Pulmonary Hypertension in Sickle Cell Disease: Novel Findings of Gene Polymorphisms Related to Pathophysiology

Pulmonary hypertension (PH) is a progressive and potentially fatal complication of sickle cell disease (SCD), affecting 6-10% of adult SCD patients. Various mechanisms and theories have been evaluated to explain the pathophysiology of this disease. However, questions remain, particularly regarding the clinical heterogeneity of the disease in terms of symptoms, complications, and survival. Beyond the classical mechanisms that have been thoroughly investigated and include hemolysis, nitric oxide availability, endothelial disorders, thrombosis, and left heart failure, attention is currently focused on the potential role of genes involved in such processes. Potential candidate genes are investigated through next-generation sequencing, with the transforming growth factor-beta (TGF-β) pathway being the initial target. This field of research may also provide novel targets for pharmacologic agents in the future, as is already the case with idiopathic PH. The collection and processing of data and samples from multiple centers can yield reliable results that will allow a better understanding of SCD-related PH as a part of the disease's clinical spectrum. This review attempts to capture the most recent findings of studies on gene polymorphisms that have been associated with PH in SCD patients.

Peripheral Neuropathy in Patients with Hepatitis C Infection-Reversibility after HCV Eradication: A Single Center Study

Chronic hepatitis C virus (HCV) infection is characterized by a variety of extra-hepatic manifestations; peripheral neuropathy (PN) is one of the most common, especially when mixed cryoglobulinemia (MCG) is present. The prevalence and risk factors of HCV-related PN in the absence of MCG are largely unknown. We conducted a prospective, single-center study, examining the prevalence and reversibility of HCV-associated neuropathy in the absence of MCG. Nerve fiber density in the epidermis was evaluated through skin biopsy and electroneurography (ENG) before HCV-treatment initiation and 1 year post sustained virological remission (SVR). Forty HCV-infected individuals (nine HIV co-infected) with no other neuron-harming factors were included; four other HCV mono- and three HIV co-infected individuals were excluded due to presence of diabetes, B12 insufficiency, or neurotoxic drugs. Twelve consecutive controls with no neuron-harming conditions were also recruited; eight more were excluded due to meeting exclusion criteria. Four patients had ENG signs of polyneuropathy (two with HCV mono- and two with HIV co-infection), while seven more (five with HCV mono- and two with HIV co-infection) had signs of mono-neuropathy, leading to PN prevalences of 22.5% and 44% for mono- and co-infection, respectively (p value 0.179). The two patients with HCV mono-infection and polyneuropathy and the one with ulnar nerve damage showed ENG improvement 1 year post SVR. Regarding intraepidermal nerve density, HCV infection, irrespective of HIV co-infection, was correlated with a lower intraepidermal neuron density that improved 1 year post SVR (p value 0.0002 for HCV and 0.0326 for HCV/HIV co-infected patients). PN is common in HCV infection; successful eradication of HCV leads to PN improvement.

High-Oxygen-Affinity Hemoglobins-Case Series and Review of the Literature

Modifications of the hemoglobin (Hb) structure in regions involving the regulation of oxygen transport may lead to an increased oxygen affinity for the hemoglobin molecule and impaired oxygen delivery to the tissues. Herein, we present six patients with high-oxygen-affinity Hb variants, either in heterozygous form or in compound heterozygosity (such as heterozygosity for Hb Hiroshima, Köln, Crete, and compound heterozygosity Hb Crete with β or δβ thalassemia), in order to demonstrate the need for prompt and accurate diagnosis and enrich the limited literature due to the rarity of such cases. Hb Crete, Hb Hiroshima, and Hb Köln have distinct pathophysiologies and may result in different clinical phenotypes. In conclusion, high-oxygen-affinity hemoglobins are rare and inherited within a dominant autosomal manner, have various clinical presentations, and should always be suspected in patients with erythrocytosis. Their management (as phlebotomy or low-dose aspirin) should be based on an individualized assessment of the risk of complications, the medical history, concomitant symptoms, and quality of life.

