Georgios Bourikas

Atrial Fibrillation and Hypercoagulability: Dependent on Clinical Factors or/and on Genetic Alterations?

AbstractIt is well known that atrial fibrillation is associated with high incidence of thromboembolic events, propably due to a prothrombotic or hypercoagulable state. However, it is unclear whether or not there is any difference of this prothrombotic state in the clinical subgroups of atrial fibrillation patients, that is, in those with paroxysmal, persistent or permanent atrial fibrillation. From the other side the role of the arrhythmia duration on the changes of coagulative variables in atrial fibrillation patients is not clearly enough.The contribution of genetic and functional alterations in factors of the coagulation and fibrinolytic pathways (that is hemostatic risk factors) to the development of hypercoagulation state in atrial fibrillation requires clarification.We investigated therefore (1) if there are differences in the prothrombotic state between patients with different clinical status of the arrhythmia, (2) if the arrhythmia duration per se could be an independent determinant of the prothrombotic state in all atrial fibrillation patients and (3) if coexistent genetic alterations in haemostatic risk factors in patients with atrial fibrillation could contribute to the development of prothrombotic abnormalities. Methods: Over a period of 23 months, we studied 55 patients with chronic non-valvular atrial fibrillation. We recruited 18 consecutive patients (13 men, mean age 59 ± 10 years) with paroxysmal atrial fibrillation 17 patients (11 men, mean age 61 ± 7 years) with persistent atrial fibrillation who underwent elective successful DC and remained in sinus rhythm at the 3 month visit and 20 patients (14 men mean age 64 ± 9) with permanent atrial fibrillation. Blood results were compared to 17 age-sex- and race-matched controls. The prothrombotic state was quantified by measurement of plasma levels of fibrinogen, soluble P-selectin (an index of platelet activation) and von Willebrand factor (a marker of endothelial dysfunction). We assessed the frequencies of factor V Leiden and prothrombin variant G20210A to determine whether particular inherited haemostatic risk factors may have contribution to the development of prothrombotic state in atrial fibrillation patients. Results: Permanent atrial fibrillation was associated with significant raised levels of von Willebrand factor, fibrinogen levels and soluble P-selectin compared to matched controls (all p < 0.001) and matched patients with paroxysmal and permanent AF (all p ranged between <0.003 and <0.002). Patients with persistent atrial fibrillation had significantly elevated von Willebrand factor levels (p = 0.0064) and fibrinogen levels (p = 0.002), but not Soluble P-selectin (p = 0.509). when compared to controls. Patients with paroxysmal atrial fibrillation had significantly elevated levels of P-selectin (p = 0.005) and fibrinogen (p = 0.003), but not von Willebrand factor (p = .0.61) compared to controls. Stepwise multiple regression analyses demonstrated that the arrhythmia duration (approximately 3 years) was an independent predictor of abnormal von Willebrand factor, fibrinogen and soluble P-selectin levels. Restoration of sinus rhythm in paroxysmal atrial fibrillation subgroup and successful electrical cardioversion of patients with permanent fibrillation atrial fibrillation did not significantly alter levels of the affected factors.The frequency of factor V Leiden was 8.9 in all studied patients with atrial fibrillation, versus 2.4% in the control group (odds ratio {OR} 4.6 [95% confidence (CI) 1.4–17.5], p = 0.02). The frequency of the prothrombin variant G20210A was 6.4.% compared with control group 1.6% (OR 4.9 [95% confidence interval (CI) 1.2–2.9], p = 0.04).There was a trend towards an increased frequency of factor V Leiden and/or prothrombin variant G20210A in patients age <55 years and in patients living at a particular area of Thrace mountains. Conclusions: Our results showed that there were significant differences in the prothrombotic state when patients with paroxysmal, and persistent atrial fibrillation were compared to matched patients with permanent atrial fibrillation and controls in sinus rhythm.The duration of the arrhythmia (about 3 years) was an independent predictor of abnormal measured factors. We found for the first time that some genetic alterations in haemostatic risk factors could be coexist in atrial fibrillation patients and may be a contributor to the development of hypercoagulability in atrial fibrillation patients.

