Cytomegalovirus-Induced Polyarteritis Nodosa in a Liver Transplant Recipient.

Polyarteritis nodosa (PAN) is a necrotizing vasculitis that has been associated with viral infections, especially hepatitis B virus. We hereby report a case of tissue-invasive cytomegalovirus (CMV)-induced PAN in a liver transplant recipient presenting with acute kidney injury and active urinary sediment. Treatment directed against both PAN and CMV resulted in improvement in kidney function, normalization of urinary indices and resolution of the CMV infection. There was no recurrence of either PAN or CMV after a 3-year follow-up period.

[Job demands, meaningful work, and turnover intention among nurses]. / Richieste lavorative, significatività percepita del lavoro e intenzione di turnover degli infermieri.

BACKGROUND: The shortage of nurses is a worldwide issue. Since turnover intention (TI) is considered one of the major determinants of turnover behaviour, it is essential to look deeper into the way it operates. OBJECTIVES: This study uses the job demands-resources model to investigate the TI of nurses, on the one hand looking at the relationship that some demands (workload, emotional dissonance and abusive supervision) have on TI and on the other, investigating the role of a specific resource (meaningful work - MW) in terms of its effect on TI and as a potential moderator of the relationship between each demand and TI. METHODS: The research project was carried out in a large hospital in Northern Italy by administering a self-report questionnaire to all nurses; 630 questionnaires were distributed, 423 (67.14%) of which were completed. The statistical analyses were performed with PASW 18. RESULTS: The results highlight a positive relationship between demands and TI and a negative relationship between meaningful work and TI. Moreover, a significant moderating effect of meaningful work on the relationship between emotional dissonance and TI also emerged. No significant moderating effects were found for the relationship between the other two demands and TI. CONCLUSIONS: This research allowed us to verify the importance of constructs such as abusive supervision and meaningful work that have not yet been extensively studied, within the context of nursing staff in Italy; it also offered a range of suggestions for organizational developments and for further investigations in this field.

[Identification of risk factors for work-related stress in a hospital: a qualitative and quantitative approach]. / L'identificazione dei fattori di rischio stress lavoro-correlato in un'Azienda Sanitaria Ospedaliera: un approccio quali-quantitativo.

BACKGROUND: Italian legislation establishes the obligation for the employer to assess any risks to the safety and health of workers, including those relating to work-related stress (WRS). Several studies have proved the existence of a link between WRS and both individual diseases and organizational results. OBJECTIVE: The research aimed at detecting WRS risk factors in a hospital consisting of 53 departments employing 2334 workers. METHODS: A qualitative and quantitative approach was adopted divided into six steps: 1) analysis of the hospital indicators; 2) semistructured interviews of the 53 department heads; 3) preparation of a checklist including 42 WRS risk indicators; 4) observation by shadowing of the 53 departments; 5) setting up of 53 focus groups with staff from each department; 6) distribution of the check-list to a representative sample of 747 employees. RESULTS: Data analysis showed a "low" level of WRS risk regarding the hospital as a whole, a "medium" level regarding six transversal indicators and eight departments. Three indicators considered particularly significant were examined in detail: "workplace and ergonomic conditions", "shift work", "interruptions in work flow". CONCLUSIONS: The results helped to identifj a series of best practices aimed at reducing WRS risk that are applicable to other health care settings. The qualitative and quantitative approach produced a keen involvement of the employees of the hospital which will positively encourage the real efficacy of the measures taken.

Global cardiovascular risk management in different Italian regions: an analysis of the Evaluation of Final Feasible Effect of Control Training and Ultra Sensitisation (EFFECTUS) educational program.