The role of anti-diabetic drugs in NAFLD. Have we found the Holy Grail? A narrative review

PURPOSE

Non-alcoholic fatty liver disease (NAFLD) has become a leading cause of liver disease, affecting 30% of the global population. NAFLD prevalence is particularly high in obese individuals and patients with type 2 diabetes mellitus (T2DM). NAFLD ranges from simple fat deposition in the liver to necroinflammation and fibrosis (non-alcoholic steatohepatitis (NASH)), NASH-cirrhosis, and/or hepatocellular carcinoma. Insulin resistance plays a key role in NAFLD pathogenesis, alongside dysregulation of adipocytes, mitochondrial dysfunction, genetic factors, and changes in gut microbiota. Since insulin resistance is also a major predisposing factor of T2DM, the administration of anti-diabetic drugs for the management of NAFLD seems reasonable.

METHODS

In this review we provide the NAFLD-associated mechanisms of action of some of the most widely used anti-diabetic drugs, namely metformin, pioglitazone, sodium-glucose transport protein-2 inhibitors (SGLT2i), glucagon-like peptide 1 receptor analogs (GLP1 RAs), and dipeptyl-peptidase-4 inhibitors (DPP4i) and present available data regarding their use in patients with NAFLD, with and without T2DM.

RESULTS

Both metformin and DPP4i have shown rather contradictory results, while pioglitazone seems to benefit patients with NASH and is thus the only drug approved for NASH with concomitant significant liver fibrosis by all major liver societies. On the other hand, SGLT2i and GLP1 RAs seem to be beneficiary in patients with NAFLD, showing both remarkable results, with SGLT2i proving to be more efficient in the only head-to-head study so far.

CONCLUSION

In patients with NAFLD and diabetes, pioglitazone, GLP1 RAs, and SGLT2i seem to be logical treatment options. Larger studies are needed before these drugs can be recommended for non-diabetic individuals.

Gaucher-like Cells in Thalassemia Intermedia: Is It a Challenge?

We describe two cases of thalassemia intermedia (TI) patients with the presence of Gaucher-like cells in hematopoietic tissue biopsies, raising diagnostic dilemmas. The first is a 56-year-old female with bone lesions, splenomegaly, hypochromic microcytic anemia and Gaucher-like cells in the bone marrow, with a final diagnosis of TI, and the second is a 69-year-old male with TI, monoclonal gammopathy of undetermined significance (MGUS) that accelerated to multiple myeloma (MM) requiring treatment, bone disease and Gaucher-like cells in the bone marrow and the spleen, and heterozygoty of Gaucher disease (GD). Gaucher-like cells are difficult to differentiate from true Gaucher cells, that are the hallmark of GD suspicion. These cells are usually reported in the lymphohematopoietic system. They have been described in myeloproliferative disorders, hematological malignancies, infectious diseases, hemoglobinopathies and other hemolytic anemias. The presence of Gaucher-like cells in patients with thalassemia major has been well documented, whereas there are limited references regarding cases with thalassemia intermedia. The identification of these cells in thalassemia probably reflects the high cell turnover. The bony complications in GD and TIare not yet fully explained in the literature, and this raises the question of whether Gaucher-like cells could play a pathogenetic role in the bone disease of thalassemia, as Gaucher cells are considered to play a similar role in bone complications of GD. Moreover, given the rarity and similarity of Gaucher and Gaucher-like cells, we would like to highlight that the presence of Gaucher-like cells in the bone marrow should not be overlooked, as they might be obscuring an underlying pathology, in order to ensure that hematologists, internists and hematopathologists will be promptly and accurately diagnosed.

Case Report of Myelodysplastic Syndrome in a Sickle-Cell Disease Patient Treated with Hydroxyurea and Literature Review

The safety profile of hydroxyurea (HU) in patients with sickle-cell disease (SCD) is relatively well known. However, despite the suspected association of HU with myeloid neoplasms in myeloproliferative neoplasms (MPN), and the publication of sporadic reports of myeloid malignancies in SCD patients treated with HU, the possible excess risk imparted by HU in this population having an increasing life expectancy has failed to be demonstrated. Herein, we report one case of myelodysplastic syndrome emanating from the results on safety and effectiveness of HU on the largest European cohort of 1903 HU-treated adults and children who were followed-up prospectively in an observational setting over 10 years, accounting for a total exposure of 7309.5 patient-years. A comparison of this single case with previously published similar cases did not allow us to draw any significant conclusions due to the paucity of these events.