Cardiovascular involvement in patients with β-thalassemia major without cardiac iron overload

BACKGROUND Cardiovascular complications are common in beta-thalassemia major (beta-TM), mainly attributed to increased cardiac iron depositions. Early cardiovascular involvement in patients without cardiac symptoms and without cardiac iron overload has not been adequately investigated. METHODS Twenty six patients (11 males) with beta-TM, on chelation therapy, age 23+/-4 years without cardiac iron overload (measured by magnetic resonance imaging), and 30 age and gender matched healthy controls were included in the study. Carotid-femoral and carotid-radial pulse wave velocity (PWVc-f and PWVc-r) and augmentation index (AI) were measured by SphygmoCor device; carotid intima-media thickness; left ventricular (LV) dimensions and function; left atrial (LA) volume and function were assessed by echocardiography. RESULTS Patients with beta-TM had higher PWVc-f (8.4+/-1.4 vs 7.2+/-1.1 m/s, p=0.002) and augmentation index (21.7+/-10.9 vs 14.7+/-9.7%, p=0.04) indicating decreased aortic elastic properties; greater LV mass index (72.0+/-13.3 vs 63.8+/-11.5 g/m(2), p=0.04) and greater LA volumes. Multivariate logistic regression analysis revealed that higher PWVc-f was independently associated with higher LV mass [OR 1.74 95%CI (1.09-2.88), p=0.026]; and greater LA dimensions [OR 1.68 95%CI (1.04-2.72), p=0.035]. CONCLUSIONS In the absence of cardiac iron overload, asymptomatic patients with beta-TM demonstrated aortic stiffening associated with increased LV mass and LA enlargement. These alterations may represent signs of early cardiovascular involvement.

Absence of Bruton's tyrosine kinase (Btk) mutations in patients with acute myeloid leukaemia

Brutons tyrosine kinase (Btk) is a non‐receptor protein tyrosine kinase (PTK) that is expressed in all haemopoietic lineages except mature T cells and plasma cells. Despite the broad range of expression, mutations that inactivate this molecule affect primarily the development of the B‐cell lineage. As a PTK, Btk could potentially be involved directly or indirectly in the processes that relate to the malignant transformation of all the cell lineages where this molecule is expressed. Previous studies have failed to demonstrate mutations in patients with B‐cell origin acute lymphoblastic leukaemia (ALL).

Effect of HbS in the determination of HbA2 with the Menarini HA-8160 analyzer and comparison with other instruments

It is known that the presence of hemoglobin S (HbS) affects the determination of hemoglobin A2 (HbA2) levels in clinical samples. We quantitated this effect using the Menarini HA‐8160 analyzer and compared with other instruments (HELENA beta‐thal quik column, TOSOH HLC‐723G7 and BIORAD Variant II) using the HELENA SAS‐MX alkaline gel electrophoresis kit as the reference method. The %HbA2 values from the HA‐8160 analyzer and the alkaline gel electrophoresis show a good linear correlation in the absence of HbS. A strong positive bias in the %HbA2 values from the HA‐8160 is apparent in the presence of HbS in the samples, when compared with the alkaline electrophoresis. The analytical imprecision and bias of the three HPLC instruments are comparable both in the presence and absence of HbS. The manual column method shows a lower bias in the absence of HbS but is more affected when HbS is present in the samples.

Successful treatment of lymph node extramedullary plasmacytoma with bortezomib

Dear editor, The extramedullary plasmacytomas (EMPs) are localized mainly in the upper respiratory tract. Lymph node plasmacytoma is defined as a lymph node tumor composed of monoclonal proliferation of plasma cells. The diagnosis of lymph node EMP is based not only on the finding of a plasma cell tumor at an extramedullary site (lymph node) but also on the exclusion of multiple myeloma (MM). Radiotherapy with or without local resection is the current treatment of choice because these tumors are usually radiosensitive. With radiation doses of 4,000–5,000 cGy, local recurrence develops in 5%, and systemic progression develops in less than 30% of the patients [1]. The size of EMP has been reported to be a bad prognostic factor regarding the likelihood of control [2]. Therefore, the treatment of large EMP presented in other sites than the upper respiratory system remains a challenge. Chemotherapy is considered as a treatment option in systemic progression to MM or recurrent relapses. The proteasome inhibitor bortezomib has recently been evaluated in the setting of relapsed and therapy–refractory plasmacytic malignancies with some evidence of effectiveness in MM with extramedullary manifestations of the disease [3, 4]. We report here a patient suffering from refractory EMP who received bortezomib and achieved complete remission. A 63-year-old male patient presented with retroperitoneal mass, measuring 8×10 cm, and after total surgical excision, histological examination of the mass, and a bone marrow biopsy, as well as a detailed biochemical and radiological evaluation to exclude MM, the patient was diagnosed as having retroperitoneal lymph node EMP (previously reported by Pantelidou et al. 2005 [5]). Despite radiotherapy to a total dose of 4,400 cGy, he relapsed 20 months later. Computed tomography (CT) disclosed seven enlarged paraaortic lymph nodes with diameters of 1.0– 3.8 cm on axial images. Bone marrow aspiration and biopsy, detailed biochemical evaluation, and skeletal survey did not reveal any evidence of systemic MM. Four courses of vincristine, adriamycin, and dexamethasone (VAD) followed by high-dose melphalan with autologous stem cell transplantation were given, and partial remission was achieved. Unfortunately, the patient relapsed again after 4 months. The CT demonstrated enlargement of celiac axis, retropancreatic, pericaval, and periaortic lymph nodes; a total of 22 enlarged lymph nodes were identified, measuring 1.0–4.2 cm in diameter on axial images. The involved nodes exhibited homogeneous soft tissue densities and mild enhancement after iodinated contrast media administration (Figs. 1a, 2a). Based on the early relapse after high-dose melphalan supported by autologous stem cell transplantation and the extended lymph node involvement, treatment with the proteasome inhibitor bortezomib was considered. After obtaining the patient’s informed consent, he received bortezomib (1.3 mg/m) as intravenous bolus injections D. Pantelidou (*) . C. Tsatalas . D. Margaritis . A. G. Anastasiadis . G. Bourikas Hematology Department, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece e-mail: dpantelidou@yahoo.gr Tel.: +30-25510-74511 Fax: +30-25510-76154

