Elexacaftor/tezacaftor/ivacaftor (ETI) has proven highly effective in people with cystic fibrosis (pwCF) carrying at least one F508del mutation. This prospective cohort study aims to better characterize the heterogeneity in responses to ETI and to identify patients who better respond to the treatment. We evaluated treatment response after 6 months into ETI therapy, in terms of changes in sweat chloride concentration, ppFEV1 and sex- and age-specific standard deviation scores of body mass index (BMISDS). K-means clustering analysis was carried out to group patients according to their patterns of response. Baseline characteristics and treatment responses were compared between the identified clusters. The study included 164 pwCF who received ETI at the paediatric and adult CF centres of Milan. At 6 months from treatment initiation, sweat chloride concentration decreased by a mean value of –53 mmol/L (95% CI: –57; –50); ppFEV1 increased by 16.4 points (14.6; 18.1) and BMISDS by 0.41 (0.34; 0.49). Sweat chloride concentration did not improve in 2 (1.2%) patients; 18 (11.0%) patients had changes in ppFEV1<3 points; BMISDS did not increase in 32 (19.5%) patients. Cluster analysis identified two groups of patients: group 1 and group 2. Patients in group1 had a lower reduction in sweat chloride concentration (mean changes: –48 vs –61 mmol/L, p < 0.001) and lower increases in ppFEV1 (+9.2 vs +25.2, p < 0.001) and BMISDS (+0.16 vs +0.81, p <0.001) as compared to patients in group 2. Patients in group 1 had a milder clinical phenotype, characterized by better respiratory function, less airways resistance, better nutritional status, lower P. aeruginosa infection rate and lower prevalence of diabetes. Most pwCF had remarkable clinical benefit from ETI, however a non-negligible share of them showed suboptimal responses. Further research is needed to better characterize the determinants of poor response to ETI.

Excimer Laser Coronary Atherectomy (ELCA) is a well-established therapy that emerged for the treatment of peripheral vascular atherosclerosis in the late 1980s, at a time when catheters and materials were rudimentary and associated with the most serious complications. Refinements in catheter technology and the introduction of improved laser techniques have led to their effective use for the treatment of a wide spectrum of complex coronary lesions, such as thrombotic lesions, severe calcific lesions, non-crossable or non-expandable lesions, chronic occlusions, and stent under-expansion. The gradual introduction of high-energy strategies combined with the contrast infusion technique has enabled us to treat an increasing number of complex cases with a low rate of periprocedural complications. Currently, the use of the ELCA has also been demonstrated to be effective in acute coronary syndrome (ACS), especially in the context of large thrombotic lesions.

TYPE: Abstract Publication TOPIC: Chest Infections PURPOSE: The concomitant diagnosis of cystic fibrosis (CF) and immunodeficiency (ID) is considered uncommon. Despite ID is a potentially treatable comorbidity, a full immunological screening in a large CF population is still lacking. The aim of this study was to investigate the prevalence of ID in CF adults. METHODS: This is an observational prospective study enrolling consecutive CF adults outpatients at the Milan Adult CF Center from January 2018 to March 2019. Patients were tested for full blood count, IgG, IgA, IgM, IgG subclasses, lymphocytes subsets, and HIV test during clinical stability. ID definition was based on European Society for Immunodeficencies (ESID) criteria. RESULTS: Among 178 recruited CF adult patients, 46 (24.4%) showed at least one abnormal result at the broad immunological screening leading to ID definition. CF patients with ID showed no statistical significant differences compared to CF patients without ID in terms of demographics characteristics, mutations, exacerbation, FEV1, and severity of disease. CONCLUSIONS: These data shows that IDs are common among adults with CF. These patients should be evaluated by a multidisciplinary team, including an experienced clinical immunologist and a CF clinician for further testing and the evaluation of immunoglobulin replacement therapy. CLINICAL IMPLICATIONS: A broad immunological screening should be performed in adult patients with CF. DISCLOSURE: No significant relationships. KEYWORDS: cystic fibrosis, immunological screening

