Vincenzo Paoletti

Role of anti-cyclic citrullinated peptide antibodies in discriminating patients with rheumatoid arthritis from patients with chronic hepatitis C infection-associated polyarticular involvement

This study was performed to assess the utility of anti-cyclic citrullinated peptide (anti-CCP) antibodies in distinguishing between patients with rheumatoid arthritis (RA) and patients with polyarticular involvement associated with chronic hepatitis C virus (HCV) infection. Serum anti-CCP antibodies and rheumatoid factor (RF) were evaluated in 30 patients with RA, 8 patients with chronic HCV infection and associated articular involvement and 31 patients with chronic HCV infection without any joint involvement. In addition, we retrospectively analysed sera collected at the time of first visit in 10 patients originally presenting with symmetric polyarthritis and HCV and subsequently developing well-established RA. Anti-CCP antibodies and RF were detected by commercial second-generation anti-CCP2 enzyme-linked immunosorbent assay and immunonephelometry respectively. Anti-CCP antibodies were detected in 23 of 30 (76.6%) patients with RA but not in patients with chronic HCV infection irrespective of the presence of articular involvement. Conversely, RF was detected in 27 of 30 (90%) patients with RA, 3 of 8 (37.5%) patients with HCV-related arthropathy and 3 of 31 (9.7%) patients with HCV infection without joint involvement. Finally, anti-CCP antibodies were retrospectively detected in 6 of 10 (60%) patients with RA and HCV. This indicates that anti-CCP antibodies can be useful in discriminating patients with RA from patients with HCV-associated arthropathy.

Increased soluble P-selectin levels in hepatitis C virus-related chronic hepatitis: correlation with viral load.

Background Platelet functional abnormalities are commonly found in patients with chronic liver disease; however, their nature and clinical significance are still a matter of discussion. Methods Soluble P-selectin (sP-selectin, a marker of in vivo platelet activation) levels, lipid pattern, and clotting activity were investigated in 39 patients with histologically confirmed chronic C hepatitis. Results Serum factor VIIc (P<0.01), total cholesterol (P<0.005), high density lipoprotein (P<0.001), and low density lipoprotein (P<0.05) levels were lower in patients compared with healthy subjects, whereas triglyceride and fibrinogen levels were similar in both groups. Platelet counts were lower in chronic hepatitis patients compared with controls (P<0.0001), and approximately 20% of patients had thrombocytopenia (platelet counts <110x103/μL). Platelet-associated immunoglobulin G (PAIgG) was present in 30.8% of patients. Plasma sP-selectin levels were higher in hepatitis C patients compared with controls (P<0.0001), and significant differences were observed with respect to the Scheuer score (P<0.01). The analysis of the distribution of plasma sP-selectin showed the presence of higher levels in patients with low platelet counts compared with patients with normal platelet counts and controls (P<0.0001); moreover, sP-selectin levels did not correlate with the presence of PAIgG. On the other hand, sP-selectin levels directly correlated with serum hepatitis C virus (HCV)-RNA (P<0.05) and inversely correlated with platelet count, blood lipids, and factor VIIc. Conclusions The results obtained in this study support the hypothesis that HCV infection might be directly responsible for a condition of in vivo platelet activation in patients with chronic C hepatitis.

Association of low-grade inflammation and platelet activation in patients with hypertension with microalbuminuria.

Increased levels of sCD40L (soluble CD40 ligand) have been associated with enhanced in vivo platelet activation, and may represent a molecular link between inflammation and a prothrombotic state. The aim of the present study was to analyse the relationship between platelet activation, endothelial dysfunction, low-grade inflammation and sCD40L in patients with hypertension with or without MA (microalbuminuria). A cross-sectional comparison of sCD40L levels was performed in 25 patients with MH (essential hypertension with MA) pair-matched for gender and age with 25 patients with EH (essential hypertension) and 25 HS (healthy subjects with normotension). Circulating levels of CRP (C-reactive protein), a marker of inflammation, sP-selectin (soluble P-selectin), a marker of in vivo platelet activation, and ADMA (asymmetric dimethylarginine) and vWF (von Willebrand factor), markers of endothelial dysfunction, were analysed in each subject. sCD40L levels were increased in patients with MH compared with either patients with EH (P<0.001) or HS (P<0.0001). A highly significant correlation between plasma sCD40L and sP-selectin (P<0.0001), vWF (P<0.001) or CRP levels (P<0.05) was observed in patients with MH. Multivariate regression analysis showed that sP-selectin was the strongest independent predictor of sCD40L levels (P<0.0001) in patients with MH. Patients with hypertension with both vWF and CRP levels above the median had the highest sCD40L levels (P<0.0001). Factorial ANOVA of all of the patients with hypertension confirmed that only patients with MH with low-grade inflammation had elevated levels of sCD40L. In conclusion, sCD40L levels appear to discriminate a subset of patients characterized by MA and low-grade inflammation, suggesting that inhibition of the CD40/CD40L system may represent a potential therapeutic target in subjects with hypertension at a high risk of cardiovascular events.