BACKGROUND AND AIM: The Final Evaluation Feasible Effect of Ultra Control Training and Sensitization (EFFECTUS) is an educational program, aimed at improving global CV risk stratification and management in Italy. The present study evaluates differences on clinical approach to global CV risk among physicians involved in the EFFECTUS program and stratified in three geographical macro-areas (North, Center, South) of our Country. METHODS AND RESULTS: Physicians were asked to submit data already available in their medical records, covering the first 10 adult outpatients, consecutively seen in the month of May 2006. Overall, 1.078 physicians (27% females, aged 50 ± 7 years) collected data of 9.904 outpatients (46.5% females, aged 67 ± 9 years), among which 3.219 (32.5%) were residents in Northern, 3.652 (36.9%) in Central and 3.033 (30.6%) in Southern Italy. A significantly higher prevalence of major CV risk factors, including obesity, physical inactivity, hypertension and diabetes, was recorded in Southern than in other areas. Accordingly, Southern physicians more frequently prescribed antihypertensive, glucose and lipid lowering agents than other physicians, who paid significantly more attention to life-style changes in their clinical practice. CONCLUSIONS: This analysis of the EFFECTUS study demonstrates a high prevalence of CV risk factors in Italy, particularly in Southern areas, and indicates some important discrepancies in the clinical management of global CV risk among physcians working in different Italian regions.

Plasmacytoma-like posttransplant lymphoproliferative disorder following orthotopic liver transplantation: a case report.

Posttransplant lymphoproliferative disorders (PTLDs) are among the most serious and potentially fatal complications of both stem-cell and solid-organ transplantation. Most monomorphic PTLDs are of B-cell origin and frequently associated with Epstein-Barr virus (EBV) infection in the setting of pharmacological immunosuppression posttransplantation. The majority of monomorphic PTLDs commonly resemble diffuse large B-cell or Burkitt's lymphoma; plasmacytoma-like PTLDs are very rare. We report a case of plasmacytoma-like PTLD arising in the allograft in a 66-year-old male diagnosed 2 months following an orthotopic liver transplant for alcohol-related end-stage liver disease. The liver biopsy revealed marked infiltration of atypical plasma cells with lambda light chain restriction and positivity for EBV by in situ hybridization confirming the diagnosis. Also noted was a remarkable increase of tissue eosinophils. Reduction of immunosuppression led to improvement in his clinical condition, and also resolution of the hepatic lesions and abdominal lymphadenopathy noted on imaging studies. While a few cases of plasmacytoma-like PTLDs have been described in literature, to our knowledge, this is the first reported case of early onset plasmacytoma-like PTLD in a liver transplant recipient occurring in the allograft with associated lymphadenopathy having distinct histopathologic features including tissue eosinophilia. Timely recognition of such an entity is critical in order to initiate early and appropriate intervention.

Impact of physicians' age on the clinical management of global cardiovascular risk: analysis of the results of the Evaluation of Final Feasible Effect of Control Training and Ultra Sensitisation Educational Programme.

AIM: To evaluate the potential impact of physicians' age on global cardiovascular (CV) risk management in the population of the Evaluation of Final Feasible Effect of Ultra Control Training and Sensitisation (EFFECTUS) study. METHODS: Involved physicians were stratified into three age groups (≤ 45, 46-55 and > 55 years), and asked to provide clinical data covering the first 10 adult outpatients, consecutively seen in May 2006. RESULTS: Overall 1078 physicians, among whom 219 (20%) were aged ≤ 45, 658 (61%) between 46 and 55, and 201 (19%) > 55 years, collected data of 9904 outpatients (46.5% female patients, aged 67 ± 9 years), who were distributed into three corresponding groups: 2010 (20%), 6111 (62%) and 1783 (18%), respectively. A higher prevalence of myocardial infarction and stroke was recorded by younger physicians rather than those aged > 46 years. Older physicians frequently recommended life-style changes, whereas a higher number of antihypertensive, antiplatelet, glucose and lipid-lowering prescriptions was prescribed by physicians aged ≤ 45 years. CONCLUSIONS: This analysis of the EFFECTUS study indicates a higher prevalence of vascular diseases among outpatients who were followed by younger physicians, who prescribed a higher number of CV drugs than older physicians. These older physicians have more attitude for prescribing favourable life-style changes than younger physicians.

Primary hyperlipidemias in children: effect of plant sterol supplementation on plasma lipids and markers of cholesterol synthesis and absorption.

