Deep in situ microscopy for real-time analysis of mammalian cell populations in bioreactors.

An in situ microscope based on pulsed transmitted light illumination via optical fiber was combined to artificial-intelligence to enable for the first time an online cell classification according to well-known cellular morphological features. A 848 192-image database generated during a lab-scale production process of antibodies was processed using a convolutional neural network approach chosen for its accurate real-time object detection capabilities. In order to induce different cell death routes, hybridomas were grown in normal or suboptimal conditions in a stirred tank reactor, in the presence of substrate limitation, medium addition, pH regulation problem or oxygen depletion. Using such an optical system made it possible to monitor real-time the evolution of different classes of animal cells, among which viable, necrotic and apoptotic cells. A class of viable cells displaying bulges in feast or famine conditions was also revealed. Considered as a breakthrough in the catalogue of process analytical tools, in situ microscopy powered by artificial-intelligence is also of great interest for research.

Myasthenia gravis treatment in the elderly presents with a significant iatrogenic risk: a multicentric retrospective study.

BACKGROUND: Myasthenia gravis (MG) is an autoimmune disease treated with acetylcholinesterase inhibitors and immunosuppressant/immunomodulatory drugs. MG is frequently diagnosed in elderly patients, a fragile population in which treatment adverse effects (TAE) have not been evaluated until now. METHODS: We retrospectively analysed the files of all MG patients with disease onset after age 70 years in four French University Hospitals, including clinical, electrophysiological, biological, and treatment data, with an emphasis on TAE. MG outcomes were assessed using the Myasthenia Gravis Foundation of America (MGFA) status scale. RESULTS: We included 138 patients (59% of men) with a mean follow-up of 4.5 years (range 1-19). Mean age at diagnosis was 78 years (70-93). Anti-acetylcholine receptor antibodies were found in 87% of cases, electrophysiological abnormalities in 82%, and thymoma in 10%. MG outcome was good in a majority of cases, with 76% of treated patients presenting with alleviated symptoms at follow-up. TAE were observed in 41% of patients, including severe TAE in 14% of cases. Seven patients (5.1%) died, including four (2.9%) from MG-related respiratory failure, and three (2.2%) from MG treatment-related complications, i.e., sepsis in 2 cases and brain toxoplasmosis in 1 case. TAE were observed in 53% of patients treated with azathioprine, 23% of patients treated with corticosteroids, and 15% of patients treated with mycophenolate mofetil. CONCLUSIONS: This retrospective study demonstrates MG in the elderly presents with a significant iatrogenic risk, including fatal immunosuppressant-related infections.

Intensification of the photodegradation efficiency of an emergent water pollutant through process conditions optimization by means of response surface methodology.

Heterogeneous photocatalysis has been increasingly investigated during the past years and has been recognized as a promising technique for clean and safe water purification. The current study exploits the advantage of this technique demonstrating that the removal of a biorefractory water pollutant named clofibric acid can be really improved by photocatalysis through a parametric comprehensive investigation and optimization study based on response surface methodology. Its novelty comes from the approach used to enhance the efficiency of the photocatalytic degradation of clofibric acid. A custom central composite design consisting of 49 trials was applied for process modeling and a quadratic robust model was derived based on the analysis of variance for the optimization of the process parameters. The effective removal of the target molecule with about 70% carbon mineralization was achieved under optimal photocatalytic conditions: 1.5 mg/L as the initial concentration of pollutant, 0.61 g/L catalyst, and an irradiation time of 190 min. Further, it was provided that nitrates play a positive role in the removal of this pollutant, while hydrogenocarbonates slow down its elimination. The ecotoxicity evaluation at different trophic levels confirmed the low toxicity of photodegradation by-products. Data analysis demonstrated that response surface methodology is a reliable approach for the optimization of the interactive effects of photocatalytic process parameters and is able to enhance their performance for the complete elimination of this hardly removed water pollutant.

Immune-Mediated Rippling Muscle Disease Associated With Thymoma and Anti-MURC/Cavin-4 Autoantibodies.

