Acetylcholinesterase inhibitors are ineffective in MuSK-antibody positive myasthenia gravis: Results of a study on 202 patients.

BACKGROUND: Myasthenia gravis (MG) with MuSK antibodies (MuSK-MG) represents a distinct subtype with different responses to treatments compared to patients with AChR antibodies, especially in terms of tolerance to acetylcholinesterase inhibitors (AChEI). However, AChEI are often used as first line symptomatic treatment in MuSK-MG, despite reports that they are poorly tolerated, seldom effective or even deleterious. METHODS: We analyzed demographic, clinical and therapeutic responses and side-effects in the large cohort of 202 MuSK-MG patients cared for at the MG Clinic of Azienda Ospedaliero-Universitaria Pisana. RESULTS: 165 patients had received AChEI at first evaluation. Only 7/165 patients (4.2%) reported an initial clinical benefit. Conversely, 76.9% of patients reported at least one side effect, most commonly neuromuscular hyperexcitability (68.4%), gastrointestinal (53.9%) and neurovegetative (35.8%) disturbances. 56 (33.9%) patients reported a concomitant worsening of muscle weakness and twelve patients (7.3%) suffered a cholinergic crisis. According to these patients, the severity of cholinergic side effects was greater at higher doses of AChEI, but side effects occurred regardless of the dose administered and ceased once the drug was discontinued. CONCLUSIONS: This is the largest population of MuSK-MG patients reported for perceived responsiveness and tolerance to AChEI treatment. Our obervations strongly suggest avoiding this treatment in MuSK-MG.

Management of patients with extensive locally advanced thyroid cancer: results of multimodal treatments.

PURPOSE: Surgery plays a key role in the treatment of thyroid cancer (TC) patients. Locally advanced cases, however, can require an extensive surgical approach with technical issues and a high risk of complications. In these cases, a multidisciplinary evaluation should be carried out to evaluate pros and cons. The aim of this study was to share our experience, as a multidisciplinary team, in the management of patients with locally advanced TC with a particularly extensive local disease, whose surgical approach could be challenging and part of a multimodal treatment. METHODS: We retrospectively evaluated clinical, surgical, and oncologic features of all patients with locally advanced TC who had undergone multidisciplinary surgery from January 2019 to June 2020. RESULTS: Six patients (two cases each of poorly differentiated, papillary, and medullary TC) were included. Four out of six were suffering from symptoms related to the advanced disease. At pre-surgical evaluation, a multidisciplinary team proposed extended surgery with radical intent via cervicotomy and sternotomy, considering other therapies not feasible or probably ineffective without it. No one passed away in intra- or perioperative time. At the end of follow-up (median 2.6 years), all patients presented a remission of symptoms due to the advanced disease, four patients were submitted to adjuvant therapies and only one patient died for a cause unrelated to the disease. CONCLUSION: This series of very advanced TCs shows the effectiveness of a surgery performed by a multidisciplinary team in controlling symptoms, allowing adjuvant therapies, and improving the survival of patients whose cases would otherwise be very difficult to manage.

Presence, enzymatic activity, and subcellular localization of paraoxonases 1, 2, and 3 in human lung tissues.

AIMS: The human paraoxonases family (PONs) includes three calcium-dependent esterases: PON1, PON2, and PON3. The presence of PONs mRNA in human lungs is known, however, their enzymatic activity and subcellular localization have not been sufficiently explored. MAIN METHODS: In this work, the presence of PONs in human lung tissues, at both mRNA and protein levels, was confirmed by Real-Time RT-PCR and Western blot analysis. Moreover, the activities of PONs were determined in cytosol and microsomes of 30 subjects and in mitochondria of 8 representative lung tissues using selective and non-selective substrates. Besides, to exclude the possible contribution of other esterases on PON1 organophosphate activity, the effect of bis-p-nitrophenyl phosphate (BNPP) and phenylmethylsulfonyl fluoride (PMSF), esterase inhibitors, and ethylenediaminetetraacetic acid (EDTA), a general paraoxonase inhibitor, was tested. Finally, the presence and activities of PONs in the A549 pulmonary cell line were also evaluated in order to be used as a model for studies on paraoxonases' metabolism. KEY FINDINGS: Our results demonstrated high interindividual variability in both PONs mRNA/protein levels and enzymatic activities and pointed out the presence of all PONs in human lungs and their subcellular distribution in the cytosol, microsomes, and mitochondria. SIGNIFICANCE: These findings add further information to our knowledge of pulmonary metabolism and, given that PON1 can metabolize some drugs used for respiratory diseases, the presence of PON1 activity in the lung tissue should no longer be ignored in the development of treatment plans and the design of new drugs.

