Arrhythmogenic right ventricular cardiomyopathy. Contribution of cardiac magnetic resonance imaging to the diagnosis.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited disease of the heart muscle, mostly due to genetically defective desmosomal proteins. The disease is characterized by fibrofatty replacement leading to ventricular arrhythmias and sudden death in young people and athletes. There is no single clinical gold standard examination for making a definitive diagnosis. The diagnosis is based on multiple parameters, including: (1) global or regional dysfunction and structural alteration of the right ventricle demonstrated on imaging; (2) tissue characterization by endomyocardial biopsy; (3) repolarization and (4) depolarization electrocardiographic abnormalities; (5) arrhythmias; and (6) family history. The so-called phenocopies must be included in the differential diagnosis, always taking into account that there is no single criterion sufficiently specific for a reliable diagnosis of ARVC. Contrast-enhanced cardiac magnetic resonance imaging (CE-CMR) is not yet included in the revised diagnostic criteria, although this is the only imaging modality able to depict fibrosis as late gadolinium enhancement (LGE) deposition. This review analyzes the role of CMR imaging in the diagnostic work-up of ARVC. The lack of specific diagnostic criteria contributes to the under-recognition of the nonclassic variants of ARVC, i.e., dominant or isolated left ventricular disease.

C1272F: a novel type 2A von Willebrand's disease mutation in A1 domain; its clinical significance.

Most mutations identified in 2A VWD patients are localized in the A2 domain, although missense substitutions have also been recognized in the A1 domain. We describe a novel heterozygous missense mutation in the A1 domain of VWF gene responsible for type 2A phenotype. Analysis of the complete exon 28 was carried out in a patient and his mother with life-long histories of moderate to severe bleeding and laboratory data of type 2A VWD. The analysis of exon 28 of VWF gene showed a 3815 G → T transversion resulting in C1272F mutation. It is probably associated with a group I mechanism according to patients' clinical symptoms, and, in the case of the propositus, the lack of clinical response to treatment with desmopressin. The mutation was not found in 100 normal alleles. This substitution affected the normal S-S bound between C1272 and C1458, which is involved in A1 loop structure, altering the normal multimerization and function of VWF. The VWFpp/VWF:Ag ratio in the propositus and his mother was >3, suggesting a shortened survival of VWF. We believe it is important to report the complete clinical phenotype corresponding to the new mutation to increase the knowledge in the clinical field.

Immunolocalization of Vasa, PIWI, and TDRKH proteins in male germ cells during spermatogenesis of the teleost fish Poecilia reticulata.

Vasa, PIWI and TDRKH are conserved components of germ granules that in metazoans are involved in germline specification and differentiation, as documented by mutational experiments in some model animals. So far, investigations on PIWI during spermatogenesis of fish has been limited to a few species, and no information is available for TDRKH, another protein involved in the piRNA pathway. In this study, the immunolocalization of these three germline determinants was analyzed in male gonads of the teleost fish Poecilia reticulata to document their localization pattern in the different stages of germ cell differentiation. To analyze their distribution pattern during the different stages of spermatogenesis we performed immunohistochemistry (IHC) and immunofluorescence (IF) assays using primary polyclonal antibodies after testing their specificity with Western Blot. Moreover, sections of testis stained with haematoxylin and eosin clarified the structural organization of P. reticulata testis, while the use of the confocal microscope and the nuclear staining clarified the different stages of germ cell differentiation during spermatogenesis. The results showed that Vasa, PIWI and TDRKH were specifically immunolocalized in the germ cells of P. reticulata, with no specific signal detected in Sertoli cells and in other somatic cells of the gonad. These markers were detected in all stages of differentiation from early spermatogonia to advanced spermatids. Vasa staining was the strongest in spermatogonia, and then decreases throughout differentiation. Instead, both PIWI and TDRKH staining increases during differentiation, and their distribution pattern, similar to what observed in the mouse, suggests their concerted participation in the piRNA pathway also in this fish.

von Willebrand's disease diagnosis and laboratory issues.

