Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

The emerging role of reassessment of genetic testing results in the diagnosis of the unexplained sudden cardiac arrest's causes

Background

The most common cause of Unexplained Sudden Cardiac Arrest (USCA) are hereditary primary arrhythmic syndromes and subclinical forms of cardiomyopathies. Both of them may be difficult to diagnose.

Objective

The aim of this study was to re-examine the role of genetic testing in patients after USCA during follow-up.

Methods

In the years 2014–2017 we studied 44 unrelated patients (pts) (23 men (53%), mean age 36 years) after USCA. All pts underwent cardiac evaluation including ECG, Holter, echo, coronary angiography, stress exercise test and, if necessary cardiac MRI and provocative drug testing. Standard diagnostic criteria were used according to currently available ESC guidelines. We performed next generation sequencing with panel covered coding regions of &gt;4800 genes (26pts), 194 genes (5pts) and whole exome sequencing &gt;2ehab724.3204 genes (5pts). Variants of frequency no greater than 0,001 in existing variants' databases and classified as damaging by at least 3 of applied software algorithms were assessed for pathogenicity according to ACMG standards. The enrolled patients were followed up. During the follow up, the classification of rare variants according to ACMG standards was repeated.

Results

Based on applicable standards and the clinical data collected, clinical diagnosis was made in 17 (39%) probands (Long QT Syndrome 21%, Brugada Syndrome 7%, Short QT Syndrome 7%, Early Repolarization Syndrome and Catecholaminergic Polymorphic Ventricular Tachycardia 2%, both). Genetic tests were performed in 36 pts. We identified 27 rare variants in 22 pts, in genes associated with inherited arrhythmia or cardiomyopathies, of these 23 rare variants were identified in years 2014–2017. The first classification was in 2017, then only 2 variants (in FLNC) were considered pathogenic and the remaining 21 were classified as Variants of Unknown Significance (VUS). During the years 2019–2021, 23 earlier identified rare variants were reclassified according to The American College of Medical Genetics and Genomics (ACMG) standards, of these 5 VUS became pathogenic/likely pathogenic variants. In addition, we performed genetic tests in next 5 pts – we identified 4 rare variants – 3 pathogenic and 1 VUS.

Detection of certain hereditary background of SCA increased from 6,5% in years 2014–2017, to 25% in years 2019–2021.

The median follow-up period was 2366 days (interquartile range 1785–2903 days). 17/44 (39%) pts had adequate discharge of ICD. Two pts were observed with reduction of left ventricular contractility and the development of the initial stages of dilated cardiomyopathy.

Conclusion

This study shows clinical utility of extensive clinical assessment and follow-up of patient after USCA. Routine genetic testing by next generation sequencing in the patients can help in diagnosis and re-evaluation of rare variants should be made during the follow-up.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): grant of National Institute of Cardiology, Warsaw, Poland

P2826Clinical and genetic yield of familiar screening after sudden death of young patients

Background

In Europe, approximately 9000 patients under the age of 45 die suddenly every year. In this group the predominant reasons of sudden death (SD) are channelopathies, cardiomyopathies, myocarditis and substance abuse. The main challenge is the identification of the cause of an unexpected death, especially when the autopsy was not done routinely.

Objective

The aim of the study was to investigate the value of clinical and genetic screening in relatives of subjects who died suddenly under the age of 45.

Methods

In the years 2017–2018 we evaluated 53 relatives (41 1st degree) of 25 young SD subjects. Clinical screening included a review of medical history, clinical examination, ECG, transthoracic echocardiogram, 24- hour EKG Holter monitoring, stress test and, cardiac MRI, provocative drug tests, if necessary. Standard diagnostic criteria were used according to currently available ESC guidelines. The most affected 1st degree relative of the SD victim was named as proband.

DNA samples from 25 probands were examined by next generation sequencing (NGS) using a custom panel which included 174 genes associated with 17 cardiac diseases-TruSight Cardio (TSC) panel. Variants identified with NGS were followed-up in probands and other relatives with Sanger sequencing.

Baseline analysis of NGS results was based on searching for genetic variants with very low frequency (<0.001) with high bioinformatic prediction scores with special regard to phenotypically consistent genes. The frequencies of variants were compared with the GnomAD database, Phase 3 of 1000 Genomes, NHLBI GO Exome Sequencing Project (ESP) 6500. For the bioinformatic prediction scores we used data summarized in VarSome database. The clinical significance of the variants was based on ClinVar database.

Results

Based on comprehensive clinical evaluation of relatives the diagnosis was made in 16/25 (64%) families, namely long QT syndrome (n=7/16; 43,75%), hypertrophic cardiomyopathy (n=5/16; 31,25%), Brugada syndrome (1/16; 6,25%), arrhythmogenic right ventricular cardiomyopathy (n=1/16; 6,25%), thoracic aortic aneurysm (n=1/16; 6,25%) and complete heart block (n=1/16; 6,25%). In 9/25 families (36%) exams showed minor abnormalities, but definite diagnosis could not be made.

We found pathogenic variants in 11/25 (44%) probands. We identified 9 variants in a subgroup of probands with diagnosis (frameshift in MYBPC3 and PKP2, missense variants in KCNQ1, SCN3B, SCN5A,MYH7,TPM1, SCN2B, KCNH2 genes) and 2 variants in a subgroup of probands without diagnosis (frameshift in TTN gene and a missense in KCNH2 gene).