Evaluation of myocardial involvement in systemic lupus erythematosus by signal-averaged electrocardiography and echocardiography.

Objective — The myocardial involvement in systemic lupus erythematosus (SLE) patients, frequently found at autopsy or at endomyocardial biopsy, is less easily detected clinically. The myocardial lesions are characterized by an increase in interstitial connective tissue and myocardial scarring. Signal-averaged electrocardiography (ECG-SA) is currently used for recording ventricular late potentials which are the expression of slowed and disorganized conduction through zones of myocardial scarring. M-mode, two-dimensional and Doppler echocardiography (ECHO) represent relatively simple methods for evaluating the left ventricular function.This study was aimed to evaluate by ECG-SA and ECHO the myocardial involvement of SLE patients without clinical and electrocardiographic evidence of cardiac disease. Methods and results — Twenty outpatients with SLE were studied and compared with 18 normal controls. Late potentials were recorded in 20% of SLE patients and in 5.5% of controls. A significant increase of abnormal left ventricular diastolic filling was found in the SLE patients, characterized by reduced E/A (p = 0.018), a lower deceleration rate of early diastolic flow velocity (p = 0.048) and a prolonged isovolumic relaxation time (p = 0.001). SLE patients had diastolic dysfunction of various degrees although the depolarization abnormalities detected by ECG-SA were found only in a few subjects. Conclusions — The depolarization abnormalities, revealed by ECG-SA, probably reflect a longer extent of myocardial fibrosis in SLE patients with ECHO evidence of abnormal left ventricular filling. The simultaneous occurrence of ECHO and ECG-SA alterations could be a marker of subclinical myocardial involvement.

Natural history of cardiac involvement in myotonic dystrophy (Steinert's disease): a 13-year follow-up study.

Myotonic dystrophy (MD) is associated with a wide spectrum of cardiac abnormalities, but only a few longitudinal studies have investigated the natural course of heart disease in MD. To assess whether neuromuscular involvement significantly predicts cardiac disorders in MD, 83 patients with various grades of disease severity were enrolled in a 13-year follow-up study (mean, 60.6 ± 37.8 months) that included periodic physical and instrumental cardiac examinations (standard and Holter electrocardiography, echocardiography). During follow-up, muscular disease worsened clinically in 9 patients (11%) whose baseline severity grade changed accordingly; only 3 of them demonstrated parallel worsening of cardiac disturbance, however, compared with a large number of patients who showed additional cardiac abnormalities. These included further worsening of pre-existing pathologic features (19/83) and the appearance de novo of serious arrhythmias and/or conduction defects (23/83). Pacemaker implantation was necessary in 11 of 83 patients (13.2%) who had symptomatic bradyarrhythmias, bifascicular block, and P-R prolongation with a His-to-ventricle interval exceeding 55 ms, as documented by electrophysiologic study. Eight (9.6%) patients died: 2 from noncardiac and 1 from unknown causes, 1 from heart failure, and 4 from sudden death closely related to documented ventricular tachycardia. The incidence and seriousness of arrhythmic and conduction disturbances correlated with the severity of the muscular involvement. Nevertheless, cardiac and muscular disease did not show a linear progression. Cardiac involvement generally worsened more rapidly than did skeletal muscle disease.

Nonsyndromic pulmonary valve stenosis and the PTPN11 gene.