SUMMARY: In this paper, the recent developments in the diagnosis and laboratory issues of von Willebrand's disease (VWD) are presented. Dr. Castaman reviews the functional tests available for the diagnosis of VWD and their pathophysiological significance, focusing on which tests are best used in the diagnosis and classification of VWD. Dr Montgomery reviews an emerging issue that is accelerated clearance of von Willebrand factor (VWF) occurring in some variants of VWD. This phenotype can be suspected by the presence of an increased ratio between the VWF propeptide and the VWF antigen. These patients have typically a robust, but short-lived increase of FVIII and VWF after desmopressin. Dr Meschengieser reviews the determinants of bleeding after surgery in patients with VWD, emphasizing the role of bleeding history in predicting this risk.

[One or more functional somatic syndromes? Comparison of the health status of fibromyalgia and electro-hypersensitive people]. / Un ou plusieurs syndromes somatiques fonctionnels ? Comparaison de l'état de santé de personnes fibromyalgiques et électro-hypersensibles.

INTRODUCTION: Functional somatic syndromes, grouping somatic symptoms without an organic explanation, are defined either by their predominant symptoms or by an attribution to an, often hypothetical, cause. Due to many similarities, some authors consider that there is only one FSS due to a general phenomenon of "somatization". The objective of this work was to compare two functional somatic syndromes, one defined by its symptoms, fibromyalgia, and the other by a specific contested attribution, electro-hypersensitivity. METHOD: Fibromyalgia or electro-hypersensitive participants (EHS) were recruited from September 2016 to April 2017 through associations of patients in Auvergne-Rhône-Alpes. Home interviews included the collection of medical, psychopathological, and symptom histories. The assessment of psychological distress, quality of life and the search for other functional somatic syndromes was performed through structured questionnaires, self-administrated scales, and clinical examination. RESULTS: Sixteen fibromyalgia subjects and sixteen EHS subjects were included. There are differences in symptomatology, although many symptoms are common to both conditions. Lifetime history of psychiatric disorders and current psychological distress and psychopathology are frequent in both groups but more prevalent in fibromyalgia subjects. The experience of the symptoms, their interpretation, the diagnostic itineraries and the therapeutic behaviours differ radically according to the group, even if for all socio-professional impact is high and quality of life are altered. CONCLUSION: The health status of fibromyalgia persons is overall worse than the health status of electro-hypersensitive individuals in this small sample. Despite the overlap in symptoms and a similar impact on daily functioning, this exploratory study suggests that heterogeneous mechanisms of "somatization" may be at stake in functional somatic syndromes.

Antibodies elicited by naked DNA vaccination against the complementary-determining region 3 hypervariable region of immunoglobulin heavy chain idiotypic determinants of B-lymphoproliferative disorders specifically react with patients' tumor cells.

Several reports have suggested that the mechanism of protection induced by antiidiotypic vaccination against low-grade lymphoproliferative disorders is likely to be antibody mediated. Here we test the hypothesis that DNA vaccination with the short peptide encompassing the complementary-determining region 3 hypervariable region of immunoglobulin heavy chain (VH-CDR3) may elicit a specific antibody immune response able to recognize the native antigens in the form required for therapy. As a test system, we used the VH-CDR3 sequences derived from two patients with non-Hodgkin's B lymphomas (PA, AS) and one patient with hairy cell leukemia (BA) to immunize outbred Swiss mice. This experimental model could mimic a clinical setting in which different patients present distinct HLA haplotypes. Individual tumor-specific VH-CDR3 sequences were amplified by a two-step procedure and directly cloned into multigenic plasmid vectors (pRC100 and derived) with and without mouse interleukin 2 (mIL-2). Each tumor-specific sequence was characterized by sequencing. Female Swiss mice were vaccinated i.m. with plasmids expressing the tumor-specific VH-CDR3 sequence alone (pRC101-PA), mIL-2 plus the VH-CDR3 sequence (pRC111-PA), or a different unrelated antigen (NS3 of hepatitis C virus; pRC112), the sole mIL-2 (pRC110), and the empty plasmid (pRC100). Boost injections were performed at 3 and 16 weeks from the first vaccination, and sera were drawn before each vaccination and at 6, 9, and 19 weeks. Induction of anti-VH-CDR3s antibodies in the sera and their ability to recognize native antigens on patients' tumor cells were evaluated by FACS analysis. Up to 56% (n = 25) of mice vaccinated with pRC111-PA plasmid and 20% (n = 15) of mice vaccinated with pRC101-PA developed a specific immune response that was maintained throughout 19 weeks of observation in 40% of pRC111-PA-vaccinated mice. No response was detected in sera obtained from mice vaccinated with the other plasmids (n = 45). pRC111-PA injection s.c. was less effective (13%, n = 15) than i.m. injection (53%, n = 15). Indeed, we demonstrated that antibodies elicited by naked DNA vaccination against three different patient-derived VH-CDR3 peptides (pRC111-PA or BA or AS) readily reacted with binding epitopes on the idiotypic proteins expressed on the surface of tumor cells derived from each patient; 60, 40, and 40% of, respectively, PA-, BA-, and AS-vaccinated mice developed specific antibodies. No cross-reactivity was detected among the three different CDR3s against tumor cells derived from the other two patients. The outbred mouse strategy confirmed the significant matching potential of three different VH-CDR3 peptides to be efficaciously presented through different MHCs. We conclude that individual VH-CDR3 DNA vaccination can result in a potentially effective specific immune response against non-Hodgkin's B lymphoma cells by a rapid and low-cost therapeutic approach.