Conclusion

This study shows that clinical and genetic familial screening after sudden death of young patients may be effective, helps in identifying individuals at risk and allows to implement an adequate treatment to prevent subsequent sudden death.

Acknowledgement/Funding

Institute of Cardiology in Anin 2.9/II/17

The Decreased Circulating Platelet Mass and Its Relation to Bleeding Time in Chronic Renal Failure

The mean platelet volume, measured optically and by the electrical impedance method, was analysed in the patients with chronic renal failure. All parameters describing the circulating platelet biomass except the platelet volume heterogeneity were decreased in these patients. There is a strong inverse relation between the Ivy bleeding time and the platelet mass in the patient group.

Our results indicate that the smaller platelets circulating in the patients with chronic renal failure may contribute to the uremic bleeding diathesis, and disturbed thrombocytopoiesis occurs in chronic renal failure.

The clinical significance of changes in ezrin expression in osteosarcoma of children and young adults

Ezrin is a protein that functions as a cross-linker between actin cytoskeleton and plasma membrane. Its clinical role in osteosarcoma is unclear. The aim of this study was to investigate, in osteosarcoma, the prognostic value of ezrin expression at biopsy and changes in expression levels after preoperative chemotherapy. Thirty-eight newly diagnosed osteosarcoma patients aged 6-23 years were included. At diagnosis, 20 patients had localized disease, the others had distant metastases. Median follow-up was 75 months (range 13-135). Ezrin expression was assessed immunohistochemically in biopsy tissue and primary tumour specimens resected after chemotherapy. The influence on survival of changes in ezrin expression after chemotherapy was analysed. Ezrin expression was significantly higher after preoperative chemotherapy and changes compared to biopsy tissue were significantly lower in patients with early progression than in patients with relapse or no further evidence of disease (p = 0.006 and p = 0.002, respectively). Similarly, ezrin expression was higher after preoperative chemotherapy and exhibited less change in expression in deceased patients compared to patients surviving more than 5 years (both p = 0.001). Ezrin expression at biopsy was significantly associated with both histopathological aggressiveness (p < 0.001) and tumour size (p = 0.037). The results of this study provide evidence that changes in overexpression of ezrin due to preoperative chemotherapy could be a useful predictive and prognostic marker in patients with osteosarcoma.

Next-generation sequencing for diagnosis of thoracic aortic aneurysms and dissections: diagnostic yield, novel mutations and genotype phenotype correlations

Background

Thoracic aortic aneurysms and dissections (TAAD) are silent but possibly lethal condition with up to 40 % of cases being hereditary. Genetic background is heterogeneous. Recently next-generation sequencing enabled efficient and cost-effective examination of gene panels. Aim of the study was to define the diagnostic yield of NGS in the 51 TAAD patients and to look for genotype–phenotype correlations within families of the patients with TAAD.

Methods

51 unrelated TAAD patients were examined by either whole exome sequencing or TruSight One sequencing panel. We analyzed rare variants in 10 established thoracic aortic aneurysms-associated genes. Whenever possible, we looked for co-segregation in the families. Kaplan–Meier survival curve was constructed to compare the event-free survival depending on genotype. Aortic events were defined as acute aortic dissection or first planned aortic surgery.

Results and discussion

In 21 TAAD patients we found 22 rare variants, 6 (27.3 %) of these were previously reported, and 16 (73.7 %) were novel. Based on segregation data, functional analysis and software estimations we assumed that three of novel variants were causative, nine likely causative. Remaining four were classified as of unknown significance (2) and likely benign (2). In all, 9 (17.6 %) of 51 probands had a positive result when considering variants classified as causative only and 18 (35.3 %) if likely causative were also included. Genotype-positive probands (n = 18) showed shorter mean event free survival (41 years, CI 35–46) than reference group, i.e. those (n = 29) without any plausible variant identified (51 years, CI 45–57, p = 0.0083). This effect was also found when the ‘genotype-positive’ group was restricted to probands with ‘likely causative’ variants (p = 0.0092) which further supports pathogenicity of these variants. The mean event free survival was particularly low (37 years, CI 27–47) among the probands with defects in the TGF beta signaling (p = 0.0033 vs. the reference group).

Conclusions

This study broadens the spectrum of genetic background of thoracic aneurysms and dissections and supports its potential role as a prognostic factor in the patients with the disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-016-0870-4) contains supplementary material, which is available to authorized users.

Online mindfulness-based intervention for late-stage bipolar disorder: pilot evidence for feasibility and effectiveness

OBJECTIVES

People in the late stage of bipolar disorder (BD) experience elevated relapse rates and poorer quality of life (QoL) compared with those in the early stages. Existing psychological interventions also appear less effective in this group. To address this need, we developed a new online mindfulness-based intervention targeting quality of life (QoL) in late stage BD. Here, we report on an open pilot trial of ORBIT (online, recovery-focused, bipolar individual therapy).

METHODS

Inclusion criteria were: self-reported primary diagnosis of BD, six or more episodes of BD, under the care of a medical practitioner, access to the internet, proficient in English, 18-65 years of age. Primary outcome was change (baseline - post-treatment) on the Brief QoL.BD (Michalak and Murray, 2010). Secondary outcomes were depression, anxiety, and stress measured on the DASS scales (Lovibond and Lovibond, 1993).

