impact of allogeneic hematopoietic stem cell transplantation on the biochemical and clinical aspects of the disease. The patient presented at the age of 15 years with severe gastrointestinal symptoms, cachexia, peripheral neuropathy and diffuse leukoencephalopathy. The diagnosis of MNGIE disease was established by the increased levels of thymidine and deoxyuridine in plasma and the complete deficiency of thymidine phosphorylase activity. The novel c.[978dup] (p.Ala327Argfs*?) variant and the previously described variant c.[417 + 1G > A] were identified in TYMP. The donor for the allogeneic hematopoietic stem cell transplantation was her fully compatible sister, a carrier of the disease. The patient had a completely uneventful post- transplant period and satisfactory PB chimerism levels. A marked and rapid decrease in thymidine and deoxyuridine plasma levels and an increase of the thymidine phosphorylase activity to the levels measured in her donor sister was observed and is still present sixteen months post-transplant. Disease symptoms stabilized and some improvement was also observed both in her neurological and gastrointestinal symptoms. Follow up studies will be essential for determining the long term impact of allogeneic hematopoietic stem cell transplantation in our patient.

Pharmacological treatment of stable COPD: need for a simplified approach.

Chronic obstructive pulmonary disease (COPD) is one of the most common diseases worldwide. Although different guidelines regarding therapeutic algorithms exist, the most widely adopted approach is the one suggested by the Global Initiative in Chronic Obstructive Lung Disease in which patients are stratified according to their dyspnea severity and their exacerbation history during the previous year. This combined assessment of COPD, which takes into consideration all aforementioned characteristics of COPD patients as well as the number of blood eosinophils, results in a proposed therapeutic algorithm which is complex and hard to memorize. This complexity is probable one of the causes that most health care professionals are not adherent to the guidelines when treating COPD patients. Here, we propose a simplified therapeutic algorithm for the treatment of COPD patients taking into consideration the current evidence on the use of bronchodilators and inhaled corticosteroids.

Multidimensional severity assessment in bronchiectasis: an analysis of seven European cohorts.

INTRODUCTION: Bronchiectasis is a multidimensional disease associated with substantial morbidity and mortality. Two disease-specific clinical prediction tools have been developed, the Bronchiectasis Severity Index (BSI) and the FACED score, both of which stratify patients into severity risk categories to predict the probability of mortality. METHODS: We aimed to compare the predictive utility of BSI and FACED in assessing clinically relevant disease outcomes across seven European cohorts independent of their original validation studies. RESULTS: The combined cohorts totalled 1612. Pooled analysis showed that both scores had a good discriminatory predictive value for mortality (pooled area under the curve (AUC) 0.76, 95% CI 0.74 to 0.78 for both scores) with the BSI demonstrating a higher sensitivity (65% vs 28%) but lower specificity (70% vs 93%) compared with the FACED score. Calibration analysis suggested that the BSI performed consistently well across all cohorts, while FACED consistently overestimated mortality in 'severe' patients (pooled OR 0.33 (0.23 to 0.48), p<0.0001). The BSI accurately predicted hospitalisations (pooled AUC 0.82, 95% CI 0.78 to 0.84), exacerbations, quality of life (QoL) and respiratory symptoms across all risk categories. FACED had poor discrimination for hospital admissions (pooled AUC 0.65, 95% CI 0.63 to 0.67) with low sensitivity at 16% and did not consistently predict future risk of exacerbations, QoL or respiratory symptoms. No association was observed with FACED and 6 min walk distance (6MWD) or lung function decline. CONCLUSION: The BSI accurately predicts mortality, hospital admissions, exacerbations, QoL, respiratory symptoms, 6MWD and lung function decline in bronchiectasis, providing a clinically relevant evaluation of disease severity.

Overexpression of hnRNPA2/B1 in bronchoscopic specimens: a potential early detection marker in lung cancer.

BACKGROUND: Overexpression of heterogeneous nuclear ribonucleoprotein (hnRNP) A2/B1 has recently been suggested to be a promising marker for early detection of lung cancer. The aim of this study was to determine the utility of its detection in bronchoscopic specimens. PATIENTS AND METHODS: Brushing and biopsy specimens were obtained from 61 patients suspected of having lung cancer, as well as from 30 healthy subjects (controls), who underwent bronchoscopy. hnRNPA2/B1 expression levels were evaluated by immunoblotting. RESULTS: Specificity of hnRNP A2/B1 overexpression was 75.9% in brushing and 78.3% in biopsy. Sensitivity in non-small cell lung cancer was 84.8% in brushing and 80.8% in biopsies, while in small cell lung cancer it was 66.7 % and 75%, respectively. Overexpression of hnRNPA2/B1 was also detected in bronchoscopic specimens of nine patients initially undiagnosed. The follow-up of these patients 2 years later showed that seven of them had developed lung cancer. CONCLUSION: Overexpression of hnRNPA2/B1 was significantly higher in patients suffering from lung cancer and may be useful in the early detection of lung cancer.