UMJ is an open access publication of the Ulster Medical Society (http://www.ums.ac.uk). The Ulster Medical Society grants to all users on the basis of a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence the right to alter or build upon the work non-commercially, as long as the author is credited and the new creation is licensed under identical terms. specific symptoms, but faecal incontinence has not been previously reported in the literature. 1 2 5 The histopathological evaluation of colorectal follicular lymphoma can be difficult. It is not uncommon for initial histological misinterpretation and requirement of multiple biopsies before the definite diagnosis. This case emphasises the challenge of accurate histopathological diagnosis. Suitable biopsy samples and immunophenotyping analysis are recommended for accurate interpretation of the pathological diagnosis of follicular lymphoma. 4, 5 The management of gastrointestinal follicular lymphoma is not well established because of its rarity, but multidisciplinary approach should be undertaken. In this patient, after a watchful period, local radiotherapy was implemented with good effect. This appears in accordance to general consensus, as intestinal follicular lymphoma is usually approached as nodal follicular lymphoma and a watch-and-wait strategy or radiation therapy can be applied in case of limited disease. 1

The neutrophil derived protease, Neutrophil elastase (NE), in patient sputum is a biomarker of bronchiectasis severity. The vicious cycle of bronchiectasis pathogenesis suggests NE reduces ciliary beat frequency (CBF), compromising mucociliary clearance. Early studies assessing high concentration porcine elastase or patient sputum on CBF confirmed this hypothesis. The aim of this study was to investigate the effect of physiological NE concentrations on nasal cilia with the hypothesis that NE inhibitors may be a target for improving mucociliary clearance in bronchiectasis. Nasal brushing was performed on healthy volunteers (free from respiratory infections for at least 5 weeks). CBF of nasal epithelial cells evaluated by high-speed video light microscopy immediately in suspension and following culture at air liquid interface (ALI). Media/buffer alone or NE (0.1 U/ml)±NE inhibitor (AZD9668, 10 nM) were added and CBF calculated at 37°C. A cohort of 10 volunteers (mean age: 29.2 years; males: 40%; 100% non smokers) was selected. The mean (SD) of all CBF measurements from nasal epithelial cells in suspension was 13.83 (3.46) Hz, with a significant increase after NE exposure (12.5% (95% CI 11.3% to 13.6%), p<0.0001). Addition of NE to the apical surface of ALI cultures also resulted in increased CBF (15.0% (4.3%–25.1%) n=5 p=0.01) suggesting presence of NE at the airway surface increases CBF. The CBF increase occurred within 5 min and persisted beyond 72 hours. The increase of CBF was not reversible by washing with media (2.5%, p=0.5) or the subsequent addition of NE inhibitors (7%, p=0.4). Ciliated cells pre-treated with NE inhibitor showed no significant increase in CBF (3.5%, p=0.4), suggesting the increase is mediated by the protease action of NE. In conclusion, NE, at concentrations present in bronchiectasis sputum, increase CBF. The cause of reduced CBF in bronchiectasis airways and the role of NE in mucociliary clearance require review.

INTRODUCTION:Influenza epidemics are one of the main causes of morbidity and mortality worldwide. Influenza vaccination is considered the most important public health intervention to prevent seasonal influenza infection. European health authority policies focus on patient protection by vaccinating both these subjects and their care-givers, including health-care workers (HCWs). The aim of this survey is to investigate knowledge about influenza vaccination and intention to get vaccinated among Italian HCWs who take care patients with respiratory disease.METHODS:An anonymous web-based survey was addressed to members of the Italian Respiratory Society (IRS).RESULTS:Among the 1,776 IRS members who have been invited to the survey, 144 (8.1%) completed the survey (97 men; median age 59 years; 85.4% Respiratory Disease). The vast majority recommended vaccination to all their patients (81%). More than two thirds of respondents considered influenza vaccination safe for immunocompromised patients. More than 50% of respondents underwent seasonal influenza vaccination in 2015 and 68% declared the intention to undergo vaccination in 2016 epidemic season. Reasons for having vaccination mainly referred to 'protect oneself from influenza' (63%), 'protect patients' (31%) or household members' (6%). The main reasons for vaccination refusal were 'lack of time' (45%), 'concerns about side effects' (22%), 'do not get influenza easily and/or not afraid of influenza infection' (22%) and 'disagreement with indication of vaccination for HCWs' (9%).CONCLUSIONS:The promotion of better knowledge and attitude towards influenza vaccination among Italian specialists remains an unmet goal and should be addressed by appropriate multifaceted interventions.