RESULTS

Twenty-six people consented to participate (Age M=46.6 years, SD=12.9, and 75% female). Ten participants were lost to follow-up (38.5% attrition). Statistically significant improvement in QoL was found for the completers, t(15)=2.88, 95% CI:.89-5.98, p=.011, (Cohen׳s dz=.72, partial η(2)=.36), and the intent-to-treat sample t(25)=2.65, 95% CI:.47-3.76, (Cohen׳s dz=.52; partial η(2)=.22). A non-significant trend towards improvement was found on the DASS anxiety scale (p=.06) in both completer and intent-to-treat samples, but change on depression and stress did not approach significance.

LIMITATIONS

This was an open trial with no comparison group, so measured improvements may not be due to specific elements of the intervention. Structured diagnostic assessments were not conducted, and interpretation of effectiveness was limited by substantial attrition.

CONCLUSION

Online delivery of mindfulness-based psychological therapy for late stage BD appears feasible and effective, and ORBIT warrants full development. Modifications suggested by the pilot study include increasing the 3 weeks duration of the intervention, adding cautions about the impact of extended meditations, and addition of coaching support/monitoring to optimise engagement.

Anthropometric and physiological characteristics of Melanesian futsal players: a first approach to talent identification in Oceania

This study assessed the anthropometric and physiological characteristics of elite Melanesian futsal players in order to determine the best performance predictors. Physiological parameters of performance were measured in 14 Melanesian (MEL-G, 24.4±4.4 yrs) and 8 Caucasian (NMEL-G, 22.9±4.9) elite futsal players, using tests of jump-and-reach (CMJ), agility (T-Test), repeated sprint ability (RSA), RSA with change-of-direction (RSA-COD), sprints with 5 m, 10 m, 15 m, and 30 m lap times, and aerobic fitness with the 30-15 intermittent fitness test (30-15 IFT). The anthropometric data revealed significantly lower height for MEL-G compared with NMEL-G: 1.73±0.05 and 1.80±0.08 m, respectively; P = 0.05. The CMJ was significantly higher for MEL-G than NMEL-G: 50.4±5.9 and 45.2±4.3 cm, respectively; P = 0.05. T-Test times were significantly lower for MEL-G than NMEL-G: 10.47±0.58 and 11.01±0.64 seconds, respectively; P = 0.05. MEL-G height was significantly related to CMJ (r = 0.706, P = 0.01), CMJ_peakP (r = 0.709, P = 0.01) and T-Test (r = 0.589, P = 0.02). No significant between-group differences were observed for sprint tests or 30-15 IFT, including heart rate and estimated VO_2max. Between groups, the percentage decrement (%Dec) in RSA-COD was significantly lower in MEL-G than NMEL-G (P = 0.05), although no significant difference was noted between RSA and RSA-COD. Within groups, no significant difference was observed between %Dec in RSA or RSA-COD; P = 0.697. This study presents specific anthropometric (significantly lower height) and physiological (significantly greater agility) reference values in Melanesians, which, taken together, might help coaches and physical fitness trainers to optimize elite futsal training and talent identification in Oceania.

Effect of aerobic exercise on insulin, insulin-like growth factor-1 and insulin-like growth factor binding protein-3 in overweight and obese postmenopausal women

AIM

The purpose of presented study was to verify the influence of aerobic physical activity program on the serum insulin, insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-3 (IGFBP-3) concentrations in overweight and obese postmenopausal women.

METHODS

Somatic parameters and serum concentrations of insulin, IGF-1 and IGFBP-3 were measured in 21 overweight and obese women, before and after 8-week cycloergometer physical workout and 16 age-matched, controls. Age of all studied women ranged from 54 to 78 years.

RESULTS

The comparative analysis of biochemical indices measured before and after the training program showed that the systematic exercise cause the significant decrease in insulin (P<0.05) and IGF-1 concentrations (P<0.05). There were no differences in these parameters in controls over the studied period. The level of IGFBP-3 was not significantly changed in both investigated groups. In women participating in the training program the positive correlation (P<0.05) between changes in IGF-1 levels (Δ) and changes in insulin concentrations (Δ) within two terms of the study were found. The magnitude of changes (Δ) in insulin and IGF-1 levels over the study period correlated with their concentrations measured before the training program (P<0.01).

CONCLUSION

Results of the present study indicate that regular aerobic physical activity decreases serum insulin and IGF-1 levels in postmenopausal women. The magnitude of insulin and IGF-1 concentration changes depend on their initial levels. Changes of IGF-1 levels are associated with insulin concentration modifications.

Ischemic epigenetics and the transplanted kidney

The primary purpose of this investigation was to study oxidative demethylation of DNA following ischemia/reperfusion injury (I/RI) that putatively influences posttransplant gene expression in transplanted kidneys. Our hypothesis was that as a result of I/RI, oxidative damage, which is inherent in solid organ transplantation, may lead to aberrant demethylation of cytosine-guanine (CpG) sites within gene promoter regions of DNA. The methylated CpG sites normally contribute to the binding of proteins that render DNA inaccessible to transcription factors. Therefore, conversion of methylated cytosines to nonmethylated cytosines by oxidative damage in postischemic organs might facilitate enhanced gene expression in donor organs by exposing the demethylated CpG site in a gene promoter to DNA-binding proteins that enhance gene transcription. In this study, we investigated the demethylation of a specific CpG within the IFNgamma response element resident in the promoter region of the C3 gene in the rat kidney. In response to 24 hours of cold ischemia and a subsequent 2 hours of reperfusion in an isolated ex-vivo circuit, we observed a significant change in the ratio of methylated to unmethylated cytosines at this site. Epigenetic modifications to donor DNA have not been previously investigated, but our own data suggests that they have the potential to modify gene expression posttransplantation. Since epigenetic modification may become stable and heritable upon mitosis, such changes to the donor organ DNA may persist with enormous implications for transplant outcomes.