Acquired reactive perforating collagenosis associated with myelodysplastic syndrome evolving to acute myelogenous leukaemia

testing for allergy was not undertaken. Oilatum PlusR contains benzalkonium chloride (6% w/w) and triclosan (2% w/w). Allergic and irritant contact dermatitis with both of these agents are reported and benzalkonium chloride is a caustic agent at a concentration of 10%.4,5 Triclosan has a low sensitizing potential, as was found in a large Swiss study,4 but there are reports of allergic contact dermatitis as a result of antibacterial handwashes in health-care workers.6,7 Benzalkonium chloride is a more likely candidate for the severe irritant reaction seen in the two children. Recently, similar but less extensive reactions as a result of antiseptic bath oil have been documented.8,9 Irritant dermatitis previously described has mainly affected flexural skin of atopic children, thought to be because of increased penetration at these sites.8,9 Most patients have reported little or no discomfort,8 but our patients experienced pain with associated restriction of movement. A recent communication describing an irritant dermatitis to Oilatum PlusR revealed more typical findings on skin biopsy of an irritant reaction.8 This may be explained by milder skin changes, as this reaction occurred at a normal concentration of the emollient, but with prolonged use. Our patients were exposed to excessively concentrated solutions of antiseptic bath oil. In combination with the decreased barrier function of their skin as a result of pre-existing eczema, the concentration of benzalkonium chloride is a likely irritant. In addition to language difficulties contributing to misunderstanding of the appropriate dilution of bath oils, this case demonstrates the requirement for explicit instructions. It is planned to develop language-specific information sheets at our clinic to avoid the misuse of medicaments and to aid in the understanding of skin conditions. The potential severity of irritant reaction with the erroneous use of antiseptic bath oil is highlighted by this case. Until the biopsy result was explained to the children’s mother, she did not admit to using greater concentrations of the bath oil than instructed, as she thought it should improve their skin, not worsen it. The fact that both children were affected by such a well-demarcated inflammatory eruption increased suspicion of an exogenous cause. Antiseptic bath oils provide benefit in the treatment of atopic eczema, reducing the frequency and severity of infective exacerbations.1 However, the cases presented illustrate that incorrect use can lead to a severe irritant dermatitis that can be difficult to diagnose. Once diagnosed, this complication is readily treated by avoidance of bath oil and intensive emollient application.

Pregnancy in β-thalassemia trait carriers: an uneventful journey

Abstract Normochromic normocytic anemia during pregnancy reflects the significant increase in plasma volume, which disproportionately exceeds the increase in the red cell volume. In β-thalassemia (β-thal) trait carriers who become pregnant the plasma volume expansion may cause more pronounced anemia because the anemia of pregnancy is added to the pre-existed hypochromic microcytic anemia. In β-thal women, pregnancy outcome and obstetric complications do not differ from the general population. Anemia in β-thal carriers is generally not severe enough to warrant anxiety. No specific therapy is indicated and pregnant women generally require only supportive care with an anticipated favorable pregnancy outcome.