Difficulties in Diagnosing and Treating Disseminated Bacillus Calmette-Guérin (BCG) Infection After Intravesical BCG Therapy in a Patient with Liver Cirrhosis: A Case Report

Patient: Male, 62-year-old

Final Diagnosis: BCGitis

Symptoms: Fever • general fatigue

Medication: —

Clinical Procedure: Bone marrow biopsy • liver biopsy

Specialty: Infectious Diseases • General and Internal Medicine

Outcomes of pregnancies in patients with Gaucher Disease: The experience of a center of excellence on rare metabolic Disease-Gaucher Disease, in Greece

OBJECTIVE

Pregnancy is reported to exacerbate manifestations in women with Gaucher Disease (GD). The objective of our study was to examine the outcome of pregnancies of Caucasian women with GD in a Greek Center of Excellence on GD.

STUDY DESIGN

Fifteen GD women were enrolled. All data were collected by questionnaire: fertility, normal pregnancies, spontaneous-elective-therapeutic abortions, maternal -neonatal status, birth weight and chromosomal abnormalities.

RESULTS

Forty-one pregnancies were reported among 15 women: mean conception age (±SD) 27.7 ± 5.8years (range 17-42years). Thirty-seven conceptions were spontaneous, 4 were after in vitro fertilization (IVF). Twenty three out of the 41 (56.1 %) pregnancies were normal. Eleven out of the 41 (26.8 %) pregnancies resulted in spontaneous abortions, 3 out of 41 (7.3 %) in elective and 3 out of 41 (7.3 %) in therapeutic abortions. Therapeutic abortions were due to worsening of GD manifestations, fetal chromosomal abnormalities and GD type 2 embryo. Nine out of 15 women had maternal complications: gestational diabetes, splenomegaly, hepatomegaly, thrombocytopenia, osteoporosis and postpartum hemorrhage. Twenty three out of the 41 pregnancies resulted in live births. Nine out of the 23 (39.1 %) deliveries were caesarian sections and 14 out of 23 (60.9 %) were vaginal. The total number of neonates was 24 (14 females / 10 males). Mean gestational age on delivery (± SD) was 35.9 ± 3.1 weeks (range 26-38 w). Average female birth weight (±SD) was 2671.4 ± 851.6 g (range 900-4100 grams) and male was 3333 ± 996.4 g (range 1930-4700 grams). Nine out of 24 (37.5 %) neonates had low birth weight. Average low birth weight (±SD) was 1931.1 ± 420.52 g (range 900-2300 grams). Twenty out of the 24 (83.3 %) neonates were healthy. Four out of 24 neonates had neonatal complications: two neonates had GD type 1, one had GD type 3 and one neonate died two days after delivery (it was born at 26 weeks). Four neonates were hospitalized in incubators at the intensive neonatal care unit due to low birth weight. Thirty-nine women did not receive enzyme replacement therapy for GD during pregnancy, while, in two pregnancies, treatment was discontinued during the first trimester and re-administered after that. Mean first menarche age (±SD) was 13.6 ± 0.7 years. Thirteen out of 15 women were menopausal, mean menopausal age (± SD) 466 ± 2.6 years.

CONCLUSION

Most of GD women experience uncomplicated pregnancies and deliver normal, healthy infants, although the rate of complications and the rate of abortions is high in this population.

P777Changes in glycated hemoglobin in patients with heart failure with reduced ejection fraction treated with sacubitril/valsartan

Introduction

Glycemic control reflected by glycated hemoglobin (HbA1c) is regarded as a risk factor and a strong predictor of mortality in patients with heart failure (HF). Hyperglycemia may contribute to oxidative stress, endotelial dysfunction and cardiac fibrosis and influence negatively heart failure prognosis in patients with or without diabetes. Treatment with neprilysin inhibitors in combination with angiotensin II receptor antagonist,(ARNIs) has shown beneficial effects in morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF).