Plant sterols lower serum cholesterol concentration. Available data have confirmed the lipid-lowering efficacy in adults, while there is a relative dearth of data in children and almost exclusively restricted to subjects with familial hypercholesterolemia (FH). Aim of the present study was to evaluate the efficacy, tolerability and safety of plant sterol supplementation in children with different forms of primary hyperlipidemias. The effect of plant sterol consumption on plasma lipids was evaluated in 32 children with heterozygous FH, 13 children with Familial Combined Hyperlipidemia (FCH) and 13 children with Undefined Hypercholesterolemia (UH) in a 12-week open-label intervention study using plant sterol-enriched yoghurt. Plasma lipids and apolipoproteins were measured by routine methods. Markers of cholesterol synthesis (lathosterol) and absorption (campesterol and sitosterol) were measured by GC-MS. Tolerability and adherence to recommended regimen was very high. A significant reduction was observed in LDL-cholesterol in the three groups (10.7, 14.2 and 16.0% in FH, FCH and UH, respectively). Lathosterol concentrations were unchanged, reflecting a lack of increased synthesis of cholesterol. Of the two absorption markers, only sitosterol showed a slight but significant increase. Daily consumption of plant sterol dairy products favorably changes lipid profile by reducing LDL-cholesterol. To our knowledge, this is the first report of the use of plant sterols-enriched foods in treating children with primary hyperlipidemia such as FCH and UH, likely to be the most frequent form also in the young age in the western populations.

[Association between demographic characteristics and psychosocial factors of job stress in a sample of health care workers employed in two Italian hospitals]. / Correlazioni tra variabili demografiche e fattori psicosociali di stress occupazionale in un campione di operatori sanitari di due aziende ospedaliere.

BACKGROUND: Job stress has negative effects on both health care work ers' (HCW) health and on work organization. OBJECTIVES: To assess whether the presence of stressful conditions, individually considered, or combined in the iso-strain model, is significantly associated with specific socio-demographic characteristics, also with the aim of providing organizational tools for management to reduce stress in the working environment according to Italian law 81/2008. METHODS: The extended version of the Job Content Questionnaire was administered to 265 healthy HCW in seven paired wards of two hospitals. The five psychosocial scales Job Demand (JD), Job Control (JC), Social Support (SS), Skill Underutilization (SuS), and Job Insecurity (JI) were calculated. The factors JD, JC, and SS were combined together to separate a group of 33 HCW in iso-strain conditions from another group of 232 HCW not in iso-strain conditions. Several socio-demographic variables were collected. RESULTS: Statistically significant associations were found between socio-demographic characteristics and psychosocial factors, whereas the iso-strain conditions were not related to any socio-demographic parameter. CONCLUSIONS: Data suggest the need for alternative policies to reduce job stress: for example, actions addressed to operative units or HCW with specific socio-demographic characteristics could be effective in improving individual psychosocial factors; however, integrated actions aimed at reorganizing the working environment as a whole should be implemented to correct iso-strain conditions.

Effects of a phytosterol-enriched dairy product on lipids, sterols and 8-isoprostane in hypercholesterolemic patients: a multicenter Italian study.

BACKGROUND AND AIMS: Plant sterols, added to several food sources, lower serum cholesterol concentrations. Plant sterol-induced cholesterol lowering is paralleled by a mild decrease in plasma levels of the antioxidant beta-carotene, the amount of this decrease being considered clinically non-significant. Whether the effect on lipid profile of daily consumption of plant sterol-enriched low-fat fermented milk (FM) is paralleled by a concomitant variation in a reliable marker of the oxidative burden like plasma isoprostane levels is unresolved. METHODS AND RESULTS: The effect of plant sterol consumption on plasma lipid and isoprostane levels of hypercholesterolemic patients was evaluated in a multicenter, randomized double blind study. Hypercholesterolemic patients consumed a FM daily for 6 weeks. Subjects were randomized to receive either 1.6g of plant sterol-enriched FM (n=60) or control FM product (n=56). After 6 weeks of plant sterol-enriched FM consumption, LDL cholesterol was reduced from 166.2+/-2.0 to 147.4+/-2.8 mg/dL (p=0.01). A significant reduction was observed for total cholesterol (from 263.5+/-2.6 to 231.0+/-3.2mg/dL, p=0.01). There was greater LDL cholesterol lowering among hypercholesterolemic patients with higher LDL cholesterol at baseline. We found a reduction of plasma 8-isoprostane in patients taking plant sterol-enriched FM (from 43.07+/-1.78 to 38.04+/-1.14 pg/ml, p=0.018) but not in patients taking the control product (from 42.56+/-2.12 to 43.19+/-2.0 pg/ml, p=NS). Campesterol and beta-sitosterol levels were not influenced by phytosterol consumption. CONCLUSIONS: Daily consumption of low-fat plant sterol dairy product favourably changes lipid profile by reducing LDL-cholesterol, and may also have an anti-oxidative effect through a reduction of plasma isoprostanes.