Histo-cytological diagnostic accuracy in lung cancer.

OBJECTIVE: The majority of patients with lung cancer are treated on the basis of a diagnosis made from the analysis of a small tumour biopsy or a cytological sample and histotype is becoming a critical variable in clinical workup as it has led to the introduction of newer biologically targeted therapies. Consequently, simply classifying cancers as small cell lung cancers or non-small cell lung cancers is no longer sufficient. METHODS: From 2009 to 2011, a review of the histo-cytological database was conducted to identify all small biopsy and cytology specimens collected for diagnostic purposes in patients with a thoracic lesion. In total, 941 patients were studied by examining exfoliative and/or aspirative cytological samples. To establish the accuracy of these methods, cytological and biopsy diagnoses were compared with each other and with subsequent resection specimens when available. Moreover, during the diagnostic workup, we examined a validated panel of immunohistochemical markers. RESULTS: The diagnostic concordance of pre-operative diagnoses with surgical samples was high in both cytology and biopsy samples [κ = 0.71, confidence interval (CI) = 0.6-0.81; P < 0.0001 and κ = 0.61, CI = 0.41-0.82; P < 0.0001 respectively; good agreement] but concordance between cytology and biopsy was moderate (κ = 0.5, CI = 0.43-0.54; P < 0.0001). Immunohistochemistry-aided diagnoses were definitive for histotype in 92.8% of both cytology (206/222) and biopsy (155/167) specimens. CONCLUSION: We found that lung cancer diagnosis and subtyping of cytology and biopsy samples are highly feasible and concordant; thus, the diagnostic approach to lung cancer does not require more invasive procedures.

Detection and therapeutic implications of c-Met mutations in small cell lung cancer and neuroendocrine tumors.

BACKGROUND: We evaluated the mutation status of c-Met in small cell lung cancer (SCLC) and neuroendocrine tumors (NET), for which relatively limited therapeutic targets have been explored. MATERIALS AND METHODS: c-Met was re-sequenced using cell lines and clinical samples. For in vitro studies, DNA constructs containing a juxtamembrane domain (JMD) and tyrosine kinase domain (TKD) were generated. Detected mutations were introduced into the construct and effects on c-Met phosphorylation and interaction with tyrosine kinase inhibitor drugs BMS777607 and SU11274 were assessed. RESULTS: 97 specimens were analyzed: 13 SCLC and 2 pulmonary carcinoid cell lines, 46 SCLC and 36 NET clinical specimens. Mutations were only detected in the JMD. No mutations were detected in the TKD. Found mutations consisted of the previously reported R988C and T1010I mutations. One novel JMD mutation, P996S, was detected in a SCLC specimen. The mutation rate in SCLC cell lines was 25% (31% including a derivative cell line), and 6.5% in clinical specimens. The mutation rate in NET was 8.3%. In vitro, there were no differences between wild type, R988C or T1010I mutants regarding c-Met phosphorylation at Y1003, located in the JMD, and at Y1234/1235, located in the TKD. BMS777607 and SU11274 were shown to inhibit phosphorylation of c-Met in wild type and R988C and T1010I mutants in a similar fashion. CONCLUSIONS: In SCLC and neuroendocrine tumors MET mutations are relatively rare. Detected mutations were located in the juxtamembrane domain and were of no functional relevance as they did not influence c-Met phosphorylation, regardless of TKI treatment.