Purpose

We sought to investigate eventual reductions in HbA1c in patients receiving the novel therapy.

Methods

We enrolled a total of 52 stable patients with HFrEF eligible for treatment with ARNIs. Patients were administered a target dose of 200mg bid (97mg sacubitril/103mg valsartan) and we measured HbA1c before, 3months and 6months after initiation of therapy. Changes in HbA1c levels were tested with General Linear Model Repeated Measures test. Spearmans' Rho correlation analysis was performed to investigate possible relationship between the above.

Results

Mean age was 62±10 years, 69,2% of patients were on New York Heart Association (NYHA) functional class II, 23,1% on NYHA III and 7,7% on NYHA IV. 57,7% had ischemic while 42,3% dilated cardiomyopathy, 25% chronic kidney disease and 38,5% diabetes mellitus. Mean Body Mass Index (BMI) was 29,88±4,66 kg/m2. Median value of baseline HbA1c was 5,8% (IQR 0,9). Compared to baseline values, HbA1c decreased to 5,6 (IQR 0,9) and 5,7 (IQR 0,83) (p=0,012) at three and six months of treatment, respectively. Change in HbA1c levels was associated significantly with the presence of diabetes mellitus (p=0,013) and diabetic patients showed greater relative reduction in HbA1c (8%) compared to non diabetic patients (1%). Spearmans' Rho test revealed statistically significant association between changes in HbA1c levels from initiation to three months of therapy, while changes between initiation to six months of administration did non correlate with the presence of diabetes.

Changes in HbA1c

Conclusions

HbA1c levels were reduced significantly during treatment with sacubitril/valsartan. Changes were independent of diabetes in six months of treatment.

P2876Repeating non-invasive risk stratification tests improves the prediction of outcomes of ICD patients in the EUTrigTreat study

Background

Non-invasive risk stratification of SCD aims to predict the risk by assessing measures of substrate (LVEF), of triggers (PVCs; T-wave alternans, TWA) and of autonomic function (heart rate turbulence, HRT). However, the value of repeating these tests during follow-up is unclear.

Purpose

To study the predictive value of repeated non-invasive risk assessment.

Methods

EUTrigTreat is a prospective trial aimed to improve non-invasive risk stratification in ICD patients. The study protocol included non-invasive testing at baseline and a repeat after 6 to 12 months. The population included ischemic and non-ischemic cardiomyopathies and arrhythmogenic heart disease. Test results were categorized as pathologic (1) versus non-pathologic (0) for LVEF ≤40%, PVCs >400 in 24h, abnormal exercise TWA (Cambridge Heart) and abnormal HRT (TO >0.1% and/or TS ≤2.0ms/RRI). Time dependent Cox regression modelling was performed for mortality, and a Fine-and- Gray competing risk analysis for shocks, including adjustment for independent predictors in the overall study population (mortality: age, LVEF, history of AF, NT-proBNP, NYHA class, eGFR; shocks: LVEF, secondary prevention).

Results

A total of 635 patients were included with a follow-up of 4.3±1.5 years, 96 (15%) received an ICD shock and 108 (17%) died. The table shows the results at baseline and with repeating the tests after 8±1 months.

Worsening of LVEF compared to a stable LVEF >40% and persistent abnormal HRT were independent predictors of mortality. Improvement in HRT was associated with a lower mortality. Worsened results upon TWA testing was associated with a 3 times higher risk of shocks. A persistent low LVEF was an independent predictor of both mortality and ICD shocks.