Kidney allocation to liver transplant candidates with renal failure of undetermined etiology: role of percutaneous renal biopsy.

The feasibility, value and risk of percutaneous renal biopsy (PRB) in liver transplant candidates with renal failure are unknown. PRB was performed on 44 liver transplant candidates with renal failure of undetermined etiology and glomerular filtration rate (GFR) <40 mL/min/1.73 m(2) (n = 37) or on renal replacement therapy (RRT) (n = 7). Patients with >or=30% interstitial fibrosis (IF), >or=40% global glomerulosclerosis (gGS) and/or diffuse glomerulonephritis were approved for simultaneous-liver-kidney (SLK) transplantation. Prebiopsy GFR, urinary sodium indices, dependency on RRT and kidney size were comparable between 27 liver-transplant-alone (LTA) and 17 SLK candidates and did not relate to the biopsy diagnosis. The interobserver agreement for the degree of IF or gGS was moderate-to-excellent. After a mean of 78 +/- 67 days, 16 and 8 patients received LTA and SLK transplants. All five LTA recipients on RRT recovered kidney function after transplantation and serum creatinine was comparable between LTA and SLK recipients at last follow-up. Biopsy complications developed in 13, of these, five required intervention. PRB is feasible in liver transplant candidates with renal failure and provides reproducible histological information that does not relate to the pretransplant clinical data. Randomized studies are needed to determine if PRB can direct kidney allocation in this challenging group of liver transplant candidates.

Stromelysin gene promoter polymorphism and common carotid geometry in diabetic subjects.

AIM: Stromelysin (MMP3), through its action on collagen and other matrix metalloproteinases, influences arterial wall remodeling. In healthy subjects, the 5A/6A polymorphism located in the promoter of the MMP3 gene is associated with common carotid remodeling, 6A/6A subjects having increased arterial diameter, wall thickness (intima-media thickness, IMT) and decreased wall shear stress (WSS). In the present study, we have investigated the influence of the 5A/6A polymorphism on common carotid remodeling in subjects with diabetes mellitus. METHODS: Diabetic subjects (N.=136) and age-matched healthy male controls (N.=101) have been studied. Common carotid diameter, IMT and flow velocity have been measured by echo-Doppler. Blood viscosity has been measured by a cone/plate viscometer. WSS has been calculated. RESULTS: Diabetic patients had increased common carotid diameter, IMT, and decreased flow velocity and WSS (all P<0.05), compared with controls. In controls, subjects homozygous for the 6A allele had increased diameter, IMT and decreased WSS. In diabetics, no difference was observed in vascular parameters among the three genotypes. CONCLUSION: The 5A/6A polymorphism of the MMP3 gene influences arterial remodeling of the common carotid artery in healthy subjects, but not in patients with diabetes mellitus. Therefore, the significance of the 5A/6A polymorphism as a marker of risk in this high cardiovascular risk population seems to be somehow blunted.

[Determining factors of job-satisfaction: presence of work-family conflict in a sample of Italian nurses]. / Le determinanti della soddisfazione lavorativa del personale infermieristico: il ruolo del conflitto lavoro-famiglia.