Generation of transgenic rabbits by the novel technique of chimeric somatic cell cloning

A novel technique of chimeric somatic cell cloning was applied to produce a transgenic rabbit (NT20). Karyoplasts of transgenic adult skin fibroblasts with Tg(Wap-GH1) gene construct as a marker were microsurgically transferred into one, previously enucleated, blastomere of 2-cell non-transgenic embryos, while the second one remained intact. The reconstructed embryos either were cultured in vitro up to the blastocyst stage (Experiment I) or were transferred into recipient-females immediately after the cloning procedure (Experiment II). In Experiment I, 25/102 (24.5%) embryos formed blastocysts from whole embryos and 46/102 (44.12%) embryos developed to the blastocyst stage from single non-operated blastomeres, while the reconstructed blastomeres were damaged and degenerated. Thirteen (12.7%) embryos did not exceed 3- to 4-cell stages and 18 (17.7%) embryos were inhibited at the initial 2-cell stage. Out of 14 blastocysts which were subjected to molecular analysis, the transgene was detected in the cells of 4 blastocysts. In Experiment II, 163/217 (75.0%) embryos were transferred into 9 pseudopregnant recipient-rabbits (an average of 18 embryos per recipient). Four recipient-females (44.4%) became pregnant and delivered a total of 24 (14.7%) pups. Molecular analysis confirmed that two pups (1.2%), one live and one stillborn, showed a positive transgene signal. Live transgenic rabbit NT20 appeared healthy and anatomically as well as physiologically normal. The results of our experiments showed that transgenic adult skin fibroblast cell nuclei, which have been introduced into the cytoplasmic microenvironment of single enucleated blastomeres from 2-cell stage rabbit embryos, are able to direct the development of chimeric embryos not only to the blastocyst stage but also up to term.

Stroke volume and systolic time intervals: beat-to-beat comparison between echocardiography and ambulatory impedance cardiography in supine and tilted positions

The aim of the study was to compare stroke volume (SV), ejection time (ET) and pre-ejection period (PEP) measurements obtained using a central haemodynamics ambulatory monitoring device based on impedance cardiography (ICG), in supine and tilted positions (60 degrees), with pulsed Doppler echocardiography as a non-invasive reference method. The Holter-type ICG device was used for off-line, beat-to-beat, automatic determination of SV, ET and PEP. ICG data were compared with those obtained simultaneously using pulsed Doppler echocardiography in the ascending aorta from a suprasternal projection, 1 min before and 10 min after tilting. The tests were performed in 13 young, healthy subjects (six men and seven women, aged 23-33 years). Linear regression between the measured values obtained for all subjects was described by the following formulas: SVicg= 13.9 + 0.813 x SVecho (r = 0.857, SEE = 9.03, n = 496), ETicg = 16.8 + 0.987 x ETecho (r = 0.841, SEE=21.3, n = 496), PEPicg= 22.8 + 0.890 x PEPecho (r = 0.727, SEE = 14.6, n = 496). The data showed that ambulatory impedance cardiography gives useful absolute values of SV and systolic time intervals measured in supine and tilted positions.

FISH mapping of two putative keratin gene clusters on cat (Felis catus) chromosomes

Genes encoding keratins are evolutionary highly conserved and clustered in two linkage groups in mammalian genomes. Canine keratin 9 (K-9) and keratin 2e (K-2) cosmid-derived gene probes were used to localize the acidic and basic-neutral keratin gene clusters to cat chromosomes E1q12 and B4q15, respectively. The status of the physical map of the cat genome is discussed.

[Neuroblastoma: epidemiology, pathomorphological and molecular diagnosis, prognosis]

Neuroblastoma is the third most common neoplasm of childhood. About 70% of cases occurs by 5 years old and around 95% cases in the patients younger than 10 years old. Neuroblastoma is part of the spectrum of the family neuroblastic tumors. The family consists of heterogeneous group of tumors, difficult to classify. Additionally some cases of neuroblastoma show tendency to self-maturation and regression. The family consists of neuroblastoma (NB), ganglio-neuroblastoma (GNB) and ganglineuroma (GN). In recent years there has been considerable development in the classification concepts from purely histological to clinico-pathological one. These schemes include clinical, pathological and molecular features od tumors which allow more accurate prognostication.

[Clinical characteristics of osteosarcomas and cell aneuploidy in children and adolescents -- retrospective studies]

The relationship between the clinical status skeletal involvement, frequency of metastases and histopathological grading of osteosarcomas 18 children and adolescents and abnormal DNA content (aneuploidy) was analysed. Our findings demonstrate a correlation between Index DNA (DI), percentage of aneuploidy population to histopathological grading and prognosis. No significant correlation was found between aneuploidy and the site of skeletal involvement.