Isolated pulmonary valve stenosis (PVS) is a congenital heart defect (CHD) with an estimated frequency of 4/10,000 live births, and an incidence of about 10% of all children with CHD [Pierpont and Moller, 1987]. Typical PVS consists of a domed form fusion of pulmonary semilunar valves, with poststenotic dilatation of the main pulmonary artery, which is a common form of right ventricular outflow tract obstruction [Ferencz et al., 1997]. PVS can be associated with major cardiovascular defects, but frequently occurs as an isolated malformation, with uniform anatomic characteristics. About 10% of patients with PVS display additional cardiac anomalies [Ferencz et al., 1997], mainly in the formofmalformationsyndromes, including fetalrubella, fetal cytomegalovirus infection (CMV), Ehlers-Danlos, Goldenhar, Costello, and others [Burn and Goodship, 2002]. However, PVS is the classic CHD associated with Noonan (NS) and multiple lentigines/LEOPARD (ML/LEOPARD) syndromes. In these patients, the valvular stenosis usually consists of a characteristic valve leaflet dysplasia [Ferencz et al., 1997]. The dysplastic form of PVS is less common than the typical valve stenosis, and is more commonly associated with noncardiac malformations (such as NS), which are unusual in isolated PVS. Moreover, recurrence of nonsyndromic PVS has been reported in several families, and both syndromic and nonsyndromic familial valve stenosis are inherited as autosomal dominant traits [Pierpont and Moller, 1987]. The risk of recurrence in sporadic cases of nonsyndromic PVS is 2% [Burn and Goodship, 2002]. Recently, NS and ML/LEOPARD syndromes have been related toPTPN11 genemutations [Tartaglia et al., 2001; Digilio et al., 2002], in accordance with animal models, which have shown that PTPN11 gene mutations are associated with dysplastic PVS with thickened semilunar valves, comparable to what observed in NS patients [Chen et al., 2000]. PTPN11 mutations have been identified in 37% of sporadic and 59% of familial NS patients, and in nine of 10 ML/ LEOPARD individuals [Digilio et al., 2002; Tartaglia et al., 2002]. The genotype–phenotype correlation study hasdemonstrateda significant associationbetweenPVS and PTPN11 mutations [Tartaglia et al., 2002]. In order to investigate the precise role of PTPN11 mutations in the pathogenesis of the nonsyndromic, nondysplastic form of valve stenosis, we gathered patients with nonsyndromic PVS and investigated for PTPN11 gene mutations. Twenty affected patients were selected. Informed consent and family history were obtained from all subjects and their parents. All patients were evaluated to exclude syndromic conditions, in particular Noonan and ML/LEOPARD syndromes. Sixteen patients were sporadic, and four were familial. The cardiac diagnosis wasmade by echocardiography and/or cardiac catheterization, or surgery. In all patients, the right ventricular-to-pulmonary artery peak-to-peak gradient exceeded 40 mmHg at Doppler echocardiography. No cases showed dysplasia of the pulmonary valve leaflets. Patients included nine females (45%) and 11males (55%). Ages ranged between 0.2 and 34 years (mean age SD1⁄4 8.4 4.6 years). PTPN11coding regions with exon-intron boundaries (GenBankAccessionNumber: NM_008234)were amplified from genomic DNA by polymerase chain reaction (PCR) and analyzed by single strand conformation polymorfism (SSCP) (Genephor Unit; Amersham-Pharmacia Biotech, Uppsala, Sweden). Fragments with anomalous mobility shifts were sequenced (ABI PRISM 310 Genetic Analyzer automated sequencer; Applied Biosystems, Foster City, CA). No fragment with an aberrant migration pattern was identified by these methods. This result suggests that PTPN11mutations occur only in patients with PVS and NS or ML/LEOPARD syndromes, and not in patients with nonsyndromic defects. Even considering that neither the noncoding regions of the gene nor wide deletions and rearrangements were investigated, these results are interesting. In fact, all PTPN11 mutations reported to date in syndromic patients with or without PVS were of the missense type, with a detection rate ranging from 45% using denaturing high-performance liquid chromatography (dHPLC), to slightly over 50% using direct sequencing [Tartaglia et al., 2001, 2002]. Grant sponsor: Italian Ministry of Health; Grant sponsor: Italian Ministry of Instruction, University, and Research.

Tumor necrosis factor-alpha and myocardial function in patients with myotonic dystrophy type 1

An imbalance of TNF system activity has been reported in patients with myotonic dystrophy type 1 (DM1). Nevertheless, the question whether TNF-alpha action is directly implicated in the pathogenesis of DM1 or is a simple marker of disease activity is still open. Therefore, the present study was aimed to investigate serum tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, and IL-6 levels in association with the disease stage, cytosine-thymine-guanine (CTG) expansion and cardiac function of 56 patients with DM1 (40+/-14 years) and 28 healthy controls (42+/-12 years). All subjects were submitted to resting electrocardiogram (EKG), Signal-averaged EKG (SA-EKG), and M-mode/2-D echocardiography. TNF-alpha levels were higher in patients compared to controls (p<0.0003) and were associated to disease stage (p<0.02). Significant correlation were observed between TNF and CTG expansion (p<0.005) or PQ intervals (p<0.0005). Ventricular late potentials (VLPs) occurred in 54% of cases. In these patients, TNF-alpha levels were higher compared to those without VLPs (p<0.05). We may conclude that TNF-alpha levels might represent and adjunctive criterion for disease staging in patients with myotonic dystrophy type 1, and that elevated TNF levels in DM1 may lead to cardiac fibrosis affecting diastolic function, conduction, and automaticity.