BACKGROUND: Organization research has shown increasing interest in the dynamics of work-family conflict (w.f.c.). The NEXT study highlights that w.f.c. significantly influences satisfaction for one's job and the decision to quit the nursing profession. OBJECTIVES: This study analyzes w.f.c. in a sample of Italian nurses, with the aim of examining the main differences in relation to personal variables, and understanding the degree to which w.f.c. explains job satisfaction. METHODS: A self-reporting questionnaire was administered to 325 nurses in different hospitals of Northern Italy. Descriptive, reliability and Anova data analysis was performed. The relationships between variables were analyzed through correlations (Pearson's r); the role of w.f.c. in explaining job satisfaction was estimated via multiple regression. RESULTS: W.f.c. appeared to be more critical in subjects who had care responsibilities and in those who had more demanding work assignments. W.f.c. contributed to explaining job satisfaction, even if it was not its principal determining factor. CONCLUSIONS: This area of research appears to be important in that it leads to a better comprehension of the dynamics involved in work satisfaction and can suggest possible initiatives for support and development.

Beta-sitosterolaemia: a new nonsense mutation in the ABCG5 gene.

BACKGROUND: Sitosterolaemia is a rare autosomal recessive disorder characterised by elevated plasma levels of plant sterols and cholesterol. Sitosterolaemia is caused by gene mutations in either of two ATP-binding cassette (ABC) half transporters, ABCG5 and ABCG8. The plasma sterol profile and genetic analysis of a 10-year-old girl who had tuberous xanthomas is the subject of this report. MATERIALS AND METHODS: Genomic DNA was isolated from white blood cells from the proband, her family and a control group of healthy people. All exons of ABCG5 and ABCG8 were sequenced. Plasma cholesterol and triglycerides were measured by routine methods. All other plasma sterols were measured by Gas Chromatography coupled to Mass Spectrometry. RESULTS: The proband was found to be homozygous for a single nucleotide mutation in exon 10 of the ABCG5 gene, consisting of a C to T transition at nucleotide 1336 of the coding sequence, which results in the premature termination of the ABCG5 protein at amino acid 446 (Arg446X). Her mother and brother were also homozygous for the same mutation and all had elevated plasma beta-sitosterol levels. The father was heterozygous and showed normal beta-sitosterol levels. This mutation was not found in healthy normolipidaemic subjects. CONCLUSIONS: We describe a novel nonsense mutation in exon 10 of the ABCG5 gene in a 10-year-old girl showing clinical and biochemical features of sitosterolaemia. This family study broadens the spectrum of the ABCG5/ABCG8 mutations causing sitosterolaemia and helps highlight the correlations between such gene mutations, biochemical phenotype and the development of cardiovascular disease.

[Job satisfaction among nursing personnel: application of the Italian version of the Stamps Index of Work Satisfaction (1997)]. / La soddisfazione lavorativa del personale infermieristico. Adattamento italiano della scala Index of Work Satisfaction di stamps.

BACKGROUND: A high level of job satisfaction among nurses is related to a feeling of wellbeing, productivity and patient satisfaction. Furthermore job satisfaction is considered capable of reducing turnover and absenteeism. OBJECTIVES: This contribution describes the first application of the Italian version of Stamps' Index of Work Satisfaction (1997), consisting of a 44 item questionnaire used to evaluate job satisfaction among professional nurses operating in healthcare organizations. METHODS: Working in four different hospitals of the Piemdont and Lombardy regions. RESULTS: Analysis of the principal components revealed the presence of seven factors (Autonomy, Professional status, Pay, Job requirements, Work Organization policies, Interaction with physicians, Interaction with nurses) with an elevated internal coherence that explains 52% of the total variance. The first five factors coincided with those defined by Stamps (1997), while the last two were the result of the separation of the original "Interactions" factor. Validity, measured by correlation with a single item of job satisfaction, was good. The reliability of the entire questionnaire and the single sub-scales, measured by Cronbach's alpha coefficient and item-total correlations, was satisfactory and the scores' distribution curves were symmetrical. The sample's job satisfaction levels appeared higher for Professional status, Interaction with nurses and Autonomy factors, but regarding Work Organization policies, Task requirements and Pay factors perceptions of dissatisfaction emerged. The variability of perceived job satisfaction appeared related to age, service seniority and hospital. CONCLUSIONS: Subject to further confirmation of validity and reliability, the questionnaire may be used as a tool to survey the job satisfaction levels perceived by professional nurses operating in healthcare organizations, with the additional purpose of identifying management strategies and target groups in which to carry out specific activities aimed at promoting job satisfaction.