[Flow cytometry estimate of s phase cell cycle and prognosis of osteosarcoma in children and adolescents]

Flow cytometry analysis has been used to measure the S phase in paraffin embedded osteosarcoma tissues of 22 children and adolescents who were surgically treated. The aim of this study was the assessment of S phase cell cycle in relation to survival, localization of tumour and histopathological grading. Our findings demonstrate the usefulness of flow cytometry determination of S phase cell cycle as a prognostic factor. Higher percentage of S phase cells predict worse prognosis.

[Aneuploidy and histopathological classification, according to the Musculoskeletal Tumour Society and WHO, of osteosarcoma in children and adolescents]

A flow cytometry analysis in children and adolescents with osteosarcoma was carried out. Investigation concerned 32 fresh surgical specimens (from patients after preoperative chemotherapy) and 18 paraffin-embedded tumour tissues (archive material). The correlation of aneuploidy population parameters to malignancy grading acc. to WHO (GI-GIII) and MSC histopathological classification, was investigated. It was shown that all specimens with aneuploid populations correlated with the histophatological diagnosis of osteosarcoma. Thus cytometry analysis can be a useful and rapid complementary method to conventional histophtatological diagnosis. On the contrary, no correlation was found between the aneuploid parameters and the low grade and high-grade osteosarcoma acc. to WHO and MSC classification. The Multicycle computer system is useful in retrospective analysis of paraffin-embedded tumour tissues. It is suggested that for this kind of investigation fresh diagnostic specimens (before preoperative chemotherapy) would be more adequate.

[Difficulties in the histopathological evaluation of osteogenic sarcoma]

The performed analysis concerned the results of the histopathological examination of 169 cases of osteogenic sarcomas with reference to diagnostic difficulties. It was found that the most difficult cases belong to the extreme groups of the classification i.e. were high or very low differentiated osteogenic sarcomas. The most difficult diagnostically cases according to the structural classification concern analogically the extreme group of cases of the non-conventional histology. However, the dominant number of the diagnosed cases did not belong to the extreme groups of classification.

[Value of comparing flow cytometry examination and histopathology in prognosing of osteogenic sarcoma - preliminary report]

Our preliminary report presents two cases of osteogenic sarcoma examined after initial chemotherapy. In both cases histological maps with morphological effects of chemotherapy and flow cytometry of DNA content in tumour cells were made. Results of flow cytometric DNA histograms were linked with an estimation of the proliferative potential of tumours. The correlations between histological grade, proliferative potential of tumours with the morphological effects of chemotherapy were confirmed in the presented cases. Flow cytometry results were ready in a few hours after surgery, when full histopathological analysis was available in 2-4 weeks. Analysis of the two methods of estimation of osteogenic sarcoma suggests that flow cytometry may be a complementary method to histological examination and estimation of proliferating rate, especially aneuploid cell population and this information can be helpful in clinical management.

[Local recurrences after salvage operations in the therapy of osteogenic sarcoma cases - an analysis of adverse effects based on studied cases]

Therapeutic approach in osteogenic sarcoma until 1982 was connected mainly with surgery. Introduction of chemotherapy to the therapeutic protocols of osteogenic sarcoma improved the 5 years survival of patients with osteogenic sarcoma from 20% to 60-70%. The approach to surgical treatment was also changed. The principle of this treatment is usually to perform an operation to spare the limb with an intraoperative frozen section examination of bone marrow. In our Institute during the last 14 years about 300 cases were diagnosed, out of which about 200 were treated surgically, among these about 50% underwent treatment by salvage operations. Only in 7 cases local recurrences of disease were confirmed. Five of these cases were tumours of distal metaphysis of the femur, one case of proximal metaphysis of the tibia and one case of proximal metaphysis of the humeral bone. The sex range M/F was: 5/2, the average age of onset about 14 years. Various factors playing a role in therapeutic adversities were analysed. Among these were: radical surgery, grade of differentiation of the tumour, histological subtype, soft tissue infiltration, reaction to preoperative therapy and the type of chemotherapy. The conducted analysis indicates the role played by sparing surgery in adversities in therapy (3 cases). Attention was also given to the distinct tendency of osteogenic sarcoma to produce vascular embolism which is a source of haematogenously spreading metastases. In 7 cases vascular tumour embolism caused the appaerance of metastatic focuses adjacent to the primary tumour. A certain role in therapeutic adverities is played by the lack of response to preoperative chemotherapy (4/7 cases). The influence of other factors needs further investigation.

[Correlation of the histological subtype of osteogenic sarcoma with the percentage of necrosis after initial chemotherapy]

The material comprises 195 cases of osteogenic sarcoma in children and adolescents. The tumours were grouped in accordance with two classifications; gradual classification which incorporates three levels of morphological maturation of sarcoma and structural classification which distinguishes conventional and nonconventional types of sarcoma. In every case histological mapping of the tumour was performed with the aim to establish the percentage of necrosis and postnecrotic resorbtion of the tumorous mass after the initial chemotherapy. The purpose of this study was to establish the correlation of the tumour necrosis with both histopathological classifications. The main conclusion was, that the gradual classification is more accurate for the changes occurring in the tumour tissue after chemotherapy.

[Comparative study of histopathological patterns of primary tumour and pulmonary metastases of malignant tumours in children and adolescents after complex therapy]

The histopathological features of the primary site and 102 pulmonal metastases were compared in the material from 40 malignancies in children and adolescents. All patients were treated by chemotherapy. Among the malignancies 30 were osteogenic sarcomas. A great histological variability in the multiple metastases removed at one surgical procedure and also in the metastases removed in the subsequent surgeries, were found. Summing up, the whole investigation; in 61.8% of metastatic focusses no difference was found in the histopathological patterns seen at the primary site and pulmonary metastases, in 17.6% total regression was observed, in 13.8% dedifferentiation and in 6.8% maturation of the tumours tissue were observed.