[Rotator cuff diseases in occupational medicine between occupational diseases and accidents: medical-legal considerations]. / La patologia della cuffia dei rotatori in Medicina del Lavoro tra tecnopatia ed infortunio: considerazioni medico-legali.

The authors have gone through the complaints concerning all the cases of shoulder accidents at work filed by the Genoa office of the Italian Workers' National compensation Agency (INAIL) during the two years' period 2006-2007, reviewing in particular those somehow affecting rotator components. The aim of this paper is to assess the real role played by the occupational trauma in the rotator cuff tear. The data gathered so far have shown, on the one hand, a high prevalence of pre-existing inflammatory and degenerative diseases and, on the other, a rather modest influence of the trauma which, for this reason, has usually borne, as an immediate medico-legal consequence, the rejection of a cause-effect relationship between the accident and the rotator cuff lesion, without taking into any account whether the worker was likely to be affected by an occupational disease (ex table Ministerial Decree n. 81 April 9th 2008- item 78). In such cases a systematic and in-depth investigation of the occupational case history is suggested, in order to highlight the possible pre-existence of a former biomechanical overload of the upper limbs, so as to allow the physician to detect a pathology often misdiagnosed.

Treatment with interleukin-2 in malignant pleural mesothelioma: immunological and angiogenetic assessment and prognostic impact.

BACKGROUND: Administration of interleukin-2 (IL-2) has shown some effects on malignant pleural mesothelioma (MPM) tumour regression. The purpose of this study was to investigate the ability of IL-2 to modify immunological effector cells and angiogenesis in MPM patients and their prognostic value. METHODS: Tumour-infiltrating lymphocytes (CD4, CD8, Foxp3), mast cells (MCs) (tryptase and chymase), microvessel count (MVC) and VEGF were determined by immunohistochemistry in two series of MPM patients: 60 patients treated with intra-pleural preoperative IL-2 and 33 patients untreated. RESULTS: Tryptase MCs, and CD8 and Foxp3 lymphocytes were significantly increased in the IL-2-treated group, whereas MVC was significantly lower in the same group. Moreover, in the IL-2-treated group, greater tryptase+MCs and greater Foxp3 lymphocytes were associated with improved and poorer clinical outcomes, respectively. Notably, when these two immunological parameters were combined, they predicted outcomes more effectively. CONCLUSIONS: This study showed that IL-2 treatment leads to a significant increase of immunological parameters, concomitantly with a reduction in vasculature, providing new insight into the cancer mechanisms mediated by IL-2. Moreover, these results suggest that tryptase-positive MCs and Foxp3+ lymphocytes predict clinical outcomes in IL-2-treated patients, highlighting the critical role of the inflammatory response in mesothelioma cancer progression.

Peripheral obstructive arterial disease and carotid artery stenosis in end stage renal disease: a case-control study.

AIM: Cardiovascular diseases are an important cause of morbidity and mortality in end stage renal disease (ESRD) patients. The purpose of this study was to evaluate the predominance of carotid stenosis and peripheral obstructive arterial disease (POAD) in a group of patients subject to dialysis compared with a control group. METHODS: It is a control-case study performed on patients at different hemodialysis facilities; the exams were carried out in ambulatory care. Two groups of patients were examined, the first group was made up of 40 dialysis patients (46.6% men, average age 58.8), the second was the control group made up of 58 subjects matched by age, sex, arterial pressure, presence of diabetes and smoking habits. All patients underwent an Eco-Color Doppler exam on the over aortal trunks and lower extremities and had their Ankle-Brakial-Index (ABI) measured. Carotid stenosis was considered only if equal or over 50%. RESULTS: Twenty percent of dialysis patients showed carotid stenosis (CS) versus 12% in the control group, with an OR of 7.9 (CI 95% 1.3-47.7) adjusted to sex, age and hypertension. The ultrasound picture of the lesions showed large amounts of calcium deposits. Predominance of POAD in dialysis patients was 20% versus 9% in the control group. In dialysis patients the OR adjusted to age, sex and arterial pressure was 6.3 (CI 95%, 1.2-32.6). CONCLUSION: The ultrasound picture of the lesions showed mainly underpopliteal lesions with ''rosary bead'' calcifications. In diabetic dialysis patients the OR was 7.6 (CI 95% 1.4-46.3).

