Neural Correlates for Apathy: Frontal-Prefrontal and Parietal Cortical- Subcortical Circuits

Apathy is usually defined as the overt manifestation of a lack of motivation, and decreased emotional engagement, lack of concern or indifference, and a flattening of affect. Apathy is a major clinical condition which strongly impacts in every day life events, affects the common daily living abilities, reduced the inner goal directed behavior, and gives the heaviest burden on caregivers. Is a quite common comorbidity of many neurological disease, However, there is no definite consensus on the role of apathy in clinical practice, no definite data on anatomical circuits involved in its development, and no definite instrument to detect it at bedside. As a general observation, the occurrence of apathy is connected to damage of prefrontal cortex (PFC) and basal ganglia; \u201cemotional affective\u201d apathy may be related to the orbitomedial PFC and ventral striatum; \u201ccognitive apathy\u201d may be associated with dysfunction of lateral PFC and dorsal caudate nuclei; deficit of \u201cautoactivation\u201d may be due to bilateral lesions of the internal portion of globus pallidus, bilateral paramedian thalamic lesions, or the dorsomedial portion of PFC. On the other hand, apathy severity has been connected to neurofibrillary tangles density in the anterior cingulate gyrus and to grey matter atrophy in the anterior cingulate (ACC) and in the left medial frontal cortex, confirmed by functional imaging studies. Specifically, these regions are involved in evaluating action and outcomes and, via the basolateral amygdala and nucleus accumbens, feed into an ascending frontostriatal pathway to the dorsolateral prefrontal cortex, which is ultimately responsible for selecting and executing behavioural responses. Damage to the ACC and OFC leads to a disruption of this circuit resulting in impaired decision-making and impaired response initiation, which presents as apathy. Emergent role concerns also the parietal. We will discuss the importance of these circuits in different pathologies, degenerative or vascular, acute or chronic.Apathy is an uncertain nosographical entity, which includes reduced motivation, abulia, decreased empathy, and lack of emotional involvement; it is an important and heavy-burden clinical condition which strongly impacts in everyday life events, affects the common daily living abilities, reduced the inner goal directed behavior, and gives the heaviest burden on caregivers. Is a quite common comorbidity of many neurological disease, However, there is no definite consensus on the role of apathy in clinical practice, no definite data on anatomical circuits involved in its development, and no definite instrument to detect it at bedside. As a general observation, the occurrence of apathy is connected to damage of prefrontal cortex (PFC) and basal ganglia; "emotional affective" apathy may be related to the orbitomedial PFC and ventral striatum; "cognitive apathy" may be associated with dysfunction of lateral PFC and dorsal caudate nuclei; deficit of "autoactivation" may be due to bilateral lesions of the internal portion of globus pallidus, bilateral paramedian thalamic lesions, or the dorsomedial portion of PFC. On the other hand, apathy severity has been connected to neurofibrillary tangles density in the anterior cingulate gyrus and to gray matter atrophy in the anterior cingulate (ACC) and in the left medial frontal cortex, confirmed by functional imaging studies. These neural networks are linked to projects, judjing and planning, execution and selection common actions, and through the basolateral amygdala and nucleus accumbens projects to the frontostriatal and to the dorsolateral prefrontal cortex. Therefore, an alteration of these circuitry caused a lack of insight, a reduction of decision-making strategies, and a reduced speedness in action decision, major responsible for apathy. Emergent role concerns also the parietal cortex, with its direct action motivation control. We will discuss the importance of these circuits in different pathologies, degenerative or vascular, acute or chronic

Metastatic angioimmunoblastic T-cell lymphoma started from thoracic paravertebral region: a Case report

Angioimmunoblastic T-cell lymphoma (AITL) is one of the most frequent nodal T-cell lymphoma. 1,2 It derives from follicular helper T-cell (TFH).3 It accounts for 15 - 20% of all peripheral T-cell lymphomas and usually affects patients in the seventh decade of life.1,2,4,5 AITL\u2019s incidence is nearly 0,05 new patient case per 100,000 people in US, and there\u2019s no sex predilection.6,7 It is characterized by polymorphic lymph node infiltrate with a prominent proliferation of high endothelial venules and follicular dendritic cells, different immune disorders and a poor prognosis. 8,9 The neoplastic T-cells express CD2, CD3, CD4 and CD10 but the marker\u2019s specificity has been debated. More specific indicators of AITL are CXCL-13, programmed death-1 (PD1), inducible costimulator (ICOS), and BCL6 transcription factor.10-12 Nearly all patients have EBV-infected B cells in their lymph nodes, but the presence of these EBV-positive cells doesn\u2019t correlate with survival.13-15 However, the role of EBV isn\u2019t clear yet: it could be secondary to the immune deregulation, or it could be a fundamental factor involved in disease\u2019s start and progression. AITL is frequently associated with polyclonal B-cell or plasma cell proliferation;8 this neoplastic proliferation of B-cells on parallel with AITL could be motivated by a cluster of pluripotent cells with the ability to differentiate into B-cells and T-cells neoplasm simultaneously, maybe due to exposition to pharmacological therap\ue8ies or specific mutagens. Clinical manifestations are often represented by group-B symptoms (fever, night sweats, weight loss), hepatosplenomegaly, anemia, lymphadenopathy, polyclonal hypergammaglobulinemia, thrombocytopenia and/or a large variety of immune disorders.16,17 Up to 50% of develop cutaneous lesions, expression of extranodal diffusion of the tumor: urticaria, purpura, pruritic maculopapular eruptions, erosions, plaques, nodules, petechiae.18-20 Despite occasionally spontaneous remissions,21 AITL prognosis is poor, with a median overall survival of 3 years