[Histopathologic differentiation of tumors derived from neuroblastic cells in children depending on age]

The histopathology of 224 tumours of neuroblastic origin was analysed in relation to the age of patients. Maturing neuroblastomas (NBS) dominated in infants, where as in the most numerous group of children 1-5 years of age, prevalence of neuroblastomas without any signs of maturation was noted. In children over 5 years of age a high incidence of tumours with evident maturation was noted (ganglioneuroblastomas and ganglioneuromas). The prevalence of maturing neuroblastomas in infants correlate well with an advantageous clinical course of neuroblastomas at this age.

Increased frequency of organ-specific cardiac antibodies in healthy relatives of patients with dilated cardiomyopathy: evidence for autoimmunity in Polish families

BACKGROUND AND HYPOTHESIS

Autoantibodies represent markers of autoimmune involvement and are found with increased frequency in patients and their symptom-free relatives at risk compared with normal controls. Cardiac-specific autoantibodies, detected by immunofluorescence, were found in 20% of symptom-free relative of patients with dilated cardiomyopathy (DCM) from England and Italy. The role of autoimmunity may vary in DCM patients from Poland due to ethnic differences in genetic susceptibility to autoimmune disease.

METHODS

We assessed the frequency of the organ-specific cardiac autoantibodies in 162 symptom-free relatives of DCM patients [85 male, mean (SD) age 27 (18) years] and 80 control subjects from Poland. Familial DCM (> 1 affected member) was present in 4 families, nonfamilial DCM in the remaining 24 pedigrees. We performed antibody screening and noninvasive cardiological assessment in the whole group.

RESULTS

The frequency of cardiac-specific autoantibodies was higher among patients with documented DCM (probands and relatives) (50%) and their symptom-free relatives (38%) than in unrelated normal subjects (10%; p = 0.0001). In 24 (86%) of the pedigrees studied, autoantibodies were found in the proband and/or in at least one family member and tended to be more common in familial than in nonfamilial DCM (50 vs. 35%, p = NS). Echocardiographic indices of left ventricular size and function were similar in relatives with and without detectable antibodies.

CONCLUSIONS

The presence of cardiac-specific autoantibodies in symptom-free relatives of DCM patients provides evidence for autoimmunity in the majority (86%) of our pedigrees, including both familial and nonfamilial forms of DCM.

Determinants of prognosis in nonischemic dilated cardiomyopathy

BACKGROUND

Dilated cardiomyopathy, a heart muscle disease of unknown cause, is characterized by high mortality and is a major cause of cardiac transplantation. It has become, therefore, increasingly important to identify patients at higher risk. The aim of this study was to assess which of the data obtained at the time of diagnosis are the best predictors of survival.

METHODS AND RESULTS

One hundred forty-four patients with dilated cardiomyopathy (118 men; mean age, 39 years) were assessed clinically, noninvasively, and hemodynamically. The effect of variables derived from the evaluation on outcome (death or heart transplantation) was examined. During a mean follow-up time of 4.1 years, 68 patients (47%) died and 9 (6%) underwent heart transplantation. The 1-, 2-, and 5-year transplant-free survival rate was 79, 69, and 44%, respectively. Cox multivariate regression analysis identified three variables as independent predictors of outcome: (1) pulmonary artery systolic pressure, P = .0001; (2) left ventricular ejection fraction, P = .0013; and (3) left ventricular end-diastolic dimension, P = .007. The prognostic index was constructed from regression coefficients and parameters significant in the Cox model. The minimal prognostic index in the study group was 1.4 and the maximal was 6.0 with a corresponding 1-year survival of 98 and 18%, respectively. The validity of the prognostic index was tested in the consecutive group of 81 patients, who were followed for a mean 2.3 years. The prognostic index of the poor outcome group differed significantly from that in survivors (3.7 vs 2.9, respectively, P < .01). The sensitivity and specificity of model predictions were 68 and 52%, respectively.

CONCLUSIONS

The severity of pulmonary hypertension and left ventricular dysfunction provides an independent insight into the prognosis of patients with dilated cardiomyopathy. The prognostic index is useful when assessing prognosis and may be helpful in the timing of heart transplantation.

Left ventricular enlargement is common in relatives of patients with dilated cardiomyopathy

Idiopathic dilated cardiomyopathy is characterized by dilation and impaired contractility of one or both ventricles. Long-term prognosis is poor. Early diagnosis has the potential for substantial reduction of morbidity and mortality. Recent studies, based on echocardiographic assessment of relatives of the patients have shown that familial dilated cardiomyopathy is relatively common. The authors studied 215 relatives (mean age, 27 years; 111 male) of 38 index patients with idiopathic dilated cardiomyopathy by clinical examination, electrocardiography, and two-dimensional, M-mode and Doppler echocardiography. Seven relatives (3%) from six families were shown to have dilated cardiomyopathy. Thus, 6 of the 38 index patients (16%) had familial disease. Furthermore, left ventricular enlargement either during diastole or systole was found in 66 of 174 healthy relatives (38%). This is significantly more frequent than in our normal control population of 100 unrelated subjects studied in the same way (18%; P < .0001). These 66 relatives with left ventricular enlargement belonged to 27 of the 38 examined families (71%). Dilated cardiomyopathy was found to be familial in 16% of patients. Of the relatives examined, 41% had left ventricular abnormalities. These findings provide further evidence for a genetic background of dilated cardiomyopathy. Relatives with left ventricular enlargement may have an early stage and/or latent form of the disease.