Coronary angiography presents several limitations for the evaluation of left main (LMCA) stenoses, due to several reasons: short length, frequent overlapping with side branches, lack of a reference segment, reverse tapering. Fractional flow reserve (FFR) is a useful tool for functional evaluation of

BACKGROUND Dendritic cells (DCs) capture apoptotic tumors and cross-present their antigens in the MHC class I and class II pathways for recognition by CD4+ and CD8+ T lymphocytes. Here we have tested the ability of fresh surgically resected colon and gastric cancer tumors to specifically activate host T lymphocytes when presented by autologous DCs. METHODS DCs derived from adherent blood mononuclear cells of five patients, after a 7-day culture with GM-CSF and IL-4, were exposed to apoptotic autologous tumor (AAT) or apoptotic autologous peritumor normal (AAN) cells and cultured 24 h with monocyte-conditioned medium to achieve full DC maturation. Tumor-specific response was evaluated as single-cell cytokine release in an enzyme-linked immunospot (ELISPOT) and as cytotoxicity in a cold target inhibition (51)Cr-release assay. RESULTS AAT-DCs induced specific IFN-gamma by T lymphocytes of two patients (rectal and gastric cancer), whereas in another two patients (rectal and gastric cancer) this response was depressed with a similar tumor-specific pattern and in one patient (rectal cancer) there was no response. Activation of IFN-gamma release was accompanied by tumor cytotoxicity and both responses were enhanced by IL-12, indicating the functional integrity of patients' lymphocytes. CONCLUSION These data show that T-cell memory against rectal/gastric carcinoma antigens can be triggered by tumor-loaded autologous DCs. However, escape mechanisms may exist among tumors of the same histological origin that can inhibit this host response. A DC-based antitumor immunological monitoring assay with autologous tumor biopsies may allow patients to be screened to determine those who are suitable candidates for immune-based immunotherapy.

The characterization of tumor-associated antigens has enabled to direct the host immune response towards the autologous tumor through appropriate loading and presentation of the antigen. In vivo conditions that generate large numbers of tumor antigens would be an important step in vaccine strategies. In this study we have therefore tested the ability of freshly isolated gastric and colorectal cancer cells to induce a specific anti-tumor response in autologous T lymphocytes. Because dendritic cells (DC) are critically involved in both initiating and boosting host immune responses, they have been used to present apoptotic bodies generated by irradiated tumor cells. Results show that these native antigens stimulate T cytotoxic response against tumor, but not peritumor normal tissues. Induction of IFN-gamma secreting cell activity, which is a standard readout in current cancer vaccine protocols, was also demonstrated by Elispot single-cells assay. These data show the antigenicity of gastric and colorectal tumor cells and open new perspectives in immunotherapy.

Prolactin (PRL) shares structural and functional features with haemopoietic factors and cytokine peptides. Dendritic cells (DC) are involved in both initiating the primary and boosting the secondary host immune response and can be differentiated in vitro from precursors under the effect of granulocyte-macrophage colony-stimulating factor (GM-CSF) plus other factors. Because PRL has been shown to functionally interact with GM-CSF, we have addressed its role on GM-CSF-driven differentiation of DC. Monocytic DC precursors from peripheral blood mononuclear cells (PBMC) were enriched either by adhesion to a plastic surface or CD14-positive selection and cultured for 7 days in serum-free medium containing GM-CSF, interleukin (IL)-4 and PRL, alone or in combination. Cells with large, veiled cytoplasm, expressing major histocompatibility complex (MHC) class II and the costimulatory molecules CD80, CD86 and CD40 and lacking the monocyte marker CD14, were considered as having the phenotype of cytokine-generated DC. Functional maturation was assessed by proliferation and interferon-gamma (IFN-gamma) release of allogeneic T lymphocytes. Physiological (10-20 ng/ml) concentrations of PRL interacted synergistically with GM-CSF and the effect was similar to that induced by IL-4 on GM-CSF-driven DC maturation. When used alone, the physiological concentrations of PRL were inhibitory, whereas higher concentrations (80 ng/ml) were stimulatory. The synergistic effect of PRL may in part be caused by its ability to counteract the down-modulation of the GM-CSF receptor observed in serum-free conditions. These data provide further evidence of the significance of PRL in the process of T lymphocyte activation.