Impairment of myocardial perfusion and function during painless myocardial ischemia.

Left ventricular (or pulmonary and systemic arterial) hemodynamics were measured for a mean of 13.6 hours during continuous electrocardiographic monitoring in 14 patients admitted to the coronary care unit because of angina at rest. Of 293 episodes of transient ST segment and T wave changes identified, 247 (84%) were completely asymptomatic. Sixty-three percent of asymptomatic episodes were associated with an elevation of the left ventricular end-diastolic or pulmonary artery diastolic pressure of 5 mm Hg or more; in 15% there were smaller elevations (2 to 4 mm Hg) and in 22% there were no changes or less than a 2 mm Hg elevation of pressure. The peak contraction and relaxation dP/dt (first derivative of left ventricular pressure) were reduced to 100 mm Hg/s or more in 84 and 81% of asymptomatic episodes, respectively. Great cardiac vein oxygen saturation measured in three patients showed an increased myocardial oxygen extraction similar to that seen in painful episodes, which preceded and accompanied asymptomatic electrocardiographic changes. These results indicate that asymptomatic electrocardiographic changes represent transient myocardial ischemia. Comparison of asymptomatic and symptomatic episodes revealed that asymptomatic episodes were generally shorter (253 +/- 159 versus 674 +/- 396 seconds, probability [p] less than 0.001) and produced less impairment of left ventricular function: there were smaller elevations of left ventricular end-diastolic or pulmonary artery diastolic pressure (5.9 +/- 5.0 versus 16.5 +/- 6.9 mm Hg, p less than 0.001), and smaller reductions of peak left ventricular contraction dP/dt (252 +/- 156 versus 395 +/- 199 mm Hg/s, p less than 0.001) and relaxation dP/dt (259 +/- 191 versus 413 +/- 209 mm Hg/s, p less than 0.001). In individual patients, however, asymptomatic and symptomatic episodes of similar duration and severity were observed. The duration and severity of ischemia appear important for the genesis of anginal pain, but additional factors must be involved.

Patients' perceptions regarding oral anticoagulation therapy and its effect on quality of life.

OBJECTIVE: Anticoagulation clinics have improved the time spent within therapeutic range and decreased hemorrhagic complications and costs in chronic oral anticoagulation. Whether these benefits correlate to patients' quality of life (QOL) remains to be determined. The impact of patients' perceptions about anticoagulation on QOL has not been evaluated. The objective of this study was to evaluate prospectively patients' perceptions and quality of life in patients chronically anticoagulated. RESEARCH DESIGN AND METHODS: A cross-sectional study was designed to investigate the prevalence of positive and negative perceptions about oral anticoagulation therapy (OAT) and to identify vulnerable groups. Patients anonymously completed the SF-36 survey and a questionnaire that focused on patients' perceptions of protection from thrombotic complications or fear of haemorrhage due to the anticoagulation. We related those perceptions to the General Health SF-36 score, to the patient's characteristics, the absolute bleeding risk (i.e. intended International Normalized Ratio [INR]), duration of therapy and medical attention. RESULTS: One thousand patients were included and 905 questionnaires evaluated. Most patients felt protected and better since the beginning of therapy (71.5% and 61.5%, respectively). Patient characteristics associated with negative perceptions were; female sex (Odds Ratio [OR] 1.58, 95% Confidence Interval [CI] 1.06-2.36, p = 0.01); patients with less than 1 year of therapy (OR 2.16, 95% CI 1.34-3.48, p = 0.006); those not satisfied with medical attention (OR 2.86, 95% CI 1.53-5.18, p = 0.0001); and those that modified their lifestyle (OR 2.75, 95% CI 1.49-4.91, p = 0.0002). Patients with a lower bleeding risk (INR 2.0-3.0) had more negative perceptions than those with a higher risk. Patients with negative perceptions achieved the lowest score in the SF-36 survey. Haemorrhages did not affect patients' perception or QOL. CONCLUSIONS: Patients' perceptions correlated with QOL. We were able to identify patient characteristics associated with poor QOL and thus the group of patients whose negative perceptions most warranted special attention from their clinicians.