Clotting state after cardioversion of atrial fibrillation: a haemostasis index could detect the relationship with the arrhythmia duration

BackgroundFibrin D-dimer levels have been advocated as an useful clinical marker of thrombogenesis.HypothesisWe hypothesized that i) there is a hyperclotting state after the return of atrial fibrillation to sinus rhythm, ii) the measurement of plasma D-Dimer levels might be a good screening tool of this clotting status, and iii) the duration of arrhythmia influences the haemostasis measured by plasma D-Dimer levels.MethodsForty-two patients with atrial fibrillation undergoing cardioversion were divided into two groups: in Group A (n = 24,14 male, 56 ± 11 years) the duration of atrial fibrillation was 72 hours or more (142.7 ± 103.8 hours), in Group B (n = 18, 10 male, 61 ± 13 years) the duration of atrial fibrillation was less than 72 hours (25 ± 16 hours). Plasma fibrin D-dimer levels were measured by enzyme immunoassay before, and 36 hours after, cardioversion. The change of plasma D-dimer levels 36 hours after cardioversion was calculated as delta-D-dimer.ResultsThere were no significant differences in demographic, clinical, and echocardiographic data, and the success of cardioversion between the two groups. Compared to the control, the baseline D-dimer levels were significantly higher in both groups. The delta D-dimer levels were significantly higher in Group A than in Group B (p < 0.005). Furthermore, plasma D-dimer levels 36 hours after cardioversion (r = 0.52, p = 0.0016) and delta-D-dimer levels (r = 0.73, p < 0.0001) showed significant correlations with the duration of atrial fibrillation.ConclusionThe longer duration of the atrial fibrillation episode could lead to a more prominent cardiovascular hyperclotting state after cardioversion, and the mean changes of plasma D-Dimer levels could be used as an useful clinical marker of the clotting state after atrial systole return.

Exploring Genomic Structure Differences and Similarities between the Greek and European HapMap Populations: Implications for Association Studies

Studies of the genomic structure of the Greek population and Southeastern Europe are limited, despite the central position of the area as a gateway for human migrations into Europe. HapMap has provided a unique tool for the analysis of human genetic variation. Europe is represented by the CEU (Northwestern Europe) and the TSI populations (Tuscan Italians from Southern Europe), which serve as reference for the design of genetic association studies. Furthermore, genetic association findings are often transferred to unstudied populations. Although initial studies support the fact that the CEU can, in general, be used as reference for the selection of tagging SNPs in European populations, this has not been extensively studied across Europe. We set out to explore the genomic structure of the Greek population (56 individuals) and compare it to the HapMap TSI and CEU populations. We studied 1112 SNPs (27 regions, 13 chromosomes). Although the HapMap European populations are, in general, a good reference for the Greek population, regions of population differentiation do exist and results should not be light‐heartedly generalized. We conclude that, perhaps due to the individual evolutionary history of each genomic region, geographic proximity is not always a perfect guide for selecting a reference population for an unstudied population.

PHENOTYPE AND GENOTYPE FREQUENCY OF β-THALASSEMIA AND SICKLE CELL DISEASE CARRIERS IN HALKIDIKI, NORTHERN GREECE

A decade of screening (years 2000 to 2010) for hemoglobinopathies in 3,931 patients was performed at the General Hospital of Poligiros, Halkidiki, Northern Greece. Among the patients examined, 10.8% heterozygotes for β-thalassemia (β-thal) were found, as well as 4.1% with sickle cell disease and 1.2% with double β-thal/Hb S [β6(A3)Glu→Val] heterozygosity. Iron deficiency was observed in 23.4%. The geographical distribution in the region revealed a substantial incidence of hemoglobinopathies even in mountainous areas. This pattern did not follow the typical distribution according to the malaria hypothesis, as incidence did not dovetail with swamp locations recorded in the past. The HBB gene mutations for 85 patients were also analyzed. Most prevalent in Halkidiki, Northern Greece, was the codon 39 (C>T) mutation (27.1%) followed by the IVS-I-110 (G>A) mutation (22.4%); this was in direct contrast to the current distribution of the same mutations seen in the rest of Greece (Greek National Genetic Database, GNGD). This frequency inversion was statistically significant, with the difference from the GNGD being 20.6% for the IVS-I-110 mutation (p <0.0005) and 7.6% for the codon 39 mutation (p = 0.0238). The history of Halkidiki, denoting a clear example of geographical isolation from the rest of the country, may possibly account for a potentially diverse genetical identity of the disease in this region.