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Objective To estimate the prevalence of nonalcoholic fatty liver disease (NAFLD) and its impact on bleeding and thrombotic events in patients with atrial fibrillation (AF). Patients and Methods Prospective multicenter cohort study including patients with nonvalvular AF receiving vitamin K antagonists (VKAs) or non-VKA oral anticoagulants (NOACs) from February 2008 for patients on VKA and from September 2013 for patients on NOACs. NAFLD was diagnosed using the validated fatty liver index, with a cutoff score of 60 or higher. Primary end points were the occurrence of major bleedings and cardiovascular events (CVEs). Results NAFLD was diagnosed in 732 of 1735 (42.2%) patients. Patients with NAFLD were younger, less frequently women, and more likely to be treated with NOACs and to have obesity, dyslipidemia, and persistent/permanent AF. During a median follow-up of 18.7 months (3155 patient-years), we recorded 78 major bleedings (incidence rate, 2.5% per year): 29 (2.1% per year) in patients with and 49 (2.7% per year) in patients without NAFLD (log-rank test P=.23). Univariate Cox proportional regression analysis showed no association of NAFLD with major bleedings (hazard ratio, 0.75; 95% CI, 0.47-1.20; P=.23). One hundred fifty-five CVEs occurred (incidence rate, 3.1% per year). No significant association was found between NAFLD and CVEs (log-rank test P=.12). In the entire population, NOAC use was associated with lower CVEs compared with VKAs (hazard ratio, 0.61; 95% CI, 0.42-0.89; P=.01). Conclusion NAFLD is highly prevalent in AF but is not associated with higher bleeding or thrombotic risk.

Background: Soluble proprotein convertase subtilisin/kexin type 9 (PCSK9) has been shown to be predictive of cardiovascular events (CVEs) in patients who are at high cardiovascular risk. No...

Background and aims Lipopolysaccharides (LPS) is emerging as a novel risk factor for cardiovascular events (CVEs). Furthermore, in vitro evidence suggested that LPS may elicit proprotein convertase subtilisin/kexin 9 (PCSK9) expression, but their relationship in vivo has not been investigated. Methods We conducted a post-hoc analysis of a prospective, single centre cohort study of 907 patients with non-valvular atrial fibrillation (AF). At baseline, PCSK9, LPS and NADPH oxidase (sNox2-dp) were measured. PCSK9 and LPS were correlated with the incidence of CVEs. Results Median PCSK9 and LPS were 1200 [900–1970] and 49.9 [15.0–108.2] pg/ml, respectively. LPS and PCSK9 were significantly correlated (rS 0.378, p Patients with concomitant high PCSK9 and LPS (LPS ≥88 pg/ml and PCSK9 ≥1570 pg/ml) had an increased risk of CVEs compared to those with low levels (LPS Conclusions This study demonstrated, for the first time in vivo, that circulating levels of PCSK9 and LPS are associated with a mechanism possibly involving NADPH oxidase activation. Patients with concomitant increase of PCSK9 and LPS showed a higher risk of CVEs.

Matrix metalloproteinases (MMPs) are proteolytic enzymes involved in the process of tumor invasion and metastasis that are found throughout tissues and also in the plasma. The aim of this study was to investigate whether the evaluation of plasma concentrations of MMPs 2, 3 and 9 may have clinical significance in breast cancer. Therefore, sera obtained from 80 patients with breast neoplasia (50 carcinomas and 30 fibroadenomas) were collected before and 96 h after surgery and the concentrations of MMPs 2, 3 and 9 were quantified using an enzyme-linked immunosorbent assay (ELISA). The mean expression level of MMP 2 was significantly higher in carcinoma compared with that in fibroadenoma patients, while there was no significant difference for MMPs 3 and 9. In addition, the group of carcinoma patients was analyzed in order to compare the mean values for each MMP obtained before and after surgery. However, the differences between pre- and post-surgery values for all three MMPs were not statistically significant. Furthermore, the plasma levels of each MMP were correlated with certain clinicopathological parameters of the tumors and we observed a significant and direct correlation between the concentrations of MMPs 2 and 9 and tumor histological grade. These data suggest that the quantification of plasma MMP 2 and MMP 9 levels may provide additional clinical information of the tumor and it is, therefore, a possible prognostic index for breast cancer.