Enhanced response to chemotactic activation of polymorphonuclear leukocytes from patients with heart valve replacement.

Artificial surfaces activate blood components. Since anticoagulant and antiplatelet therapy fail to abolish thromboembolic complications in patients with mechanical heart valve replacement (MHVR), other mechanisms might contribute to switch on a thrombotic event. We therefore investigated the reactivity to chemotactic activation of PMN from patients with MHVR. PMN responses were analyzed in 3 groups: 130 patients with MHVR and oral anticoagulant therapy, with or without aspirin, 57 patients on a comparable antithrombotic regimen, but without MHVR and 50 healthy subjects. In vitro studies showed that the release of cathepsin G and elastase from fMLP-stimulated PMN was significantly higher in the MHVR group, the leukocyte content of alpha 1-antitrypsin (an inhibitor of both enzymes) being similar in all three groups. CD11b expression after stimulation with fMLP was also significantly higher on PMN from MHVR patients than from control patients or healthy volunteers, while PMN CD11b basal expression was similar in all three groups. This increased PMN response in vitro in the absence of an obvious activation in vivo, may reflect a modified reactivity of circulating PMN passing through the artificial valves. Increased reactivity to local stimuli might allow PMN to participate in thrombus formation, despite conventional antithrombotic therapy.

Anti-factor VIII inhibitors and lupus anticoagulants in haemophilia A patients.

In a study of 170 haemophilia A patients, 43 were found to have an inhibitory effect; seven had anti-factor VIII inhibitors (a-fVIII)(A), 18 had lupus anticoagulants (LAs) with a strong (B: 12) or weak (C: 6) time-dependent effect and 18 had no time-dependent LAs (D). The a-fVIII showed a neutralizing effect only against factor VIII and negative diluted Russell viper venom time (dRVVT). The LAs were diagnosed by dRVVT; the Staclot LA agreed with the dRVVT. During the study, three patients changed from an a-fVIII to an LA pattern; they also modified their clinical response. Our prevalence of a-fVIII was low (4%) and we found 21% of LA, with a high (50%) prevalence of time-dependent inhibition. This pattern raises the possibility of the coexistence of LA and a-fVIII, stressing the need to develop specific tests to identify a-fVIII and LA.

Inhibition of human platelet activation by polymorphonuclear leukocytes.

1. The effect of unstimulated human polymorphonuclear leukocytes (PMNs) on platelet activation was examined. 2. Human platelet aggregation and adenosine 5'-triphosphate (ATP) release induced by collagen (1-2 micrograms ml-1); thrombin (0.01-0.02 u ml-1) or arachidonic acid (AA) (0.1-0.2 mM) were markedly inhibited when conducted in the presence of unstimulated PMNs. 3. Platelet inhibition induced by PMNs was dependent on the number of PMNs and on the incubation time of the mixed cell suspension. 4. Platelet inhibition was not reversed in time when PMNs were depleted from the mixed-cell suspension. 5. PMN-mediated platelet-inhibition was not mediated by AA metabolites, oxygen reactive intermediates, nitric oxide or proteases. 6. The factor(s) accounting for the platelet inhibition mediated by PMNs are not yet characterized.