Flow-mediated vasodilatation of the brachial artery and intima-media thickness of carotid artery in never-treated subjects.

AIM: Data on the association between brachial artery flow-mediated dilatation (FMD) and common carotid intima-media thickness (IMT) are contrasting. The present study investigated the relationship between FMD and IMT and carotid atherosclerosis in never treated subjects. METHODS: Seventy-seven subjects were investigated: 46 had no coronary heart disease (CHD) risk factors, 21 had only one, and 10 had more than one risk factor. IMT of the common carotid was measured by ultrasonography and FMD was evaluated according to standardized methods. RESULTS: IMT increased with increasing number of risk factors (0.66+/-0.12, 0.69+/-0.12 and 0.8+/-0.17 mm, respectively, ANOVA P<0.05). FMD decreased with increasing number of risk factors (10.44+/-5.2, 6.52+/-7.11 and 7.35+/-4.42%, respectively, P<0.05). Endothelium-independent vasodilatation was similar in the 3 groups. IMT and FMD did not correlate neither in subjects without risk factors (r=-0.151, P=0.3), nor in those with 1 (r=-0.196, P=0.4) or with 2 or more risk factors (r=-0.387, P=0.2), while in the group as a whole the correlation was borderline significant (r=-0.217, P=0.058). Eleven subjects had carotid atherosclerosis and higher values of IMT, but not reduced FMD. In multiple regression analysis, diabetes and IMT, but not FMD, were associated with carotid atherosclerosis. CONCLUSIONS: The present findings indicate that, in never treated subjects, FMD is not strictly associated with IMT or atherosclerosis of the carotid arteries.

[Selective adsorption of homocysteine using HFR-on line technique]. / Estrazione di omocisteina in corso di HFR on-line.

Homocysteine (Hcy) is grossly elevated in hemodialysis (HD) patients. Treatment with folic acid and/or vitamin B12 fails to normalize Hcy levels in the majority of patients. Treatment with various dialyzers with different flux characteristics has produced contrasting results. Hemodiafiltration reinfusion (HFR) on-line (double chamber hemodiafiltration (HDF) with regenerated ultrafiltrate reinfusion) is a novel method combining the processes of diffusion, convection and absorbance. The ultrafiltrate is regenerated through a charcoal-resin device. Our aim was to observe the effect of the HFR on-line technique on removing Hcy. We investigated the effect of this treatment on Hcy levels in 10 patients with a mean Hcy level of 57.6 micromol/L (range 24.1-119.7). We measured Hcy, folate and vitamin B12 pre- and post-dialysis and in the ultrafiltrate pre- and post-cartridge at 10, 120 and 240 min. Mean Hcy levels were 57.6 and 35.3 micromol/L (range 9.9-80.3) (p=0.005) pre- and post-dialysis, respectively, while folate and vitamin B12 were unchanged. Pre- and post-cartridge Hcy levels were 11.6 vs 2.5 (p=0.005), 9.3 vs 3.9 (p=0.005), 7.7 vs 4.6 micromol/L (p=0.012) at three time points considered, while folate and vitamin B12 were essentially undetectable. These preliminary data, which need confirmation in a long-term study, seem to indicate that HFR on-line reduces Hcy levels, not only through a possible reduction in uremic toxins, but also through the actual removal of Hcy by absorbance on the charcoal-resin cartridge.

Role of GST P1-1 in mediating the effect of etoposide on human neuroblastoma cell line Sh-Sy5y.

The oxidative stress could have a dual action on glutathione S-transferase (GST) P1-1 metabolism: transcriptional induction and/or polymerization. The former should represent a form of adaptation to oxidative stress and contribute to protect the cell, the latter one should activate apoptosis via c-Jun N-terminal kinase (JNK). We studied the effect of etoposide on human neuroblastoma cell line SH-SY5Y and on an etoposide-resistant clone to investigate whether a pleiotropic effect of etoposide on the redox status of the cell exists which is able to interfere with apoptosis through the GST P1-1 system. Etoposide treatment was able to induce GST P1-1 polymerization and activation of apoptosis. The data obtained from our etoposide-resistant clone and the possibility to reverse the sensitive phenotype to a resistant one by means of hexyl-glutathione preincubation, seem to suggest that cellular levels of glutathione have a key role in protecting GST P1-1 by oxidation and consequently the cell's decision between life and death.