Glomus tumour of the lung: case report and literature review.

Glomus tumours are uncommon neoplasms usually arising in the dermis and subcutaneous tissues where glomus bodies are generally found. Occasionally glomus tumours can occur in extracutaneous sites such as the gastrointestinal tract, bone, genitourinary system and respiratory tract. Primary pulmonary glomus tumours are very rare (only 17 cases reported in the literature), and are often confused with other solid neoplasms such as carcinoids, hemangiopericytomas and tumours belonging to the family of Ewing's sarcoma/primitive neuroectodermal tumours. We present a case of a primary pulmonary glomus tumour originating in the right main bronchus with focal invasion of the submucosa in a 69-year-old man. Histological and immunohistochemical features are reported. The current literature is briefly reviewed, with special attention to differential diagnosis and malignancy criteria.

Pharmacokinetics of azithromycin in serum, bronchial washings, alveolar macrophages and lung tissue following a single oral dose of extended or immediate release formulations of azithromycin.

OBJECTIVES: Antibacterial efficacy of azithromycin could be improved by achieving higher concentrations at the sites of infection. Azithromycin extended release (azithromycin-ER) formulation was developed to enable a higher dosage of 2 g to be administered as a single oral dose without decreasing the safety profile. The aim of this study was to compare the pharmacokinetics of azithromycin in serum, epithelial lining fluid (ELF), alveolar macrophages (AMs) and lung tissue following a single oral dose of azithromycin-ER or azithromycin immediate release (azithromycin-IR) formulation. PATIENTS AND METHODS: A total of 64 patients, diagnosed with lung cancer, requiring open-chest surgery for lung resection, completed the study. Subjects were randomized to receive oral administration of either a single 2 g dose of azithromycin-ER (32 subjects) or a single 500 mg dose of azithromycin-IR (32 subjects). Simultaneously, subjects within each treatment group were randomized to one of eight specific nominal post-dose time points for bronchoalveolar lavage and lung tissue sampling. Results For azithromycin-IR formulation, the AUC(0-24) in serum, ELF, AMs and lung tissue was 3.1, 2.3, 1674 mg.h/L and 130 mg.h/kg, respectively. For azithromycin-ER formulation, the AUC(0-24) in serum, ELF, AMs and lung tissue were 10.0, 17.6, 7028 mg.h/L and 505 mg.h/kg, respectively. The AUC(0-24) ratio following administration of azithromycin-ER relative to azithromycin-IR was 3.2, 7.7, 4.2 and 3.9 in serum, ELF, AMs and lung tissue, respectively. CONCLUSIONS: Within the first 24 h, a single 2 g azithromycin-ER dose produced dose-related increase in systemic exposure compared with a single 500 mg azithromycin-IR dose, which resulted in higher levels of azithromycin in ELF, AMs and lung tissue. Both formulations had similar safety profiles. By achieving high azithromycin exposure early in the course of treatment, without compromising tolerability, azithromycin-ER shows the potential for improved antibacterial efficacy compared with azithromycin-IR.

Mechanoreceptors in the medial and lateral glenohumeral ligaments of the canine shoulder joint.

In order to have a better understanding of the role of ligaments in canine shoulder joint stability, the presence of mechanoreceptors in the medial (MGHL) and lateral (LGHL) glenohumeral ligaments was detected by means of a modified gold chloride stain. Three morphologically distinct mechanoreceptors were identified: Ruffini receptors (type I endings), Pacinian corpuscles (type II endings) and Golgi tendon organ-like receptors (type III endings). These receptors are mainly localized at each end of the ligaments and are prevalently in their glenoid portion. In particular, in the MGHL the highest density was at the cranial arm of the insertion into the scapula. The variety of mechanoreceptors in canine shoulder ligaments might indicate an afferent function in providing the CNS with joint proprioceptive information. Therefore, besides acting as passive mechanical stabilizers, the MGHL and the LGHL may serve as sensory structures, contributing actively to joint stability. Ligamentous injuries which occur in shoulders not only affect mechanical restraint but also alter the proprioceptive input to the CNS by means of disruption of the mechanoreceptors.

