New electromechanical substrate abnormalities in high-risk patients with Brugada syndrome

Background: The relationship between the typical electrocardiographic pattern and electromechanical abnormalities has never been systematically explored in Brugada syndrome (BrS). Objectives: The aims of this study were to characterize the electromechanical substrate in patients with BrS and to evaluate the relationship between electrical and mechanical abnormalities. Methods: We enrolled 50 consecutive high-risk patients with BrS (mean age 42 ± 7.2 years), with implantable cardioverter-defibrillator implantation for primary or secondary prevention of ventricular tachyarrhythmias (ventricular tachycardia/ventricular fibrillation [VT/VF]), undergoing substrate mapping and ablation. Patients underwent 3-dimensional (3D) echocardiography with 3D wall motion/deformation quantification and electroanatomic mapping before and after ajmaline administration (1 mg/kg in 5 minutes); 3D mechanical changes were compared with 50 age- and sex-matched controls. The effect of substrate ablation on electromechanical abnormalities was also assessed. Results: In all patients, ajmaline administration induced Brugada type 1 pattern, with a significant increase in the electrical substrate (P <.001), particularly in patients with previous spontaneous VT/VF (P =.007). Induction of Brugada pattern was associated with lowering of right ventricular (RV) ejection fraction (P <.001) and worsening of 3D RV mechanical function (P <.001), particularly in the anterior free wall of the RV outflow tract, without changes in controls. RV electrical and mechanical abnormalities were highly correlated (r = 0.728, P <.001). By multivariate analysis, only the area of RV dysfunction was an independent predictor of spontaneous VT/VF (odds ratio 1.480; 95% confidence interval 1.159–1.889; P =.002). Substrate ablation abolished both BrS-electrocardiographic pattern and mechanical abnormalities, despite ajmaline rechallenge. Conclusion: BrS is an electromechanical disease affecting the RV. The typical BrS pattern reflects an extensive RV arrhythmic substrate, driving consistent RV mechanical abnormalities. Substrate ablation abolished both Brugada pattern and mechanical abnormalities

Acute myelogenous leukemia in elderly patients not elegible for intensive chemotherapy: the dark side on the moon.

Acute Myelogenous Leukemia (AML) is a common disease in people aged >60 years. About 50% of the patients are not eligible for aggressive chemotherapy (CT) and are only managed with conservative approaches. Results in this subset of patients have not been reported so far. Patients and methods: We retrospectively evaluated 244 consecutive elderly AML patients (M/F 143/101, median age 72 years, range 60–90) diagnosed at our institution from January 1989 to December 1998 and not eligible for intensive CT. Eighty-nine patients (36.5%) had evolved from previous myelodysplasia (sAML). Fifty-three out of 192 (26.4%) patients with available bone marrow (BM) analysis had oligoblastic leukaemia (blasts <40% and WBC <15×109/l). Results: Sixty-seven patients (27.5%) were managed with supportive treatment only. One hundred seventy-seven patients (72.5%), in order to control disease, received conservative CT, consisting of Hydroxyurea (HU) (127 patients, 71.7%), Cytarabine and 6-Thioguanine (39 patients, 22%) or low-dose cytarabine (11 patients, 6.3%). Median overall survival was 179 days (1–3278) with 50 patients (20.5%) surviving >12 months. Older age (>75 years), poor WHO PS (>2), lower PLT levels (5 × 109/l) showed a negative prognostic impact on survival in multivariate analysis. Conclusions: Our data outline the great heterogeneity of elderly AML patients not eligible for intensive CT. A simple scoring system including easily evaluable parameters, which could distinguish subjects with different prognosis, is proposed. Moreover, randomized studies in order to establish best conservative approaches are warranted

QUANTIFICATION OF JAK2WT AND JAK2V617F ALLELE IN mRNA FROM PH(-) MYELOPROLIFERATIVE NEOPLASMS PATIENTS: CORRELATION WITH DNA ALLELE BURDEN AND DESEASE PROGRESSION

INTRODUCTION: Currently, the JAK2V617F allele quantification in Ph- MPN is performed on genomic DNA. However, compared to DNA, mRNA analysis may offer some advantages such as: 1)higher sensitivity; 2) inclusion of platelet mRNA; 3) mRNA transcriptional functionality. Therefore, we developed an absolute allele-specific RQ-PCR method to quantify JAK2WT, V617F and ABL (as housekeeping gene) transcript levels aiming to: 1) verify specificity and sensitivity of this assay; 2)evaluate whether gene expression levels correlate with disease phenotype and may mark disease progression (i.e. ET toward PV). METHODS: To construct reference curves, including five 10-fold serial dilutions, two plasmid standards were manufactured to contain 150 bp of either JAK2WT and JAK2V617F cDNA sequence. To perform an allelic discrimination we used primers described by Merker et al (JMD, 2010): reverse primers are complementary to the WT or the mutant cDNA sequence, respectively. Assay sensitivity was determined by serial 10-fold dilutions of the K562 (JAK2WT) and HEL (V671F homo) cell lines which were included in each experiment as negative and positive controls. RESULTS: We tested cDNA synthesized from peripheral blood buffy coat specimens of 48 MPN patients (16 PV; 25 ET, 7 PMF), 13 patients with secondary polycythemia (SP) and 23 healthy donors (CTRL). Respect to the qualitative PCR method (Baxter el al, Lancet 2005) our RQ-PCR assay shows a 100% concordance rate in identifying the presence of the JAK2V617F. V617F mutation was detected in 16/16 PV (100%), 19/25 ET (76%) and 5/7 (71%) PMF samples. The mean expression of JAK2WT allele, as absolute averaged copies+SEM was: healthy donors 12127+2181; SP 12244+2489; PV 4955+1642, WT ET 10876+1781; V617F ET 5693+830 and V617F PMF 3004+1442. Statistically significant differences were detected between CTRL and PV (p <0.005) and CTRL and V617F ET (p <0.005). The mean expression of V617F allele was PV 27107+12699, ET 6524 +1877 and PMF 29464+14587. A significant difference was found comparing PV and ET (p <0.005) and ET and PMF (p <0.005). Respect to the allele burden quantitative assay (IPSOGEN), the mutational burden (V617F/(V617F+WT) ratio detected by our assay is significantly higher (59% vs 36% burden in RQ-PCR and IPSOGEN, respectively; p <0.005). Three ET patients progressed to PV phase. The sequential analysis of the mutational burden ratio at diagnosis and during disease progression showed an increase in one patient’s sample at both DNA and mRNA level. By contrast, in the remaining 2 cases the ratio remained constant at the DNA level, but significantly increased when the mRNA was analysed. CONCLUSION: Present data demonstrated that our method is as specific but more sensitive than the allele burden determination. In addition, the complementary determination of mRNA transcript levels may help in elucidate the pathogenetic mechanisms of the Ph- MPN diseases