The pathology of nonalcoholic steatohepatitis.

Nonalcoholic fatty liver disease (NAFLD) is an increasingly recognized form of chronic liver injury. Nonalcoholic steatohepatitis (NASH) is the term applied to the microscopically-defined subset of NAFLD with known progression to cirrhosis and the complications that may be associated, including metabolic imbalances, liver failure and hepatocellular carcinoma. NASH is also being considered as a significant precursor of end-stage liver disease, ''cryptogenic cirrhosis'', in which the histologic features of the initial liver disease can no longer be appreciated. Because of the increasing prevalence and the known significance of this form of liver disease, current investigations are focused on discerning the clinical features of susceptible patients, the histopathologic findings that characterize the entity and serve as markers of progression, pathogenetic mechanisms that result in triglyceride accumulation, liver injury and fibrosis, and ultimately, treatment options.

MTHFR gene polymorphism, homocysteine and cardiovascular disease.

Homocysteine is an emerging new risk factor for cardiovascular disease. It is a thiol compound derived from methionine and involved in two main metabolic pathways: the cycle of activated methyl groups, requiring folate and vitamin B12 as cofactors, and the transsulfuration pathway to cystathionine and cysteine requiring vitamin B6 as cofactor. The homocysteine metabolism represents an interesting model of gene-environment interaction. Elevations in homocysteine may be caused by genetic defects in enzymes involved in its metabolism or by deficiencies in cofactor levels. A common polymorphism in the gene coding for the 5,10-methylene tetrahydrofolate reductase (MTHFR) (C677T, Ala --> Val) is associated with a decreased activity of the enzyme due to thermolability. In case of homozygosity for the Val allele, a relative deficiency in the remethylation process of homocysteine into methionine leads to a mild-to-moderate hyperhomocysteinemia, a condition recognized as an independent risk factor for atherosclerosis. The genetic influence of the MTHFR polymorphism on homocysteine levels is attenuated in females in premenopausal age and is not significant in subjects who exhibit serum levels of folate and/or vitamin B12 above the 50th percentile of distribution in the general population. The prevalence of the Val/Val genotype varies among different ethnic groups. It is very low in African populations, whereas in Europe and North America it ranges between 5% and 15%. In Italy an even higher prevalence has been reported in some regions. The question whether the MTHFR polymorphism might be per se an independent contributor to cardiovascular risk is debated. The interaction between this or other genetic factors and environmental/nutritional conditions (i.e. intake of vitamins such as folate) is a key determinant for homocysteine concentrations in healthy conditions as well as in some disease (i.e. in renal disorders). Another example of gene/environment interaction in the field of atherosclerosis is given by the apolipoprotein E polymorphism and its influence in response to diet. The presence of a high prevalence of risk-related allelic variants of such candidate genes within a certain population could serve to locally reinforce the recommendations concerning nutrient intake.

A multiplex PCR-based DNA assay for the detection of paraoxonase gene cluster polymorphisms.

Paraoxonase (PON) is a high-density lipoprotein (HDL) associated protein which is supposed to protect low-density lipoprotein (LDL) against oxidation and to play a role in the development of atherosclerosis. Interindividual variability in serum PON activity is attributable to common variants in components of the PON gene cluster on chromosome 7. We describe experimental conditions that permit the simultaneous determination of three common PON polymorphisms (PON1-192, PON1-55 and PON2-311) that are tightly associated with an increased risk of atherosclerosis. We used a multiplex PCR-based DNA assay using mismatch primers that introduce a unique recognition site for the endonuclease HinfI in the PCR products in case of presence of the R allele of PON 1-192, of the L allele of PON1-55 and of the S allele of PON2-311. The restriction analysis with HinfI allows to identify an electrophoretic band pattern which is specific for the combination of the three polymorphisms. This technique could be applied in the association studies aimed at assessing the role of PON and their polymorphisms in many clinical settings. In a preliminary study on a small population sample from south Italy about 10% of chromosomes exhibited the presumed risk-related haplotype R(192)/L(55)/S(311).