IIIB-T4 non-small cell lung cancer: indications and results of surgical treatment.

AIM: T4 non-small cell lung cancer (NSCLC) is commonly considered a contraindication to surgery, indeed chemo-radiotherapy achieves a poor survival rate. We have reviewed our experience with T4 NSCLC patients who underwent surgery with the aim of debating the indications and results of surgical treatment in this highly selected group of patients. METHODS: We investigated a cohort of 60 patients, 49 men and 11 women, who underwent surgery for NSCLC from January 1998 to December 2002 and whose pathological staging was T4N0-2M0. The median age was 65 years (range 46-82). The tumors were classified T4 for the following reasons: intralobar satellite metastasis in 24 cases, direct mediastinum invasion in 18 cases, malignant pleural effusion in 7 cases, involvement of the superior vena cava in 4 cases, marginal invasion of the vertebral body in 3 cases, involvement of the carena in 3 cases and invasion of the left atrium in 1 case. Thirteen patients had undergone neo-adjuvant chemotherapy while 39 underwent adjuvant therapies. RESULTS: Thirty-two patients resulted with N0 disease, 5 with N1 and 23 with N2 disease. Forty patients relapsed (27 systemic and 13 local relapses). The mean survival was 20 months. Of the examined parameters only metastatic nodal involvement was significantly associated with a worse prognosis (P=0.007). CONCLUSION: Surgery for T4 NSCLC may be effective in those patients without mediastinal (N2) lymph node involvement. The prognosis was neither affected by the subtype of T4 tumor nor by the use of adjuvant therapies and/or neoadjuvant chemotherapy but only by the N status. In the preoperative work-up, every possible effort should be made to achieve a careful evaluation of lymph-nodal status (primarily by mediastinoscopy and video operative staging).

Central distribution of nociceptive intradental afferent nerve fibers in the rat.

The central distribution of intradental afferent nerve fibers was investigated by combining electron microscopic observations with a selective method for inducing degeneration of the A delta- and C-type afferent fibers. Degenerating terminals were found on the proprioceptive mesencephalic trigeminal neurons and on dendrites in the neuropil of the trigeminal motor nucleus after application of capsaicin to the rat's lower incisor tooth pulp. The results give anatomical evidence of new sites of central projection of intradental A delta- and C-type fibers whereby the nociceptive information from the tooth pulp can affect jaw muscle activity.

Immunohistochemical localization of alpha(1a)-adrenoreceptors in muscle spindles of rabbit masseter muscle.

The expression of alpha(1a)-adrenoreceptors (alpha(1a)-ARs) within the muscle spindles of rabbit masseter muscle was investigated. The alpha(1a)-ARs were detected by immunohistochemical fluorescent method and examined along the entire length of 109 cross serially sectioned spindles. The sympathetic fibers were visualized by the immunofluorescent labeling of the noradrenaline synthesizing enzymes tyrosine hydroxylase (TH) and dopamine beta-hydroxylase (DBH). In order to recognize the intrafusal muscle fiber types, antibodies for different myosin heavy chain isoforms (MyHCI) were used. TH and DBH immunolabeled nerve fibers have been observed within the capsule lamellar layers, in the periaxial fluid space and close to intrafusal muscle fibers. The alpha(1a)-ARs were detected on the smooth muscle cells of the blood vessels coursing in the muscle and in the capsule lamellar layers or within the periaxial fluid space of the spindles. Moreover, at the polar regions of a high percentage (88.1%) of muscle spindles a strong alpha(1a)-ARs immunoreactivity was present on the intrafusal muscle fibers. In double immunostained sections for alpha(1a)-ARs and MyHCI it was evidenced that both bag, and nuclear chain fibers express alpha(1a)-ARs. The receptors that we have detected by immunofluorescence may support a direct control by adrenergic fibers on muscle spindle.