Unmanipulated haploidentical transplants compared with other alternative donors and matched sibling grafts

We studied 459 consecutive patients with hematologic malignancies, median age 44 years (range, 15 to 71 years), who underwent transplantation with grafts from identical sibling donors (SIB; n = 176), matched unrelated donors (MUD; n = 43), mismatched unrelated donors (mmUD; n = 43), unrelated cord blood (UCB; n = 105) or HLA-haploidentical family donors (HAPLO; n = 92). Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine and methotrexate in the SIB recipients; antithymocyte globulin for the MUD, mmUD, and UCB recipients; and post-transplantation cyclophosphamide, cyclosporine, and mycophenolate in the HAPLO recipients. Conditioning regimens were mostly myeloablative (69%). Advanced disease phase was more frequent, but not significantly so, in the HAPLO and mmUD groups (P = .08). Acute GVHD grade II-IV was significantly less frequent in the HAPLO, UCB, and MUD groups (14% to 21%) compared with the SIB (31%) and mmUD (42%) groups (P < .001), and there was a trend toward less moderate-severe chronic GVHD in the HAPLO and UCB groups (P = .053). The proportion of patients off cyclosporine at 1 year ranged from 55% for the SIB group to 81% for the HAPLO group (P < .001). Transplantation-related mortality at 2 years was lower in the HAPLO and SIB groups (18% to 24%) compared with the MUD, mmUD, and UCB groups (33% to 35%; P = .10). Relapse rate was comparable in the 5 groups (P = .80). The 4-year actuarial survival was 45% in the SIB group, 43% in the MUD group, 40% in the mmUD group, 34% in the UCB group, and 52% in the HAPLO group (P = .10). In multivariate analysis, advanced disease was a negative predictor of survival (hazard ratio [HR], 2.4; P < .0001), together with a diagnosis of acute leukemia (HR, 1.8; P = .0001); HAPLO grafts were comparable to SIB (P = .80), whereas UCB had inferior survival (P = .03). In conclusion, unmanipulated haploidentical family donor transplants are an additional option for patients lacking a matched sibling donor

The prognostic value of the previous nephrectomy in pretreated metastatic renal cell carcinoma receiving immunotherapy: a sub-analysis of the Meet-URO 15 study

Nephrectomy is considered the backbone of managing patients with localized and selected metastatic renal cell carcinoma (mRCC). The prognostic role of nephrectomy has been widely investigated with cytokines and targeted therapy, but it is still unclear in the immunotherapy era

COVID-19 Severity in Multiple Sclerosis: Putting Data Into Context

Background and objectives: It is unclear how multiple sclerosis (MS) affects the severity of COVID-19. The aim of this study is to compare COVID-19-related outcomes collected in an Italian cohort of patients with MS with the outcomes expected in the age- and sex-matched Italian population. Methods: Hospitalization, intensive care unit (ICU) admission, and death after COVID-19 diagnosis of 1,362 patients with MS were compared with the age- and sex-matched Italian population in a retrospective observational case-cohort study with population-based control. The observed vs the expected events were compared in the whole MS cohort and in different subgroups (higher risk: Expanded Disability Status Scale [EDSS] score > 3 or at least 1 comorbidity, lower risk: EDSS score ≤ 3 and no comorbidities) by the χ2 test, and the risk excess was quantified by risk ratios (RRs). Results: The risk of severe events was about twice the risk in the age- and sex-matched Italian population: RR = 2.12 for hospitalization (p < 0.001), RR = 2.19 for ICU admission (p < 0.001), and RR = 2.43 for death (p < 0.001). The excess of risk was confined to the higher-risk group (n = 553). In lower-risk patients (n = 809), the rate of events was close to that of the Italian age- and sex-matched population (RR = 1.12 for hospitalization, RR = 1.52 for ICU admission, and RR = 1.19 for death). In the lower-risk group, an increased hospitalization risk was detected in patients on anti-CD20 (RR = 3.03, p = 0.005), whereas a decrease was detected in patients on interferon (0 observed vs 4 expected events, p = 0.04). Discussion: Overall, the MS cohort had a risk of severe events that is twice the risk than the age- and sex-matched Italian population. This excess of risk is mainly explained by the EDSS score and comorbidities, whereas a residual increase of hospitalization risk was observed in patients on anti-CD20 therapies and a decrease in people on interferon

DMTs and Covid-19 severity in MS: a pooled analysis from Italy and France

We evaluated the effect of DMTs on Covid-19 severity in patients with MS, with a pooled-analysis of two large cohorts from Italy and France. The association of baseline characteristics and DMTs with Covid-19 severity was assessed by multivariate ordinal-logistic models and pooled by a fixed-effect meta-analysis. 1066 patients with MS from Italy and 721 from France were included. In the multivariate model, anti-CD20 therapies were significantly associated (OR = 2.05, 95%CI = 1.39–3.02, p < 0.001) with Covid-19 severity, whereas interferon indicated a decreased risk (OR = 0.42, 95%CI = 0.18–0.99, p = 0.047). This pooled-analysis confirms an increased risk of severe Covid-19 in patients on anti-CD20 therapies and supports the protective role of interferon