Baseline 1 (vs. 0) Worsening 0–1 (vs. 0–0) Improvement 1–0 (vs. 1–1) Stable 1–1 (vs. 0–0) HR (CI) HR (CI) HR (CI) HR (CI) Mortality   LVEF (n=315) 1.85 (1.06–3.24) 3.47 (1.13–10.68) 0.88 (0.40–1.94) 2.22 (1.19–4.15)   TWA (n=204) 0.62 (0.28–1.37) 0.80 (0.25–2.59) 0.67 (0.18–2.47) 0.59 (0.20–1.77)   PVC (n=329) 1.26 (0.73–2.16) 0.99 (0.36–2.72) 0.63 (0.26–1.52) 1.38 (0.75–2.55)   HRT (n=163) 2.57 (0.85–7.77) 4.01 (0.39–41.17) 0.10 (0.01–0.81) 8.71 (1.11–68.24) Shocks   LVEF (n=338) 1.73 (0.93–3.22) 0.92 (0.13–6.67) 0.26 (0.06–1.08) 2.02 (1.09–3.76)   TWA (n=256) 0.82 (0.39–1.70) 2.91 (1.04–8.13) 1.31 (0.48–3.59) 1.54 (0.54–4.43)   PVC (n=366) 1.28 (0.70–2.34) 1.48 (0.54–4.09) 0.54 (0.16–1.81) 1.70 (0.86–3.35)   HRT (n=188) 1.12 (0.50–2.50) 0.57 (0.13–2.52) 0.73 (0.20–2.64) 1.06 (0.43–2.61)

Conclusion

Repeating LVEF, TWA and HRT have the potential to improve risk stratification for mortality and shocks in ICD patients.

Acknowledgement/Funding

This research has received funding from European Community's Seventh Framework Program FP7: EUTrigTreat (grant agreement no. HEALTH-F2-2009-241526).

P6596S100A8/A9 and sRAGE peripheral blood levels in patients with heart failure and an implanted cardioverter/defibrillator: relation with sustained, fast ventricular arrhythmias

Background

Prediction of sudden cardiac death in heart failure (HF) remains suboptimal. Blood levels of the S100A8/A9 heterodimer protein complex and the soluble receptor of advanced glucation end product (sRAGE) are promising biomarkers in HF, reflecting inflammatory/fibrotic and apoptotic pathways, possibly involved in ventricular arrhythmogenesis. The relation of S100A8/A9 and sRAGE with ventricular arrhythmias and sudden cardiac death risk has not been previously assessed.

Purpose

Purpose of the study was to investigate whether S100A8/A9 and sRAGE serum blood levels of patients (pts) with systolic heart failure are related to the occurrence of life-threatening ventricular tachyarrhythmias.

Patients and methods

We studied 60 pts with clinically stable heart failure due to coronary artery disease (n=37) and dilated cardiomyopathy (n=23), all with a chronically implanted ICD for primary (n=43) or secondary (n=16) sudden death prevention, all in sinus rhythm. Their mean age (±1 SE) was 62±2 years, NYHA class I-II, mean LVEF 28±1%, Nt-pro-BNP 893±85 pg/dl. Blood was drawn at study initiation for S100A8/A9 and sRAGE assessment (ELISA, R&D Systems). They all were systematically followed-up for 4 years regarding the occurrence of fast ventricular tachyarrhythmias (>180 bpm) necessitating antiarrhythmic intervention through the ICD.

Results

S100A8/A9 and sRAGE levels were 16±1.6 ng/ml and 1076±99 pg/ml respectively. S100A8/A9 levels were lower than in normal controls, while sRAGE levels were within normal limits. During the 4-year follow-up period, 39 pts had an uneventful course (Group I), while 16 pts exhibited fast ventricular tachyarrhythmic episodes necessitating ICD activation (anti-tachycardia pacing or shock, Group II). Three pts died of pump failure and 2 pts of non-cardiac causes. No differences were observed between Group I and Group II pts regarding mean NYHA class, Nt-pro-BNP levels. Group II patients had significantly lower LVEF as well as S100A8/A9 serum levels relative to pts without ventricular arrhythmias (LVEF: 30±1.2 vs, 25±1.3%, p<0.05, S1OOA8/A9: 18.9±2.2 vs 11.8±1.5 ng/ml, p<0.05), while no difference was observed between Groups regarding sRAGE levels 1097±101 1105±239 pg/ml, p:NS). S100A8/A9 levels were not related significantly to LVEF (r:-21, p=0.13).

Conclusion

S100A8/A9 protein levels are reduced in pts with stable HF and an implanted ICD. They are even lower among pts with rapid ventricular tachyarrhythmias occurring during follow-up. This finding implies that S100A8/A9 may constitute a biomarker of increased sudden cardiac death risk in HF, in addition to reduced LVEF.