Thymomas: clinical-pathological correlations.

AIM: Since World Health Organization (WHO) histologic typing of tumors of the thymus publication in 1999 only a few studies correlated this classification with the clinical features of the patients. We present the results of a retrospective analysis on patients, operated on for a thymoma, whose specimens were available, to compare the WHO thymoma histologic classification to the clinical behavior of the tumors. METHODS: The specimens of 69 patients, who underwent surgical treatment between 1983 and 1998, were analyzed, comparing the clinical features of the patients and the hystological typing of the neoplasm, according to the WHO classification. A survival analysis of clinical and pathological prognostic factors was carried out. RESULTS: The incidence of thymus-related syndrome was related to the histological subtype and increases progressively from A to B3, while in C subtype the incidence was nihl. With a mean follow-up of 108 months (range 54-239 months), we experienced 6 intrathoracic recurrencies, 3 of those were intrapleuric and 3 mediastinal. At the last follow-up, 52 patients were alive; 1 with disease. Five deaths were related to the tumor (2 mediastinal and 3 intrapleuric relapses). Actuarial five-year and ten-year survival was 95% and 88.9%. Because of the absence of deaths related to thymomas in most samples it was not possible to perform a comparison among different histological types and different clinical stages. CONCLUSIONS: The WHO histologic classification seems to correlate with the incidence of thymus related syndromes and the clinical stage of Masaoka. Despite the higher incidence of recurrences in type B3 and C thymoma the WHO classification did not prove to be a prognostic factor.

A strategy for thoracoscopic resection of small pulmonary nodules.

BACKGROUND: Preoperative procedures are often necessary to localize pulmonary nodules during thoracoscopic resection in order to reduce the necessity of resorting to thoracotomy. The aim of this report is to describe the strategy we developed to limit preoperative techniques without reducing the thoracoscopic success rate of localization. METHODS: Between January 2000 and December 2003, 183 patients underwent video thoracoscopic resection of small pulmonary nodules. The patients were divided into two groups on the basis of the radiological features of the nodule. The subjects in group 1 were operated on directly, and endothoracic ultrasonography was performed when necessary. The subjects in group 2 underwent preoperative radionuclide labeling of the nodule. RESULTS: In group 1, 112 out of 119 nodules (94%) were localized. Twenty-five out of 32 lesions, neither visible nor palpable, were found by endothoracic ultrasonography. In group 2, we localized 62 out of 64 nodules (97%). CONCLUSIONS: Currently, we cannot completely avoid preoperative labeling techniques for thoracoscopic resection of small pulmonary nodules. However, correct patient selection may limit this necessity, without an increased conversion rate to thoracotomy, if endothoracic ultrasonography is available.

Prognostic significance of osteopontin expression in early-stage non-small-cell lung cancer.

Osteopontin (OPN) is a multifunctional protein, which has recently been shown to be linked to tumorigenesis, progression and metastasis in different malignancies. Since non-small-cell lung cancer (NSCLC)'s prognosis remains bad, with few predictors of outcome, the purpose of this study was to evaluate if OPN might be involved in NSCLC's biology and therefore represent a prognostic marker and a target for new therapeutic trials. Immunohistochemistry was used to detect OPN expression, evaluated as percentage of neoplastic cells with cytoplasmic immunoreactivity, in a wide cohort of patients with stage I NSCLC (136 cases). The median value of this series (20% of positive cells) was used as the cutoff value to distinguish tumours with low (<20%) from tumours with high (> or =20%) OPN expression. A statistically significant correlation between high levels of OPN and shorter overall (P = 0.034) and disease-free (P = 0.011) survival in our patients was shown. Our results support the hypothesis that high OPN expression is a significantly unfavourable prognostic factor for the survival of patients with stage I NSCLC. This conclusion has notable importance in terms of the biological characterization of early-stage tumours and therapeutic opportunities.