Adenosine deaminase activity and its isoenzymes in the sputum of patients with pulmonary tuberculosis.

BACKGROUND: Adenosine deaminase (ADA) has been widely used for the diagnosis of tuberculous pleural effusion. Two isoenzymes have been described, ADA(1) and ADA(2). OBJECTIVE: To evaluate the diagnostic value of sputum ADA, ADA(1) and ADA(2) activity in pulmonary tuberculosis (TB). DESIGN: We measured total ADA, ADA(1) and ADA(2) activity in the sputum of 27 patients with pulmonary TB (11 had a negative Ziehl-Neelsen stain for acid-fast bacilli [AFB]). Nineteen patients with lung cancer were used as controls. RESULTS: Sputum total ADA activity was significantly higher in TB than in lung cancer patients (median 18 U/l [range 3-70] vs. 6 U/l [2-16]; P < 0.001). Sputum ADA(2) activity was significantly higher in TB compared to lung cancer patients (9 U/l [0-65] vs. 5 U/l [0-12]; P = 0.001). Sputum ADA(2) was significantly higher than ADA(1) in TB patients (P = 0.001). Sputum ADA and ADA(2) were higher in both AFB-positive and AFB-negative TB patients. Using a cut-off level of respectively 16 UI/l and 5UI/l for sputum total ADA and ADA(2), sensitivity and specificity were 55.6% and 100% for total ADA and 81.5% and 63.2% for ADA(2). CONCLUSION: Sputum total ADA and ADA(2) levels are elevated in patients with pulmonary TB. As they are elevated even in AFB-negative patients, they may assist in the early diagnosis of pulmonary TB.

Carcinoembryonic antigen, neuron-specific enolase and cytokeratin fragment 19 (CYFRA 21-1) levels in induced sputum of lung cancer patients.

OBJECTIVES: The diagnosis of lung cancer is usually based on the histological and cytological examination of material obtained by bronchoscopy. Tumour markers in serum are of little use as a diagnostic tool for lung cancer. We hypothesized that induced sputum could be a suitable material for measuring tumour markers and, accordingly, attempted to evaluate the diagnostic value of such measurements in lung cancer. Induced sputum is minimally invasive and readily obtainable. MATERIAL AND METHODS: Fifty patients with lung cancer and 24 subjects with chronic obstructive pulmonary disease (COPD) were included in the study. CEA, NSE and CYFRA 21-1 levels in serum and induced sputum were measured by immunoradiometric assays. RESULTS: Serum and sputum CEA, serum and sputum NSE and serum CYFRA 21-1 did not differ significantly between lung cancer and COPD patients. Sputum CYFRA 21-1 was 7 times greater in the lung cancer group than in the COPD group. This finding was true in both small cell (SCLC) and non-small cell (NSCLC) lung cancer. The sensitivity, specificity, positive and negative predictive values were 86, 75, 88 and 72%, respectively. CONCLUSION: Of tumour markers in induced sputum, sputum CYFRA 21-1 offered the best predictive values, although not sufficiently satisfactory to suggest its routine use in lung cancer diagnosis.

Disseminated tuberculosis complicating anti-TNF-alpha treatment.

An unusually large number of cases of tuberculosis, often of miliary or disseminated form, have been reported in patients receiving infliximab therapy for rheumatoid arthritis or Crohn's disease. We describe a patient with rheumatoid arthritis who was treated with infliximab and became systemically ill with Mycobacterium tuberculosis-disseminated infection. Patients who are candidates for treatment with tumour necrosis factor-alfa inhibitors should be evaluated for the presence of latent or active

Tidal expiratory flow limitation, dyspnoea and exercise capacity in patients with bilateral bronchiectasis.

In this study the authors investigated whether expiratory flow limitation (FL) is present during tidal breathing in patients with bilateral bronchiectasis (BB) and whether it is related to the severity of chronic dyspnoea (Medical Research Council (MRC) dyspnoea scale), exercise capacity (maximal mechanical power output (WRmax)) and severity of the disease, as assessed by high-resolution computed tomography (HRCT) scoring. Lung function, MRC dyspnoea, HRCT score, WRmax and FL were assessed in 23 stable caucasian patients (six males) aged 56 +/- 17 yrs. FL was assessed at rest both in seated and supine positions. To detect FL, the negative expiratory pressure (NEP) technique was used. The degree of FL was rated using a five-point FL score. WRmax was measured using a cyclo-ergometer. According to the NEP technique, five patients were FL during resting breathing when supine but not seated, four were FL both seated and supine, and 14 were NFL both seated and supine. Furthermore, it was shown that: 1) in stable BB patients FL during resting breathing is common, especially in the supine position; 2) the degree of MRC dyspnoea is closely related to the five-point FL score; 3) WRmax (% pred) is more closely correlated with the MRC dyspnoea score than with the five-point FL score; and 4) HRCT score is closely related to forced expiratory volume in one second % pred but not five-point FL score. In conclusion, flow limitation is common at rest in sitting and supine positions in patients with bilateral bronchiectasis. Flow limitation and reduced exercise capacity are both associated with more severe dyspnoea. Finally, high-resolution computed tomography scoring correlates best with forced expiratory volume in one second.