Prognostic Implication of the Absolute Lymphocyte to Absolute Monocyte Count Ratio in Patients With Classical Hodgkin Lymphoma Treated With Doxorubicin, Bleomycin, Vinblastine, and Dacarbazine or Equivalent Regimens

Low absolute lymphocyte count (ALC) to absolute monocyte count (AMC) ratio (ALC/AMC) is an independent prognostic factor in Hodgkin lymphoma (HL), but different cutoffs (1.1, 1.5, and 2.9) have been applied. We aimed to validate the prognostic significance of ALC/AMC in 537 homogenously treated (doxorubicin, bleomycin, vinblastine, and dacarbazine or equivalents ± radiotherapy) classical HL patients at various cutoffs. The median ALC/AMC was 2.24 (0.44-20.50). The median AMC was 0.653 × 10(9)/L (0.050-2.070). Lower ALC/AMC was associated with established markers of adverse prognosis. In total, 477 (89%), 418 (78%), and 189 (35%) patients had an ALC/AMC ratio of ≥1.1, ≥1.5, and ≥2.9; respectively; 20% had monocytosis (≥0.9 × 10(9)/L). Ten-year time to progression (TTP) was 77% versus 55% for patients with ALC/AMC ≥1.1 and <1.1 (p = .0002), 76% versus 68% for ALC/AMC ≥1.5 and <1.5 (p = .049), 77% versus 73% for ALC/AMC ≥2.9 and <2.9 (p = .35), and 79% versus 70% for ALC/AMC ≥2.24 and <2.24 (p = .08), respectively. In stages ΙΑ/ΙΙΑ and in patients ≥60 years old, ALC/AMC had no significant effect on TTP. In advanced stages, ALC/AMC was significant only at the cutoff of 1.1 (10-year TTP 67% vs. 48%; p = .016). In younger, advanced-stage patients, the differences were more pronounced. In multivariate analysis of TTP, ALC/AMC < 1.1 (p = .007) and stage IV (p < .001) were independent prognostic factors; ALC/AMC was independent of International Prognostic Score in another model. ALC/AMC was more predictive of overall survival than TTP. At the cutoff of 1.1, ALC/AMC had independent prognostic value in multivariate analysis. However, the prognostically inferior group comprised only 11% of patients. Further research is needed prior to the widespread use of this promising marker.

Potential role of AKT/mTOR signalling proteins in hairy cell leukaemia: association with BRAF/ERK activation and clinical outcome

The potential role of AKT/mTOR signalling proteins and its association with the Raf-MEK-ERK pathway was investigated in hairy cell leukaemia (HCL). BRAFV600E expression and activated forms of AKT, mTOR, ERK1/2, p70S6k and 4E-BP1 were immunohistochemically assessed in 77 BM biopsies of HCL patients and correlated with clinicopathological and BM microvascular characteristics, as well as with c-Caspase-3 levels in hairy cells. Additionally, we tested rapamycin treatment response of BONNA-12 wild-type cells or transfected with BRAFV600E. Most HCL cases expressed p-p70S6K and p-4E-BP1 but not p-mTOR, being accompanied by p-ERK1/2 and p-AKT. AKT/mTOR activation was evident in BONNA-12 cells irrespective of the presence of BRAFV600E mutation and was implicated in cell proliferation enhancement. In multivariate analysis p-AKT/p-mTOR/p-4E-BP1 overexpression was an adverse prognostic factor for time to next treatment conferring earlier relapse. When p-AKT, p-mTOR and p-4E-BP1 were examined separately only p-4E-BP1 remained significant. Our findings indicate that in HCL, critical proteins up- and downstream of mTOR are activated. Moreover, the strong associations with Raf-MEK-ERK signalling imply a possible biologic interaction between these pathways. Most importantly, expression of p-4E-BP1 alone or combined with p-AKT and p-mTOR is of prognostic value in patients with HCL.

Head-up tilt test with clomipramine challenge in vasovagal syndrome--a new tilt testing protocol

PURPOSE

The aim of the study was to randomly compare clomipramine, used as a challenge-agent during head-up tilt test, with isoproterenol, used in the conventional test, in patients with vasovagal syndrome.