Purpose: To identify potential prognostic molecular factors in ampullary adenocarcinoma that could be of significant importance. To this end, we examined the possible prognostic significance of cyclooxygenase-2 (Cox-2) and Survivin expression and the apoptotic index in a cohort of uniformly treated patients with ampullary cancer treated with radical surgical excision. Experimental Design: The entry criteria were that the patients have a pathologic diagnosis of ampullary cancer which had been resected. Expression analysis for Cox-2 and Survivin was done by immunohistochemical staining. Apoptotic cells were identified by the terminal deoxyribonucleotidyl transferase–mediated dUTP nick-end labeling (TUNEL) method. Results: Thirty-nine tumor specimens from resected ampullary adenocarcinoma patients were included. By univariate analysis, overall survival was affected by Cox-2 expression and TUNEL staining (respectively, P = 0.0003 and 0.03). Survivin expression did not influence the overall survival in our patient population (P = 0.123). Patients' clinicopathologic features (gender, age, and T and N factors) did not influence outcome. In multivariate Cox regression analysis, Cox-2 expression (relative risk, 4.330; P = 0.005) was the only variable that significantly affected overall survival. Conclusions: The results of the present article provide, for the first time, evidence that Cox-2 expression, but not Survivin expression, may represent a significant prognostic factor after surgical resection in patients affected by cancer of the ampulla of Vater. Further studies are required to determine whether Cox-2 inhibitors may be useful for the therapy or prevention of ampullary carcinoma.

Background: A study was undertaken to analyse the potential prognostic value of the immunohistochemical expression of cyclooxygenase-2 (COX-2) and p27 in 29 malignant mesotheliomas already screened for the expression of p21 and p53. Methods: Immunohistochemistry was used to determine the expression of COX-2 and p27. The correlation with survival of these factors and of p21 and p53 expression was assessed by univariate and multivariate analyses. Results: A positive statistically significant correlation was found between p27 and p21 expression (p

Background: Multivessel coronary disease after myocardial infarction is a major risk factor for unfavorable cardiac remodeling and death due to pump failure, but underlying pathophysiologic mechanisms are still uncompletely established. Post-infarction myocardial apoptosis has been recently implicated as a cause of ongoing cell loss leading to cardiac failure. Our aim was to assess the role of post-infarction myocardial apoptosis and pro-apoptotic factor expression in the non-infarcted remote myocardium of subjects with multivessel coronary disease. Methods: Twenty-one males dying after recent myocardial infarction with permanent occlusion of the infarct-related artery were selected at autopsy. Apoptosis was assessed at viable myocardial regions remote from infarction by co-staining for in situ end-labeling of DNA fragmentation and cleaved caspase-3. Expression of pro-apoptotic factor bax and hypoxia-induced factor-1alpha was evaluated by immunohistochemistry. Results: Subjects with multivessel disease (N = 11) showed a significantly two-fold higher myocardial apoptosis in comparison to subjects with single vessel disease (N = 10) (0.9% vs. 0.5%, p = 0.013). Similarly, myocardial bax expression was increased in patients with multivessel disease (3.0% vs. 1.4%, p = 0.029). Stratification for the number of diseased coronary vessels confirmed the association between extent of coronary disease and apoptotic rates (p = 0.022). Even in subjects dying over 30 days after infarction multivessel disease remained predictive of enhanced myocardiocyte apoptosis at remote regions (p = 0.033). Conclusions: Post-infarction myocardial apoptosis and bax expression in remote left ventricular regions are significantly increased in male patients with multivessel coronary disease in comparison to those with isolated infarct-related artery occlusion. These findings suggest that apoptotic cell loss in the viable non-infarcted myocardium, possibly due ongoing ischemia, may play a relevant role in the unfavorable clinical course typical of multivessel disease after myocardial infarction. © 2004 Published by Elsevier Ireland Ltd.

Purpose: The expression of apoptosis-related genes, such as survivin, bcl-2, bcl-X, and bax, has been evaluated by reverse transcriptase polymerase chain reaction (RT-PCR) and by immunohistochemistry in sentinel lymph nodes (SLNs) from melanoma patients and then correlated to the outcome of patients. Patients and Methods: Thirty-six SLNs were examined. After RNA extraction, an RT-PCR followed by Southern blot hybridization was performed to detect survivin, bcl-2, bcl-X, and bax mRNA. bcl-2, survivin, and bax gene expression was evaluated, whenever possible, also by immunohistochemistry at the protein level. Results: We found a significant correlation (P < .005) between survivin expression and outcome of patients; in fact, 61.5% of patients expressing survivin gene progressed or died because of the disease, whereas 38.5% are currently disease-free. Among patients negative for survivin expression, 100% are disease-free after a median follow-up time of 52.9 months. We did not find a significant correlation between bcl-2, bax, and bcl-X gene expression and outcome of patients. In fact, these genes were found equally expressed in patients with disease progression and in disease-free patients. Conclusion: Our findings show a variable expression of apoptosis-related genes in SLNs of melanoma patients; more interestingly, we found that survivin expression correlates to outcome of patients in a statistically significant way, whereas the expression of other genes, such as bcl-2, bax, and bcl-X, did not seem to correlate to progression of disease. We suggest that the detection of survivin gene expression by RT-PCR in SLNs may be a useful prognostic indicator.