Organ-specific cardiac autoantibodies in dilated cardiomyopathy. Frequency and clinical correlates in Polish patients

Organ- and disease-specific cardiac autoantibodies are found in a third of dilated cardiomyopathy patients from the U.K. and Italy and represent markers of autoimmune involvement. The role of autoimmunity may vary in dilated cardiomyopathy patients from different countries due to differences in genetic susceptibility to autoimmune diseases. The aim of this study was to assess the frequency of organ-specific cardiac autoantibodies detected by immunofluorescence in a consecutive series of patients with dilated cardiomyopathy and in disease and normal control subjects from Poland. The study groups included 79 patients with idiopathic (WHO criteria) dilated cardiomyopathy, 55 patients with other cardiac disease and 60 normal subjects. Cardiac antibody tests were performed by indirect immunofluorescence on human heart; skeletal muscle was used to identify cross-reacting antibodies. The frequency of organ-specific cardiac autoantibodies was higher in patients with dilated cardiomyopathy (21/79, 27%) than in controls with other cardiac disease (1/55, 2% P < 0.001) or in normal subjects (7/60, 12% P < 0.02). Conversely, cross-reactive antibodies were detected in similar proportions in patients with dilated cardiomyopathy (5/79, 6%), disease controls (7/55, 13%) and normal subjects (6/60, 10%, P = ns). The organ-specific antibody was more common in patients with dilated cardiomyopathy with insidious onset of disease (17/34, 50%) compared to those who did not exhibit this feature (4/45, 9%, P < 0.0001). Organ- and disease-specific cardiac autoantibodies were found in 27% of Polish patients with dilated cardiomyopathy at diagnosis; this is evidence for autoimmune involvement in a subset of patients from our country, as seen in a previously reported series of Western European origin. The association of antibody status with insidious onset of symptoms is in keeping with the long latency period observed in other autoimmune disorders.

The standard electrocardiogram as a screening test for hypertrophic cardiomyopathy

Phenotypic heterogeneity in hypertrophic cardiomyopathy (HC) makes definitive diagnosis difficult, particularly during family screening. We studied the electrocardiogram (ECG) as a potential initial screening test in patients with HC. Using accepted diagnostic criteria, we examined the ECGs and echocardiograms of 159 patients with a confirmed clinical or genetic diagnosis of HC. An abnormal ECG was found in 154 patients (97%) while only 146 (92%) showed an abnormal echocardiogram. Of the former, 9 patients (6%) had normal echocardiograms and had been diagnosed on the basis of identification of a mutation in the beta myosin heavy chain gene (n = 8) or obligate carrier status (n = 1). Only 1 of these 9 patients was under age 20, the time at which hypertrophy is normally expressed on the echocardiogram. The remaining 5 patients (3%) without ECG abnormality consisted of 1 patient with an echocardiogram clearly diagnostic of HC and 4 clinically normal patients (aged 13, 24, 29, and 33 years) with normal echocardiograms who had been diagnosed by mutation identification (n = 3) or obligate carrier status (n = 1). Thus only these latter 4 patients (3%) would not have been diagnosed as having HC based on an abnormal ECG and/or abnormal echocardiogram. Screening relatives for HC by ECG criteria alone detects all those whom an echocardiogram will diagnose. While echocardiography aids in the specificity of HC diagnosis, the ECG, within the context of a family with a proven case of HC, is a more sensitive marker of the disease. It is therefore both a cost-effective and useful tool for screening those to proceed to echocardiography.

Concentration of RGDS-containing degradation products in uremic plasma is correlated with progression in renal failure

A concentration of protein degradation products containing the RGDS sequence, which could contribute to a lower reactivity of uremic platelets, has been estimated in both uremic (n = 16) and control (n = 7) plasmas. Degradation products and other small molecules were separated from plasma by filtration through AMICON YM-10 filter. RGDS antigen was determined in filtered material using the radioimmunoassay method based on monospecific anti-RGDS rabbit polyclonal antibodies. The concentration of RGDS-containing degradation products in uremic plasma ranged from 0.8 to 353 nM with mean value 58.6 +/- 24.9 nM and was higher than in control (0.7 to 5.9 nM, mean value 2.1 +/- 0.9 nM). Moreover, the level of RGDS-antigen positively correlated with plasma creatinine concentration (R = 0.87, p < 0.001). The filtered material showed an inhibitory effect on fibrinogen binding to control platelets in respect to RGDS-antigen concentration. We conclude that the elevated concentration of RGDS-containing degradation products in uremic plasma is partially responsible for bleeding tendency in renal failure.

The electrocardiogram is a more sensitive indicator than echocardiography of hypertrophic cardiomyopathy in families with a mutation in the MYH7 gene

BACKGROUND

Mutations in the cardiac beta myosin heavy chain gene causing hypertrophic cardiomyopathy have been identified, and to assist both diagnosis and prediction of outcome attempts have been made to correlate phenotype and genotype. Two new mutations in codon 403 of the gene in three unrelated families are described and attention drawn to variable or even absent phenotypic expression in different family members.