Low-intensity oral anticoagulation plus low-dose aspirin versus high-intensity oral anticoagulation alone: a randomized trial in patients with mechanical prosthetic heart valves.

BACKGROUND: Mechanical heart valve replacement requires lifelong anticoagulant treatment. Aspirin has proved useful in further reducing thromboembolic events when added to oral anticoagulants. However, increased (gastrointestinal) bleeding was observed at the doses previously tested for this combination in heart valve prostheses. METHODS: We performed a prospective randomized trial to compare the combination of low-intensity oral anticoagulants (international normalized ratio 2.5 to 3.5) plus aspirin (100 mg/day) (arm A) versus high-intensity oral anticoagulants alone (arm B) (international normalized ratio 3.5 to 4.5). Arm A included 258 patients and arm B 245 patients. The two groups were comparable for all baseline characteristics. RESULTS: The outcomes of the study were embolism, valve thrombosis, and major hemorrhage. The median follow-up was 23 months. The two treatments offered similar antithrombotic protection. The incidence of embolic episodes was 1.32 per 100 patient-years (95% confidence interval 0.53 to 2.7) for arm A and 1.48 per 100 patient-years (95% confidence interval 0.59 to 3.03) for arm B. Major hemorrhage occurred in 1.13 per 100 patient-years (95% confidence interval 0.41 to 2.45) for arm A and 2.33 per 100 patient-years (95% confidence interval 1.17 to 4.14) for arm B. Gastrointestinal bleeding was not increased by this combined reduced dose of aspirin and coumarin.

Behavior of diluted activated partial thromboplastin time in pregnant women with a lupus anticoagulant.

The present study was developed to verify whether a reduction in phospholipid concentration could increase the activated partial thromboplastin time (APTT) sensitivity to detect lupus anticoagulant (LA) during pregnancy. The authors studied 38 pregnant women (10 normal subjects and 28 patients with associated clinical complications) and 40 nonpregnant control subjects. Tests to detect LA, including APTT, platelet neutralization procedure (standard APTT), the kaolin clotting time, the diluted Russell viper venom test neutralized by lysed platelets, and factor assays, were performed. Positive results were found in 5 of 28 pregnant women with associated clinical complications. The APTT, using three different phospholipid concentrations (standard and more diluted cephalin), was performed on plasma samples and on its 1:1 mixture with normal plasma. The behavior of standard and diluted APTT was similar in negative LA pregnant women and nonpregnant control subjects. The mean values showed nonsignificant differences. Four of five pregnant women with positive LA findings had a prolonged APTT, which was not corrected by the addition of normal plasma using standard conditions. When diluted phospholipids were used, only one of them had a prolonged APTT that was corrected by the addition of normal plasma. Therefore, the highest sensitivity (80%) and specificity (100%) of the APTT to detect LA in pregnant women were obtained using the standard conditions.

Binding of von Willebrand factor to collagen by flow cytometry.

We developed a new method for the detection of large von Willebrand factor (vWf) multimers binding to collagen and for the determination of vWf antigen (vWf:Ag) using flow cytometry. Collagen is coated on to polystyrene beads, allowing detection of found large vWf multimers. In addition, rabbit antibody against vWf is coated on to the beads allowing detection of all vWf:Ag. In plasma samples from healthy persons and patients (with type 1, 2A, 2N, or severe von Willebrand disease or hemophilia), 4 different assays were performed: vWf:Ag by immunoelectrophoresis; vWf ristocetin cofactor (vWf:RCof); CBA; and vWf:Ag based on an enzyme-linked immunosorbent assay using polystyrene beads. We assayed the flow cytometric method using 2 bead sizes. The optimal bead size was 3.136 microns. The results of CBA and vWf:Ag closely correlated with those of vWf:RCof and vWf:Ag (immunoelectrophoresis), respectively, and showed a low limit of detection. Interassay variance of cytometric methods was lower than interassay variance of traditional assays. In addition, we used the new assays to monitor desmopressin therapy.

Identification of surface glycoconjugates in the olfactory system of turtle.