OBJECTIVES: Rippling muscle disease (RMD) is characterized by muscle stiffness, muscle hypertrophy, and rippling muscle induced by stretching or percussion. Hereditary RMD is due to sequence variants in the CAV3 and PTRF/CAVIN1 genes encoding Caveolin-3 or Cavin-1, respectively; a few series of patients with acquired autoimmune forms of RMD (iRMD) associated with AChR antibody-positive myasthenia gravis and/or thymoma have also been described. Recently, MURC/caveolae-associated protein 4 (Cavin-4) autoantibody was identified in 8 of 10 patients without thymoma, highlighting its potential both as a biomarker and as a triggering agent of this pathology. Here, we report the case of a patient with iRMD-AchR antibody negative associated with thymoma. METHODS: We suspected a paraneoplastic origin and investigated the presence of specific autoantibodies targeting muscle antigens through a combination of Western blotting and affinity purification coupled with mass spectrometry-based proteomic approaches. RESULTS: We identified circulating MURC/Cavin-4 autoantibodies and found strong similarities between histologic features of the patient's muscle and those commonly reported in caveolinopathies. Strikingly, MURC/Cavin-4 autoantibody titer strongly decreased after tumor resection and immunotherapy correlating with complete disappearance of the rippling phenotype and full patient remission. DISCUSSION: MURC/Cavin-4 autoantibodies may play a pathogenic role in paraneoplastic iRMD associated with thymoma.

Effect of pH and heat treatment on structure, surface characteristics and emulsifying properties of purified camel ß-casein.

Oil-in-water emulsions (20%/80%, w/w) were stabilised by two types of ß-caseins (1 g/L, w/w) extracted by rennet coagulation from camel and cow's milk, respectively. Both extracts were treated under different ranges of pH (3.0, 6.0 and 9.0) and temperature (25, 65 and 95 °C for 15 min) before emulsification. The emulsifying properties of the proteins were studied by surface and interfacial measurements. Results show that the emulsifying activity (EAI) of camel ß-casein is higher than the bovine protein. Yet, both proteins exhibited heat stability and nonsignificant effect of temperature was reported. Conversely, a significant effect of pH on camel ß-casein was recorded: at pH 6.0, the lowest values of EAI were measured and explained by the formation of micellar protein structure. Under such conditions, camel ß-casein is therefore a novel emulsifying protein with high potential to stabilise oil-in-water interfaces which provides numerous applications for the food chemistry field.

Modeling and simulation of a sawdust mixture-based integrated biorefinery plant producing bioethanol.

The design, modeling and simulation of an integrated biorefinery plant assumed to convert different forestry assortments such as sawdust or shavings (sawmill waste) into bioethanol from cellulose and hemicellulose as the main product, and lignin as the most valuable co-product, was carried out. The proposed lignocellulosic ethanol biorefinery plant was simulated with ProSimPlus. The model was based on experimental results and includes an Organosolv pretreatment, enzymatic hydrolysis, fermentation and distillation to obtain bioethanol. The investigated plant size processed 70,088 tons of biomass/year, with a production capacity of 11,650 tons ethanol/year. Ethanol productivity reached 351 L/ton of dry feedstock. Considering water consumption, approximately 4.8 L of water were needed to produce a liter of ethanol. Finally, the energy targeting through conventional pinch analysis lead to 16.4 MW and 16.07 MW of hot and cold utility energy demand for the entire process respectively with the cogeneration of electricity.

Cotton textile waste valorization for removal of tetracycline and paracetamol alone and in mixtures from aqueous solutions: Effects of H3 PO4 as an oxidizing agent.