SUBJECTS AND METHODS

The serotonergic re-uptake inhibitor clomipramine was infused (5mg in 5min) at the start of head-up tilt test (Clom-HUT) in 126 patients (mean age 41+/-16 years) with positive history of recurrent neurocardiogenic syncope, and in 54 healthy control subjects (mean age 46+/-15 years). All subjects had also been tested with a conventional 60 degrees head-up tilt test (Con-HUT) for 30 min and, if negative, isoproterenol infusion was performed at the end of the test. The two tests were performed in a random order with a 24-h interval between them.

RESULTS

Fifty-two of the 126 patients (41%) and two of the 54 controls had a positive response to Con-HUT. In the Clom-HUT the proportion of patients who experienced a positive response increased to 83% (105 subjects), while this happened only to four control subjects. The predictive accuracy of Clom-HUT increased compared to Con-HUT from 58 to 86%, respectively.

CONCLUSION

The results indicate an increased responsiveness of central serotonergic neural system in subjects with vasovagal syndrome, the activation of which leads to sympathetic withdrawal. The use of clomipramine infusion during tilt test seems to improve considerably its diagnostic value.

Provocation of neurocardiogenic syncope by clomipramine administration during the head-up tilt test in vasovagal syndrome

OBJECTIVES

We sought to test the hypothesis that activation of the serotonergic system in patients with vasovagal syndrome during the head-up tilt test provokes syncope.

BACKGROUND

Central serotonergic activation participates in the pathogenesis of neurocardiogenic syncope. Drugs increasing serotonin (5-HT) in the central nervous system have not been tested as drug challenges during the head-up tilt test with clomipramine (Clom-HUT).

METHODS

The serotonergic re-uptake inhibitor clomipramine was infused (5 mg in 5 min) at the start of Clom-HUT in 55 patients (mean age 40 +/- 17 years) with a positive history of recurrent neurocardiogenic syncope and in 22 healthy control subjects (mean age 46 +/- 15 years). Blood samples were taken at 0, 5, 10 and 20 min for estimation of plasma prolactin and cortisol as neuroendocrine indicators of central serotonergic responsivity. All subjects had been previously tested with a basic 60 degrees head-up tilt test (B-HUT) for 30 min, and if negative, isoproterenol infusion was given at the end of the test.

RESULTS

Twenty-nine (53%) of the 55 patients and none of the 22 control subjects had a positive result in the B-HUT. With Clom-HUT, the proportion of patients who experienced a positive response increased to 80% (n = 44), although this happened to only one control subject. Prolactin and cortisol plasma levels increased significantly in the positive Clom-HUT patient group only.

CONCLUSIONS

The results indicate an increased responsivity of the central serotonergic neural system in subjects with vasovagal syndrome, the activation of which leads to sympathetic withdrawal. The use of clomipramine infusion with the tilt test seems to considerably improve its diagnostic value.

Association of heart failure in homozygous beta-thalassemia with the major histocompatibility complex

BACKGROUND

In beta-thalassemia major, heart failure primarily affecting left ventricular systolic function is the most common complication and cause of death. Apart from iron deposition, it has been recently reported that myocarditis might be another contributing factor in the pathogenesis of acute or chronic heart failure, acting possibly through an autoimmune mechanism. In an attempt to assess the role of immunogenetic factors in the development of heart failure associated with beta-thalassemia major, we studied the frequency of major histocompatibility antigens/alleles A, B, DR, and DQ in homozygous beta-thalassemic patients with and without heart failure primarily affecting the left ventricle.

METHODS AND RESULTS

Forty-five consecutive unrelated Greek patients with homozygous beta-thalassemia and left-sided chronic heart failure were studied. Fifty-eight unrelated Greek patients with homozygous beta-thalassemia without heart failure and 130 unrelated Greek healthy controls were also studied. In all subjects, class I HLA-A and -B typing was performed by the complement-mediated lymphocytotoxicity assay, whereas class II HLA-DR and -DQ typing was performed by polymerase chain reaction. HLA-DRB1*1401 allele frequency was significantly increased in patients with beta-thalassemia major without left-sided heart failure compared with those with heart failure (corrected P [P(c)]=0. 02, odds ratio 0.1) and healthy controls (P(c)=0.001). HLA-DQA1*0501 allele frequency was increased in patients with heart failure compared with patients without heart failure (P(c)=0.04, odds ratio 14) and healthy controls (P(c)=0.004).