Morphologic left ventricular patterns and prevalence of high-grade ventricular arrhythmias in the normotensive and hypertensive elderly

In the elderly, systemic hypertension is the main risk factor for cardiovascular diseases. Left ventricular hypertrophy, the most common adaptation to chronic pressure overload, has been recognized as an independent risk factor for an increased incidence of sudden death and arrhythmic disturbances. This study compared the prevalence of serious ventricular arrhythmias in elderly individuals with uncomplicated hypertension and in normotensive age-matched controls, using left ventricular mass index (LVMI) to differentiate patterns of anatomic adaptation to systolic, diastolic, or systolic-diastolic hypertension. The study enrolled 378 con-secutive untreated elderly subjects (≥65 years of age), without clinical evidence of heart failure; 203 were hypertensive and 175 were normotensive. Each participant underwent standard 12-lead electrocardiography, M-mode and B-mode echocardiography, and 24-hour ambulatory electrocardiographic monitoring. Serious, statistically significant arrhythmias (Lown classes ≥3) were present in 6.8% of normal subjects versus 17.1% of individuals with systolic, 31.5% of those with diastolic, and 20.4% of participants with systolic-diastolic hypertension. Arrhythmias did not differ in terms of left ventricular morphologic patterns or LVMI or between subgroups of hypertensive patients. Our data support the hypothesis that the pathogenesis of arrhythmias is related not to the electrophysiologic derangement of hypertrophied muscle but, rather, to the effects of hypertension on the cardiac structure. Cardiac fibrosis, one of the deleterious events accompanying hypertension, may be the main substrate for ventricular arrhythmias.

Liver Fibrosis: What's the Beginning of Autonomic Deficit?

Histologic diagnoses were made using standard criteria and two independent observers scored all samples using the Scheuer staging system (3). We distinguished between patients affected by moderate e brosis (scores 2 and 3) and those affected by severe e brosis, corresponding to cirrhosis (score 4). Cardiac index was determined using pulsed-wave Doppler echocardiography (Hewlett-Packard Sonos 2000, Andover, Mass., USA). Peripheral vascular resistance (PVR) was calculated as the mean arterialpressure/cardiacoutput £80.Heartratevariabilitywas evaluated in the frequency domain using appropriate software (Rozinn Electronics H4W 3.6F, Glendale, N.Y., USA). A series of consecutive 5-min intervals was calculated from the Holter ECG as a function of beat numbers. Power spectral analysis of the intervals between adjacent R waves of the electrocardiogram (RR) was performed using the fast Fourier transform mathematical function (5). Low frequency (LF; 0.04‐0.15 Hz) and high frequency (HF; 0.15‐0.40 Hz) spectral powers and the ratio of LF to HF (LF/HF) were calculated and expressed in normalized units (nU). The recordings were obtained with 5 min in the supine position and 5 min in passive head-up tilt (70°). Statistical analysis was performed using an appropriate t test. P values lower than 0.05 were regarded as statistically signie cant. None of the patients included in this study, with either chronic viral hepatitis or with cirrhosis, showed evidence of hyperdynamic circulation. Cardiac index and peripheral vascular resistances were not signie cantly different from those of healthy subjects. Moreover, our results showed no differences between patients and controls in mean systolic and diastolic arterial pressures, either in the supine or in the tilt position. The power spectral analysis showed the occurrence of a

Cardiac critical events in myotonic dystrophy: relationship with the severity of neuromuscular disease1

Background: Conduction and ventricular arrhythmic disturbances in myotonic dystrophy (MD) are the main causes of cardiac morbidity and mortality. Methods: To better define the natural history of cardiac involvement and the relationship with severity grade of neuromuscular disease, we followed up 83 MD patients (56 men and 27 women; mean age 37±14 years) for a mean period of 61±38 months (range 2–156 months). Pre-study evaluation included physical examination, 12-lead electrocardiogram, 24-h Holter monitoring, and echocardiography. Results: During the study, cardiac critical events (CCE) occurred in 20 patients (24%), five of whom died of sudden death related to documented ventricular tachycardia, 12 of whom had pacemaker implantation and three of whom experienced ventricular tachyarrhythmias. The incidence of CCE appeared to be related to disease severity; in fact, CCE progressively increased from class I to class III (2% vs. 17% vs. 78%, respectively, P<0.001). Moreover, 8% of the patients experienced CCE in spite of low-grade muscular involvement. Conclusions: Critical cardiac events are significantly associated with the more severe forms of neuromuscular disease, while in some patients cardiac involvement in MD worsens independently from skeletal muscle disease.