The use of waste and by-products locally available in large quantities and at low cost as adsorbents can be considered an appropriate approach for improving waste management and protecting the environment. Cotton textile waste was used to prepare adsorbents (MC) via pyrolysis followed by a chemical modification with H3 PO4 . MC samples were characterized by scanning electron microscopy, FTIR spectroscopy, and N2 adsorption-desorption isotherm. The results revealed that MC treated with 1 M H3 PO4 (MC1 ) showed an excellent adsorption performance. The single and binary adsorption of tetracycline (TC) and paracetamol (Pa) onto MC1 were studied. In a single system, TC was better adsorbed than Pa and maximum adsorption capacities qm are 87.7 mg/g and 62 mg/g, respectively. The adsorption follows the Langmuir and pseudo-second-order kinetic models. For a binary system, the experimental data indicate that Pa (44.04 mg/g) is better adsorbed than TC (24.13 mg/g). Adsorption equilibrium data of TC and Pa evaluated by the selectivity extended-Langmuir model in which selectivity factor was introduced provided good correlation results with the binary adsorption data. Cotton textile waste is potentially promising for the preparation of effective adsorbents for the removal of pharmaceutical residues in aqueous solutions. PRACTITIONER POINTS: Valorization of cotton textile waste into adsorbents. Adsorbents were prepared by pyrolysis at 600°C followed by chemical modification in the presence of H3 PO4 . Removal of tetracycline (TC) and paracetamol (Pa) alone or in mixtures by adsorption. Adsorbent showed high-capacity adsorption of the TC and Pa even in a mixture from solutions at low concentrations. The Langmuir and selectivity extended-Langmuir models describe the adsorption of TC and Pa alone and in mixtures, respectively.

Hydrolysis and fermentation steps of a pretreated sawmill mixed feedstock for bioethanol production in a wood biorefinery.

The aim of this work was to demonstrate the feasibility of second-generation bioethanol production using for the first time a sawmill mixed feedstock comprising four softwood species, representative of biomass resource in Auvergne-Rhône-Alpes region (France). The feedstock was subjected to a microwave-assisted water/ethanol Organosolv pretreatment. The investigation focused on enzymatic hydrolysis of this pretreated sawmill feedstock (PSF) using Cellic® Ctec2 as the enzyme, followed by fermentation of the resulting sugar solution using Saccharomyces cerevisiae strain. The cellulose-rich PSF with 71% w/w cellulose content presented high saccharification yields (up to 80%), which made it perfect for subsequent fermentation; this yield was predicted vs. time up to 5.2% w/v PSF loading using a mathematical model fitted only on data at 1.5%. Finally, high PSF loading (7.5%) and scaleup were shown to impair the saccharification yield, but alcoholic fermentation could still be carried out up to 80% of the theoretical glucose-to-ethanol conversion yield.

The French national protocol for Kennedy's disease (SBMA): consensus diagnostic and management recommendations.

BACKGROUND: Kennedy's disease (KD), also known as spinal and bulbar muscular atrophy (SBMA), is a rare, adult-onset, X-linked recessive neuromuscular disease caused by CAG expansions in exon 1 of the androgen receptor gene (AR). The objective of the French national diagnostic and management protocol is to provide evidence-based best practice recommendations and outline an optimised care pathway for patients with KD, based on a systematic literature review and consensus multidisciplinary observations. RESULTS: The initial evaluation, confirmation of the diagnosis, and management should ideally take place in a tertiary referral centre for motor neuron diseases, and involve an experienced multidisciplinary team of neurologists, endocrinologists, cardiologists and allied healthcare professionals. The diagnosis should be suspected in an adult male presenting with slowly progressive lower motor neuron symptoms, typically affecting the lower limbs at onset. Bulbar involvement (dysarthria and dysphagia) is often a later manifestation of the disease. Gynecomastia is not a constant feature, but is suggestive of a suspected diagnosis, which is further supported by electromyography showing diffuse motor neuron involvement often with asymptomatic sensory changes. A suspected diagnosis is confirmed by genetic testing. The multidisciplinary assessment should ascertain extra-neurological involvement such as cardiac repolarisation abnormalities (Brugada syndrome), signs of androgen resistance, genitourinary abnormalities, endocrine and metabolic changes (glucose intolerance, hyperlipidemia). In the absence of effective disease modifying therapies, the mainstay of management is symptomatic support using rehabilitation strategies (physiotherapy and speech therapy). Nutritional evaluation by an expert dietician is essential, and enteral nutrition (gastrostomy) may be required. Respiratory management centres on the detection and treatment of bronchial obstructions, as well as screening for aspiration pneumonia (chest physiotherapy, drainage, positioning, breath stacking, mechanical insufflation-exsufflation, cough assist machnie, antibiotics). Non-invasive mechanical ventilation is seldom needed. Symptomatic pharmaceutical therapy includes pain management, endocrine and metabolic interventions. There is no evidence for androgen substitution therapy. CONCLUSION: The French national Kennedy's disease protocol provides management recommendations for patients with KD. In a low-incidence condition, sharing and integrating regional expertise, multidisciplinary experience and defining consensus best-practice recommendations is particularly important. Well-coordinated collaborative efforts will ultimately pave the way to the development of evidence-based international guidelines.