Prolactin (PRL) has been shown to participate in lymphocyte activation. In particular, the constitutive natural killer (NK) and the lymphokine-activated killer (LAK) cytotoxicity of CD56(+) CD16(+) cells is increased by its physiological to supraphysiological concentrations. As PRL has been shown to up-regulate the production of interferon-gamma (IFN-gamma) by peripheral, blood mononuclear cells, we studied its effect on IFN-gamma production by NK cells as a possible mechanism of autocrine activation of cytotoxicity. Released and intracellular IFN-gamma, as well as IFN-gamma mRNA expression, were increased by pituitary and recombinant human PRL, which stimulated optimal NK and LAK cytotoxicity. Treatment with blocking anti-IFN-gamma monoclonal antibody (mAb) selectively affected PRL-increased killing of K562 targets, demonstrating that PRL-mediated enhancement of spontaneous cytotoxicity depends, at least in part, on up-regulation of IFN-gamma.

Balloon atrial septostomy (BAS) is of established value in the management of several congenital heart diseases in the neonatal period. This procedure, which leads to creation of a tear in the membrane of the Foramen Ovalis using a balloon catheter, may be undertaken under fluoroscopic monitoring in catheter laboratory as well as under echographic control, even bedside. In this study we present our experience and discuss the indications to these two techniques. 91 neonates underwent to BAS; in 14 of them this was carried out under two-dimensional echocardiographic control in the intensive care unit. In all the patients BAS had good result, with clinical improvement in the majority of cases (97%) and a low rate (6%) of minor complications (such as transient supraventricular arrhythmias), without differences between fluoroscopic and ultrasound monitoring. The higher rate of mortality in the fluoroscopic monitoring group (2/91 = 2.2%) was thought to depend on an extremely critical presentation of the neonates. The echographic monitoring does not seem to offer any real advantage from the technical point of view, but the necessity of a prompt treatment of very ill patients emphasizes the advantages of a quickly and easily feasible procedure. Thus, we recommend the use two-dimensional echocardiographic imaging only in the very ill neonates in whom the septostomy can be more safely performed in intensive care unit bedside.

The development of non-Hodgkin's lymphomas (NHL) is one of the major complications of AIDS. Although several biologic aspects of AIDS-related NHL have been clarified, their sensitivity to immune system cytotoxic effectors has not been tested. In this study, we have investigated the susceptibility of one major AIDS-related NHL type, Burkitt's-type lymphoma (BL), to the cytotoxic activity of lymphokine-activated killers (LAK) and prolactin-activated killers (PAK), which were generated from peripheral blood mononuclear cells upon stimulation with interleukin-2 (in the case of LAK cells) and prolactin (in the case of PAK cells). The sensitivity of AIDS-related BL to in vitro raised cytotoxic effectors was compared with that of BL variants of the general population, including sporadic BL and endemic BL. The data show that AIDS-related BL is susceptible to cytolysis by LAK cells, whereas both LAK and PAK cells can efficiently kill endemic BL. In contrast, sporadic BL showed resistance to all cytotoxic effectors tested. Intriguingly, in the case of AIDS-related and endemic BL suboptimal doses of interleukin-2 in combination with prolactin displayed a cytotoxic effect similar to that of LAK cells, suggesting a synergistic activity of the two agents. Overall, these data corroborate the notion that the distinct BL variants differ in their biologic features despite their morphologic and genetic similarity.

Exogenous prolactin (PRL) has been shown to synergize with low‐dose interleukin‐2 (IL‐2) and induce the proliferation and lymphokine‐activated killer (LAK) maturation of natural killer (NK) cells. PRL itself can also generate LAK activity. Here we show that its local production occurs during, and is necessary for, LAK development. IL‐2‐stimulated peripheral blood mononuclear cells (PBMC) and purified NK cells were exposed to anti‐human (h)PRL antiserum, and residual LAK activity was measured on day 7 against the promyelocytic leukaemia cell line HL‐60. Inhibition of LAK activity was much more evident in PBMC compared with NK cell cultures (47% decrease, P=0.013 and 18.5% decrease, P=0.048, respectively). Up‐modulation of a 32S‐methionine‐labelled 27000MW protein was detected in the lysates and supernatants of IL‐2‐stimulated PBMC immunoprecipitated with an anti‐PRL antiserum. By contrast, the cytoplasmic PRL immunoreactivity observed in freshly isolated NK cells and in IL‐2‐stimulated, but not unstimulated, NK cell cultures was not associated with PRL gene activation, and can thus be referred to internalized PRL. Preferential re‐uptake of externally derived PRL by IL‐2‐stimulated NK cells was also indicated by up‐modulation of the PRL receptor. These data, as a whole, indicate that the PRL promotion of LAK differentiation is mainly mediated by paracrine secretion, with a minor contribution from internalized PRL.