METHODS AND RESULTS

The polymerase chain reaction and heteroduplex analysis on Mutation Detection Enhancement gels were used to search for mutations in the globular head of the beta myosin heavy chain gene in families with hypertrophic cardiomyopathy. Two mutations were found in exon 13 (codon 403) of the gene. In two unrelated Polish families the mutation resulted in the conversion of arginine to tryptophan (CGG: >TGG). A second mutation, found in a British family, converted the same arginine to leucine (CGG: >CTG). These mutations were detected in family members who had electrocardiographic and echocardiographic features typical of hypertrophic cardiomyopathy; however, they were also detected in 7 other adult relatives with an abnormal electrocardiogram but a normal echocardiogram. Two unrelated adult relatives had completely normal clinical findings but carried the gene mutation.

CONCLUSIONS

Identification of a specific mutation gives no guide to the clinical phenotype. There is considerable variability in the phenotypic expression of hypertrophic cardiomyopathy. Mutations were detected in adults previously regarded as normal or in whom the diagnosis was questionable. The fact that the clinical significance of the mutation in these people is still unknown emphasises the dilemma facing screening programmes. Isolated, unexplained electrocardiographic abnormalities in first degree relatives in a family with a definitive diagnosis of hypertrophic cardiomyopathy should be regarded as evidence of a carrier state.

Dilated cardiomyopathy in children: clinical course and prognosis

The clinical profile of 19 patients with dilated cardiomyopathy ages 2-18 years (mean 13.4 +/- 4 years) was reviewed to detect any factors that might be predictive for their survival. Follow-up range from 5 to 105 months (mean 39 +/- 33 months). Routine treatment consisted of digitalis and diuretics: 14 patients received antiarrhythmics, 6 received vasodilators, and 12 were managed with immunosuppression. There were 12 survivors and 7 nonsurvivors: The 1-year mortality was 21.2% and the 2-year mortality 35.8%. All deaths were within first 2 years. Of the 12 patients who survived 2 years, a significant improvement was noticed in 9. In 3 patients tachycardia-induced cardiomyopathy was diagnosed, and abolition of supraventricular tachycardia was followed by improvement and regression of cardiomegaly. Endomyocardial biopsy was performed in 16 patients. Four with a histologic diagnosis of active myocarditis survived, and in 3 of them a considerable improvement was noticed. Of the 12 patients with nonspecific histologic findings, 6 died (p < 0.05). There were no significant differences between survivors and nonsurvivors for any of the following parameters: incidence of severe heart failure (NYHA class III-IV) and severe ventricular arrhythmias (Lown class III-V), relative heart volume, echocardiographic left ventricular diastolic diameter and shortening fraction, and the hemodynamic parameters of cardiac index, left ventricular ejection fraction, left ventricular end-diastolic pressure, and left ventricular end-diastolic volume index.

Expression of fibrinogen receptors on platelets of uremic patients is correlated with the content of GPIIb and plasma level of creatinine

Platelets of uremic patients, activated with ADP, exposed less fibrinogen receptors than control platelets, i.e. 24612 +/- 5541 and 33400 +/- 4302 receptors per platelet, respectively. However, this difference was not statistically significant. When compared with the total number of GPIIb/IIIa complexes, quantified from platelet glycoprotein IIb (GPIIb) contents, active receptors on the platelet surface represented 13.6% and 35.1% of total pool of fibrinogen receptors in uremic and control platelets, respectively. The number of exposed fibrinogen receptors was positively correlated with the amount of GPIIb copies in both uremic and normal platelets. In uremic platelets, both the number of exposed receptors and the number of GPIIb copies were correlated with the plasma creatinine concentration suggesting, that binding of fibrinogen to uremic platelets depends upon the degree of renal failure. Uremic platelets contain similar amounts of fibrinogen as control ones i.e. 13.2 +/- 2.3 micrograms and 17.6 +/- 2.2 micrograms per 1 x 10(8) platelets, respectively. Whereas for beta-thromboglobulin (beta-TG) there was a significant difference of 392 +/- 102 ng and 803 +/- 202 ng per 1 x 10(8) platelets, respectively. Reduced beta-TG content in uremic platelets suggests limited platelet activation in vivo. These results support the concept that uremic platelets have impaired functions and indicate that there is a relationship between the progression in renal failure and disability of platelets in thrombosis.

[Familial dilated cardiomyopathy with autosomal mode of inheritance. Case report]

Familial occurrence of dilated cardiomyopathy is estimated by 2-20%. We present a family with dilated cardiomyopathy inherited in an autosomal dominant way. We examined 9 members of the family, most of them are asymptomatic.

[Left ventricular hypertrophy and blood pressure values during 24-hour ambulatory monitoring and office measurements in essential hypertension]

119 hypertensive patients were examined by 24-hour ambulatory blood pressure monitoring (ABPM) and traditional (casual) blood pressure measurements. The echocardiographic examination was also performed. Mean and maximal systolic and diastolic blood pressure values, systolic and diastolic pressure amplitude as well as traditional blood pressure values were correlated with left ventricular walls thickness and left ventricular mass. Maximal values were obtained for left ventricular mass and mean systolic blood pressure (especially in the evening). No statistically significant correlation was stated for left ventricular mass and systolic pressure amplitude. The correlation coefficients of left ventricular mass and wall thickness with ABPM were significantly higher than those calculated from echocardiographic parameters and traditional blood pressure measurements.