Camel α-lactalbumin at the oil-water interface: Effect of protein concentration and pH change on surface characteristics and emulsifying properties.

Camel α-lactalbumin (Ala-C), the main whey protein of camel milk, was purified by membrane filtration. Surface hydrophobicity as well as interfacial tension were examined at different levels of pH (3.0, 6.0, 9.0) and protein concentration (0.1 %, 0.2 %, 0.4 % w/w), and compared to bovine α-lactalbumin (Ala-B). The emulsifying properties (EAI and ESI) of oil-in-water emulsions (20 %/80 %) were investigated for both proteins. The stability of the processed emulsions was characterised by ζ-potential, particle size and viscosity measurements. The main findings indicate that Ala-C exhibited greater surface hydrophobicity and undergone changes in conformational structure when pH decreased from 9.0-3.0. These changes were enhanced by increasing protein concentration from 0.1 % to 0.4 % (w/w). However, high concentrations showed low emulsifying activity, especially at pH 6.0 where interfacial tension was lower. In comparison with Ala-B, maximum EAI was close, despite the lower surface hydrophobicity of Ala-C under similar conditions. Overall, emulsions were more viscous at pH 3.0 due to the greater surface coverage than at 9.0 and 6.0. Under the conditions of this study, a protein concentration of 0.2 % resulted in the finest oil droplets and highest viscosity for both types of α-lactalbumin, and Ala-C conferred the highest long-term stability to the emulsions.

Optimization of lactic acid production using immobilized Lactobacillus Rhamnosus and carob pod waste from the Lebanese food industry.

The valorization of a solid carob waste from the Lebanese industry was investigated by optimizing the production of lactic acid using immobilized Lactobacillus rhamnosus in alginate beads and response surface methodology. The results showed that pH and alginate concentration had a significant effect on the production of lactic acid. The fermentation of non-enriched carob waste juice needed an additional nitrogen source to improve lactic acid production and yield. From extracts with 65 g/L sugars, the optimum conditions were found to be 2% for the concentration of alginate, 4% bacteria cells entrapped in beads, 80 rpm agitation speed and pH 6.4. Lactic acid concentration obtained under these conditions was 22 g/L with a yield of 76.9 g/g consumed sugar and a productivity of 1.22 g/L/h. The use of invertase pretreatment increased lactic acid concentration from 22 to 40 g/L, but reduced yield at 66.6%. Finally, cells immobilized in alginate beads could be used for at least five successive cycles.

FSHD1 and FSHD2 form a disease continuum.

OBJECTIVE: To compare the clinical features of patients showing a classical phenotype of facioscapulohumeral muscular dystrophy (FSHD) with genetic and epigenetic characteristics of the FSHD1 and FSHD2 loci D4Z4 and SMCHD1. METHODS: This is a national multicenter cohort study. We measured motor strength, motor function, and disease severity by manual muscle testing sumscore, Brooke and Vignos scores, clinical severity score (CSS), and age-corrected CSS, respectively. We correlated these scores with genetic (D4Z4 repeat size and haplotype; SMCHD1 variant status) and epigenetic (D4Z4 methylation) parameters. RESULTS: We included 103 patients: 54 men and 49 women. Among them, we identified 64 patients with FSHD1 and 20 patients with FSHD2. Seven patients had genetic and epigenetic characteristics of FSHD1 and FSHD2, all carrying repeats of 9-10 D4Z4 repeat units (RU) and a pathogenic SMCHD1 variant. In the remaining patients, FSHD was genetically excluded or remained unconfirmed. All clinically affected SMCHD1 mutation carriers had a D4Z4 repeat of 9-16 RU on a disease permissive 4qA haplotype. These patients are significantly more severely affected by all clinical scales when compared to patients with FSHD1 with upper-sized FSHD1 alleles (8-10 RU). CONCLUSION: The overlap between FSHD1 and FSHD2 patients in the 9-10 D4Z4 RU range suggests that FSHD1 and FSHD2 form a disease continuum. The previously established repeat size threshold for FSHD1 (1-10 RU) and FSHD2 (11-20 RU) needs to be reconsidered. CLINICALTRIALSGOV IDENTIFIER: NCT01970735.