Lectin binding histochemistry was performed on the olfactory system of Pseudemys scripta to investigate the distribution and density of defined carbohydrate terminals on the cell surface glycoproteins of the olfactory receptors and their terminals in the olfactory bulbs. The lectin staining patterns indicate that the receptor cells of the olfactory mucosa are characterized by glycoconjugates containing alpha-D-galactose and N-acetyl-D-glucosamine terminal residues. The vomeronasal receptor cells contain instead alpha-N-acetyl-D-galactosamine, N-acetyl-D-glucosamine and alpha-D-galactose residues. The results demonstrate that the vomeronasal receptor cells contain high density of alpha-N-acetyl-D-galactosamine sugar residues that are not expressed by receptor cells of the olfactory mucosa. The presence of specific glycoproteins, whose terminal sugars are detected by lectin binding, might be related to the chemoreception and transduction of the odorous message into a nervous signal or in the histogenesis of the olfactory system. In fact, the olfactory receptors are the only known neurons in the vertebrate nervous system that undergo a continual cycle of proliferation not only in developing animals but also in mature ones. Moreover the results show that BSA-I-B4, an alpha-D-galactosyl-specific isolectin, targets the terminal sugar residues in the ramified microglial cells.

Lectin characterization of the olfactory system in brachiopterygian fish.

Lectin binding was performed on the olfactory system of Polypterus and Erpetoichthys, the living genera of the subclass of Brachiopterygii. The lectin histochemical patterns and the Western-blot analysis indicate that the receptor cells of the olfactory mucosa are characterized by high density of specific glycoconjugate residues. The presence of glycoproteins, whose terminal sugars are detected by lectin binding, might be related to the reception of an odor stimulus and its transduction into a nervous signal or to the histogenesis of the olfactory system.

Histochemical study by lectin binding of surface glycoconjugates in the developing olfactory system of rat.

Lectin-binding histochemistry was used to investigate the distribution and density of defined carbohydrate sequences on the cell surface glycoproteins of the olfactory receptors of rat during development. The olfactory and vomeronasal receptors showed a positive labelling after biotinylated Lycopersicum esculentum lectin binding on embryonic day 16 (E16), while horseradish peroxidase-labelled Glycine max, Bandeiraea simplicifolia (BSA-I) and its B4 isomer BSA-I-B4 agglutinins started to label from day 18 (E18). From this stage onward there was a progressive increase in the intensity and number of lectin-binding olfactory receptors. The first lectin-labelled bundles of axons penetrating the olfactory bulb were observed on E20; from E21 it was possible to identify the first labelled glomeruli that, on the first day (P1) of postnatal life, showed a feature very similar to that of the adult. The lectin staining patterns indicate that during development there are differences in the kind and distribution of saccharidic moieties on the surface of rat olfactory neurons. The possible role of carbohydrate-containing glycoproteins in the reception and transduction of the odours and in the modulation of the cell-cell interactions in the olfactory system is discussed.

Anticoagulation in pregnant women with mechanical heart valve prostheses.

OBJECTIVE: To evaluate the outcome of pregnancy in women with mechanical heart valve prostheses in relation to the anticoagulant treatment used in the first trimester and the incidence of thrombotic and bleeding complications. METHODS: 92 pregnancies in 59 women were followed between 1986 and 1997. In 31 pregnancies, oral anticoagulants were discontinued when pregnancy was diagnosed and subcutaneous heparin was started (12 500 U every 12 hours) adjusted to prolong the adjusted partial thromboplastin time to twice the control level. In the second trimester oral anticoagulants were resumed but changed to heparin again 15 days before the expected delivery date. In 61 pregnancies oral anticoagulants were continued during the first trimester. The same regimen of heparin was used for delivery. RESULTS: Abortion or fetal losses were similar (p = 0. 5717) in women exposed to oral anticoagulants in the first trimester (13/61; 25%) compared with those who received adjusted subcutaneous heparin (6/31; 19%). Embolic episodes were more common (p = 0.0029) in women who received heparin (4.92%) compared with those on oral anticoagulants (0.33%). Embolic episodes were cerebral and transient. No valve thromboses were observed. No malformations appeared in the 71 newborns, except for one case of hydrocephalus. There were no maternal deaths secondary to thrombotic complications. The only death was the result of major bleeding after the delivery of a premature stillborn. CONCLUSIONS: Oral anticoagulants seem to be safer for the mother than adjusted subcutaneous heparin. Heparin does not offer a clear advantage over oral anticoagulation in the pregnancy outcome.