Tumour necrosis factor, interleukin-1 and adenosine deaminase in tuberculous pleural effusion.

Tumour necrosis factor (TNF) and interleukin-1 (IL-1) are powerful mediators with a key role in inflammation. This study was undertaken to study the presence of TNF and IL-1 in tuberculous effusion where there is marked inflammation and where examination of the pleural fluid may give information about the local inflammatory reaction. Adenosine deaminase activity (ADA, a marker of TB pleurisy) was also tested. Tumour necrosis factor, IL-1 and ADA levels were measured in the pleural fluid and serum of 97 patients; 33 with tuberculous effusion, 33 with malignant effusion, and 31 patients with benign non-tuberculous effusion. Pleural fluid TNF and ADA levels were higher in tuberculous (TB) patients than in patients with benign disorders or cancer (P < 0.01). Serum TNF levels were also higher in TB patients than other benign (P < 0.01) or malignant (P < 0.05) effusions. There was a positive correlation between serum and pleural fluid values (r = 0.998-0.999, P < 0.001) although pleural fluid concentration was higher (P < 0.001), possibly suggesting local production in the pleural cavity. Pleural fluid IL-1 levels were not raised in any patient group but there was a positive correlation between TNF and IL-1. In addition, a positive correlation was found between TNF and ADA levels, probably indicating some common production mechanism. Furthermore, ADA sensitivity in the diagnosis of tuberculous effusion was augmented by the combined use of TNF and ADA. The use of both these markers may prove useful in the differential diagnosis of TBC pleurisy.

Recurrent respiratory papillomatosis with malignant transformation in a young adult.

The term 'papilloma' was first used by Mackenzie 100 years ago, who claimed that this was the most benign tumour of the larynx. Today papillomas are considered to be caused by the Human Papilloma Virus group (H.P.V.). The majority of patients suffering from this disease which is also referred to as 'recurrent respiratory papillomatosis' require multiple surgical operations for tumour removal. Malignant transformation of papillomas, which is a rare condition, is considered to occur mainly to irradiated patients. The following report describes the case of a male patient, with a history of vocal cord papillomas since his first year of age, who developed bronchial and pulmonary spread of the disease. He died at the age of 26 years because of squamous cell carcinoma which was related to the malignant transformation of the pulmonary papillomas.

Expression of IGF-I, TGF-alpha and p53 protein in imprint smears of bronchial biopsy specimens of lung cancer.

The expression of insulin-like growth factor-I (IGF-I), transforming growth factor-alpha (TGF-alpha) and p53 protein was examined in bronchial biopsy imprint smears of patients with primary lung cancer and benign lung disorders, by immunohistochemistry. Of the 44 malignant imprint smears, 26 (59%) were positively stained for IGF-I, 18 (41%) for TGF-alpha and 29 (66%) for p53 protein. In contrast, of the 36 benign imprint smears none was positively stained for IGF-I (p<0.001), whereas 7 were positively stained for TGF-alpha (p>0.05) and 3 for p53 protein (p<0.001). There was no correlation between the expression of the examined markers and the histological type of lung cancer. The most sensitive indicator of malignancy was p53 overexpression (65.9%), the most specific was IGF-I (100%) whereas both revealed 77.5% accuracy. The combination of IGF-I and p53 revealed 75% sensitivity, 91.6% specificity and 82.5% accuracy. When one marker was positive the relative possibility of lung cancer was 67.1%. This possibility increased to 77.7% when two markers were positive and to 100% when three markers were positive. These results suggest that the evaluation of IGF-I and p53 in imprint smears could be of value in diagnosis of lung cancer.

Outcome of patients with brain metastases after combined modality therapy in small cell lung cancer (SCLC): a retrospective study.

The authors evaluated the role of whole brain radiotherapy (WBRT) on the outcome of brain metastasis and survival in 41 patients with small cell lung cancer (SCLC) treated in their department. In addition to chemotherapy, radiotherapy was given to the primary site in all responder patients. Six patients presented brain metastasis initially and 10 patients after the fourth course of chemotherapy. Brain metastases were symptomatic in 12 of 16 patients with a median time of 5 months (1-14) until symptoms developed. All patients but 2 with brain metastasis received WBRT (30 Gy in 10 fractions) in addition to chemotherapy. The median survival time of patients with brain metastasis was 8.3 months (3.5 to 16) compared to 12 months (4 to 34+) for patients without brain metastasis. In addition, the median survival time for patients with brain metastasis who responded to systemic chemotherapy was better than that of nonresponders. The authors found no improvement in survival in patients who received concomitant WBRT after chemotherapy compared to patients who received WBRT after completion of chemotherapy. In conclusion, the role of consolidating cranial irradiation in addition to chemotherapy in SCLC patients is unclear and warrants prospective randomized studies.