Myoglobinopathy is an adult-onset autosomal dominant myopathy with characteristic sarcoplasmic inclusions.

Myoglobin, encoded by MB, is a small cytoplasmic globular hemoprotein highly expressed in cardiac myocytes and oxidative skeletal myofibers. Myoglobin binds O2, facilitates its intracellular transport and serves as a controller of nitric oxide and reactive oxygen species. Here, we identify a recurrent c.292C>T (p.His98Tyr) substitution in MB in fourteen members of six European families suffering from an autosomal dominant progressive myopathy with highly characteristic sarcoplasmic inclusions in skeletal and cardiac muscle. Myoglobinopathy manifests in adulthood with proximal and axial weakness that progresses to involve distal muscles and causes respiratory and cardiac failure. Biochemical characterization reveals that the mutant myoglobin has altered O2 binding, exhibits a faster heme dissociation rate and has a lower reduction potential compared to wild-type myoglobin. Preliminary studies show that mutant myoglobin may result in elevated superoxide levels at the cellular level. These data define a recognizable muscle disease associated with MB mutation.

Microwave-assisted Organosolv pretreatment of a sawmill mixed feedstock for bioethanol production in a wood biorefinery.

A mixture of sawmill feedstocks comprising four softwood species (fir, spruce, Scots pine, and Douglas fir) was subjected to a microwave-assisted Organosolv pretreatment. The influence of H2SO4 as a catalyst, ethanol-water ratio as the solvent, and temperature on wood fractionation, cellulose yield and purity, lignin recovery, and inhibitor formation were investigated. Minute addition of H2SO4 (0.25% w/w) was found to enhance lignin extraction and hemicellulose hydrolysis, thus providing cellulose yield and purity above 68% ±â€¯2% and 61% ±â€¯3%, respectively. The increase in H2SO4 up to 1% and temperature up to 190 °C, impaired cellulose yields a result of intense hydrolysis, thus degrading cellulose and hemicellulose. Conversely, the increase in ethanol-water ratio enhanced delignification without cellulose degradation. Similarly, inhibitor formation increased with pretreatment severity (H2SO4 content and temperature), but was mitigated by higher ethanol-water ratio. Finally, under best conditions (60:40 ethanol-water, 175 °C, 0.25% H2SO4), cellulose yield and purity reached 82% ±â€¯3% and 71% ±â€¯3%, respectively.

Pharmacogenetics of myotonic hNav1.4 sodium channel variants situated near the fast inactivation gate.