CONCLUSIONS

Differences exist in the immunogenetic profile between homozygous beta-thalassemic patients with and without left-sided heart failure, raising the possibility that genetically defined immune mechanisms may play an important role in the pathogenesis of heart failure in beta-thalassemia.

Central serotonergic responsiveness in neurocardiogenic syncope: a clomipramine test challenge

BACKGROUND

Central serotonergic mechanisms appear to participate in the pathogenesis of recurrent neurally mediated syncope. The aim of the study was to investigate the responsiveness of the central serotonergic system by measuring the prolactin and cortisol responses to intravenous administration of the serotonin reuptake inhibitor clomipramine.

METHODS AND RESULTS

Twenty subjects free of any medical treatment were tested. Twelve had a history of recurrent syncopal attacks and positive tilt test (patient group, mean age 47+/-18 years, 8 men); 8 subjects without syncope and a negative tilt test result served as control subjects (mean age 49+/-10 years, 5 men). Twenty-five milligrams of clomipramine was administered intravenously within 15 minutes, and blood samples were taken at 0, 15, 30, 45, and 60 minutes. Two days later, a tilt test was performed at 60 degrees for 30 minutes and blood samples were taken at 0, 10, 20, and 30 minutes. During the clomipramine challenge, plasma prolactin levels increased in both groups. The levels at 30 minutes were higher in the patient group compared with the control group (17.3+/-7.2 vs 9.3+/-7.6 ng/mL, P=0.05). Similar results were observed for cortisol at 30 minutes (172+/-15 vs 118+/-21 ng/mL P=0. 04) and at 45 minutes (189+/-20 vs 116+/-23 ng/mL, P=0.03). The tilt test was positive in 8 (67%) out of 12 of the patient group and negative in all control subjects. In the samples taken during the tilt test, significant increases in prolactin and cortisol were observed only in the subjects with positive tilt test results.

CONCLUSIONS

Patients with a history of neurocardiogenic syncope show a higher responsiveness of the central serotonergic system to clomipramine challenge. The results support the view that central serotonergic mechanisms are involved in the pathophysiology of the syndrome.

Apolipoprotein E epsilon4 allele as a genetic risk factor for left ventricular failure in homozygous beta-thalassemia

In homozygous beta-thalassemia, the organ damage is mainly attributed to excessive iron deposition through the formation of oxygen free radicals. Despite appropriate transfusion and chelation therapy and low ferritin levels, patients still develop organ failure, heart failure being the main cause of death. This study was designed to determine whether the decreased antioxidant activity of the apolipoprotein E (APOE) 4 allele could represent a genetic risk factor for the development of left ventricular failure (LVF) in beta-thalassemia homozygotes. A total of 251 Greek beta-thalassemia homozygotes were studied. Patients were divided in three groups: group A (n = 151) with no cardiac impairment, group C (n = 47) with LVF, and 53 patients with LV dilatation and normal LV systolic function constituted the group B. DNA was obtained from all patients, and the polymerase chain reaction was used to analyze the polymorphism at the APOE locus. The APOE allele frequencies were compared with those of a Greek control sample of 216 healthy blood donors. Patients with no cardiac impairment had an APOE 4 allele frequency (7.9%) not different from population controls (6.5%, P > .05), while patients with LVF had a significantly higher frequency of APOE 4 (12.8%) than the controls (P < .05, odds ratio = 2.11, 95% confidence interval 1.03 to 4.32). The APOE 4 allele may represent an important genetic risk factor for the development of organ damage in homozygous beta-thalassemia.

Hormonal responses during tilt-table test in neurally mediated syncope

The hormonal profile during tilt testing was examined in syncopal patients. An increase in the growth hormones cortisol and prolactin was found during syncope, suggesting an implication of central serotonergic activation.