Sodium channel myotonia and paramyotonia congenita are caused by gain-of-function mutations in the skeletal muscle voltage-gated sodium channel hNav1.4. The first-line drug is the sodium channel blocker mexiletine; however, some patients show side effects or limited responses. We previously showed that two hNav1.4 mutations, p.G1306E and p.P1158L, reduce mexiletine potency in vitro, whereas another sodium channel blocker, flecainide, is less sensitive to mutation-induced gating defects. This observation was successfully translated to p.G1306E and p.P1158L carriers. Thus, the aim of this study was to perform a pharmacological characterization of myotonic Nav1.4 mutations clustered near the fast inactivation gate of the channel. We chose seven mutations (p.V1293I, p.N1297S, p.N1297K, p.F1298C, p.G1306E, p.I1310N, and p.T1313M) from the database of Italian and French networks for muscle channelopathies. Recombinant hNav1.4 mutants were expressed in HEK293T cells for functional and pharmacological characterization using the patch-clamp technique. All the studied mutations impair the kinetics and/or voltage dependence of fast inactivation, which is likely the main mechanism responsible for myotonia. The severity of myotonia is well-correlated to the enhancement of window currents generated by the intersection of the activation and fast inactivation voltage dependence. Five of the six mutants displaying a significant positive shift of fast inactivation voltage dependence reduced mexiletine inhibition in an experimental condition mimicking myotonia. In contrast, none of the mutations impairs flecainide block nor does p.T1313M impair propafenone block, indicating that class Ic antiarrhythmics may constitute a valuable alternative. Our study suggests that mutation-driven therapy would be beneficial to myotonic patients, greatly improving their quality of life.

Electrophysiological Characterization of C9ORF72-Associated Amyotrophic Lateral Sclerosis: A Retrospective Study.

OBJECTIVE: C9ORF72 is the most common genetic cause of amyotrophic lateral sclerosis (ALS). The aim of the present study was to determine whether C9ORF72-associated ALS (C9-ALS) patients present distinctive electrophysiological characteristics that could differentiate them from non C9ORF72-associated ALS (nonC9-ALS) patients. METHODS: Clinical and electrodiagnostic data from C9-ALS patients and nonC9-ALS patients were collected retrospectively. For electroneuromyography, the mean values of motor conduction, myography, and the mean values of sensory conduction were considered. Furthermore, the proportion of ALS patients with electrophysiological sensory neuropathy was determined. RESULTS: No significant difference was observed between 31 C9-ALS patients and 22 nonC9-ALS patients for mean motor conduction and myography. For sensory conduction analyses, mean sensory conduction was not significantly different between both groups. In total, 38% of -C9-ALS patient and 21% of nonC9-ALS patients presented electrophysiological sensory neuropathy (p = 0.33). In -C9-ALS patients with electrophysiological sensory neuropathy, 80% (8/10) were male and 67% (6/9) presented spinal onset compare to 25% (4/16, p = 0.014) male and 25% (4/16, p = 0.087) with spinal onset in those without electrophysiological sensory neuropathy. CONCLUSION: Although not different from nonC9-ALS, these results suggest that sensory involvement is a frequent feature of C9-ALS patients, expanding the phenotype of the disease beyond the motor and cognitive domains.

Toe dystonia in Parkinson's disease: Impact of subthalamic nucleus deep brain stimulation.

BACKGROUND: Off state toe dystonia (TD) is a symptom frequently encountered in Parkinson's disease (PD), but little is known about its evolution after subthalamic nucleus deep brain stimulation (STN-DBS). OBJECTIVE: To analyze the prevalence and the evolution of TD in PD patients candidate to STN-DBS. METHODS: Individual data of consecutive 130 PD patients who underwent STN-DBS between 2010 and 2015 were collected. RESULTS: Data were successfully collected in 95 patients. TD affect 45.3% of the patients in our cohort. TD was present in 32.7% of patients before surgery and was alleviated by STN-DBS in 48% of the cases. Motor improvement provided by STN-DBS, levodopa-equivalent treatment diminution after surgery, disease duration or age at the time of surgery were not predictive of TD evolution. A younger age at PD diagnosis was significantly associated with TD resolution. CONCLUSION: STN-DBS is partially efficient for TD but its evolution seems independent of significant predictive factors.

Ankle Strength Impairments in Myotonic Dystrophy Type 1: A Five-Year Follow-up.

BACKGROUND: In Myotonic Dystrophy type 1 (DM1) patients, ankle muscles are affected early and this impairment is reported to be a good biological marker for longitudinal studies. OBJECTIVE: To characterize the ankle dorsiflexion (DF) and eversion (EV) maximal isometric muscle strength changes in adult DM1 patients over 5 years using a standardized handheld dynamometer protocol and the Myoankle method, compare the changes measured with both methods and to the standard error of measurement, and verify the relationship between ankle muscle strength and gait performance. METHODS: The maximal isometric muscle strength of ankle DF and EV in DM1 patients from Quebec and Lyon was assessed at baseline, 18, 36 and 60 months using a handheld dynamometer (HHD) protocol and the MyoAnkle method. RESULTS: There was a decrease of torque in DF/EV of 36.0% /31.3% and 27.7% /35.5% for the Quebec and Lyon cohorts respectively (p≤0.01), but not in a linear way. In most cases (82.5%), the changes observed were greater than the standard error of measurement. DF torque measures taken by the two methods (HHD and MyoAnkle) were highly correlated (rp = 0.97-0.98, p < 0.001). CONCLUSION: Muscle strength ankle impairments are clinically meaningful in DM1 and can be accurately monitored using quantitative testing to measure the efficacy of therapeutic trials.

Anti-MAG antibodies in 202 patients: clinicopathological and therapeutic features.

OBJECTIVE: To assess the clinicopathological and therapeutic features of patients with low (≥1000 to <10 000 Bühlmann Titre Units) (BTU), medium (10 000-70 000) or high (≥70 000) anti-myelin-associated glycoprotein (anti-MAG) antibody titres. METHODS: We retrospectively and prospectively analysed standardised report forms and medical records of 202 patients from 14 neuromuscular centres. RESULTS: Mean age at onset and mean time between symptom onset to last follow-up were respectively 62.6 years (25-91.4) and 8.4 years (0.3-33.3). Anti-MAG antibody titres at diagnosis were low, medium or high in 11%, 51% and 38% of patients. Patients presented with monoclonal gammopathy of undetermined significance in 68% of cases. About 17% of patients presented with 'atypical' clinical phenotype independently of anti-MAG titres, including acute or chronic sensorimotor polyradiculoneuropathies (12.4%), and asymmetric or multifocal neuropathy (3%). At the most severe disease stage, 22.4% of patients were significantly disabled. Seventy-eight per cent of patients received immunotherapies. Transient clinical worsening was observed in 12% of patients treated with rituximab (11/92). Stabilisation after rituximab treatment during the 7-12-month follow-up period was observed in 29% of patients. Clinical response to rituximab during the 6-month and/or 7-12-month follow-up period was observed in 31.5% of patients and correlated with anti-MAG titre ≥10 000 BTU. CONCLUSION: Our study highlights the extended clinical spectrum of patients with anti-MAG neuropathy, which appears unrelated to antibody titre. Besides, it may also suggest beneficial use of rituximab in the early phase of anti-MAG neuropathy.

Incobotulinum toxin A in Parkinson's disease with foot dystonia: A double blind randomized trial.

INTRODUCTION: Plantar flexion of toe dystonia is very painful and leads to difficulties in walking. The objective of this study was to investigate the effect of incobotulinum toxin A (Xeomin) in the treatment of this type of dystonia in parkinsonian patients, using a randomized, double blind, placebo-controlled trial. METHODS: 45 parkinsonian patients with painful dystonic plantar flexion of toes were injected either with incobotulinum toxin A (Btx group), or with placebo in two muscle targets: the Flexor digitorum longus and the Flexor digitorum brevis. Three groups were compared: the first group received placebo in the Flexor digitorum longus and 100UI of Btx in the Flexor digitorum brevis (n = 16); the second group received 100 UI of Btx in the Flexor digitorum longus and placebo in the Flexor digitorum brevis (n = 13); and the third group, 2 injections of placebo (n = 16). The patients were injected in the same way twice with an interval of 3 months. The primary endpoint was measured six weeks after injections with the Clinical Global Impression (CGI) of change. Dystonia severity and associated pain were also assessed. RESULTS: Mean CGI was improved in the Btx group compared to the placebo group (P = 0.039). A significant reduction of pain and dystonia severity were observed in patients treated with Btx compared to baseline but no improvement was noted when compared to placebo group. No difference of efficacy was highlighted between the two injection sites. CONCLUSIONS: Btx injections are effective for improving clinical state of parkinsonian patients with plantar flexion of toe dystonia.