Apoptosis is a pathologic feature of cardiomyocytes in acute myocardial infarction (AMI) and heart failure. The temporal course of apoptosis in the peri-infarct area in the weeks following an AMI is still uncompletely defined. In order to study the time course of apoptosis after AMI, 16 rabbits underwent left coronary artery ligation and were sacrificed at 16, 26, 35, and 56 days after surgery. Increased apoptotic rate (AR) was observed at in the peri-infarct region than in remote myocardium (5.4% [2.5-9.6] vs 0.4% [0.1-0.9], respectively, P < 0.001) and than in sham-operated cases (0.01% [0-0.02], P < 0.001). A gradual decrease of AR in the peri-infarct region was observed over time with a 90% reduction at 8 weeks after coronary ligation. © 2006 Elsevier Ireland Ltd. All rights reserved.

The rejection of interferon alpha 1 gene-transfected mammary adenocarcinoma cells (TSA-IFN alpha) injected into syngeneic BALB/c mice was accompanied by an unusual stromal reaction and marked CD8-positive T-lymphocyte involvement. To investigate the biological background of this reaction, the possibility was evaluated that an interaction between TSA-IFN alpha and stromal cells might remodel the extracellular matrix (EM). When fibroblasts were co-cultured with TSA-IFN alpha or treated with exogenous IFN alpha, there was no change in their replication rate or collagen synthesis. By contrast, their fibronectin (FN) production and release were increased, resulting in enhanced fibroblast chemotaxis. These findings were mirrored by increased FN staining in the peritumoural and tumoural areas in vivo. IFN alpha thus determines increased FN production and hence massive local recruitment and activation of fibroblasts, with a modification of the EM. The several activities of IFN alpha should thus be considered prior to its employment in clinical trials.

Department of Medicine, Virginia Commonwealth University, Richmond, VA USA A. Abbate (A. Abbate, G. W. Vetrovec); Institute of Cardiology, Catholic University, Rome, Italy (G. G. L. Biondi-Zoccai, A. Severino, M. Campioni, G. Liuzzo, F. Crea, L. M. Biasucci); Department of Vascular Pathology, Istituto Dermopatico Immacolata, Rome, Italy (F. Limana, M. C. Capogrossi, S. Straino); Section of Oncology, Campus Bio-Medico University, Rome, Italy (D. Santini); Department of Experimental Medicine and of Pathology, Universita degli Studi “La Sapienza”, Rome, Italy (S. Scarpa, F. Vasaturo); Centro Cardiologico Fondazione Monzino, Milano, Italy (A. Germani); Department of Biochemistry and Biophysics “F. Cedrangolo”, Section of Pathologic Anatomy, Second University of Naples, Naples, Italy (A. Baldi)

Autocrine and paracrine mechanisms modulate the synthesis and secretion of extracellular matrix (ECM); moreover, each component of the ECM is capable of modulating the synthesis and release of other ECM molecules. Therefore, the synthesis of ECM glycoprotein fibronectin and laminin was studied in the human breast cancer cell lines MCF7 and MDA MB 23, plated on different ECM. Our results showed that the cells plated on a fibronectin substrate increased laminin synthesis: this event correlated with an increase in alpha2 and alpha3 integrin subunits. Staurosporine-induced apoptosis was then analyzed in the cell lines plated on different ECM. Staurosporine treatment determined the apoptosis of 35 and 33% respectively of MDA MB 231 and MCF7; these values increased to 60 and 64% in cells plated on laminin, to 48 and 63% in cells plated on fibronectin and to 64 and 69% in cells plated on matrigel. Moreover, staurosporine treatment decreased bcl-2 expression in the cells plated on fibronectin and laminin. Yet, staurosporine treatment determined PARP cleavage and PARP partial disappearance when the cells were plated on matrigel. Finally, a partial loss of function mutant Ras protein that activated only Raf pathway, was expressed in MCF7, in order to identify whether the increase of apoptosis induced by extracellular matrix involved the Raf/MAP kinase pathway. The increase of apoptosis of the cells plated on matrigel suggested that the activation of the Raf pathway is probably involved in the decrease of survival on matrigel. These data demonstrate that the modification of ECM modulates the apoptotic process of breast cancer cells and suggest that it is worthwhile to dissect the role of ECM in the control of apoptotic process.

We report hypoxia-inducible factor-1 (HIF-1) expression in myocardium of patients with recent acute myocardial infarction (AMI), supporting the hypothesis of HIF-1 as a possible mediator of response to ischemia. A potential diagnostic role of determining tissue expression of HIF-1 as a marker of ischemia, and potential therapeutic implications by trying to modulate HIF-1 activity in order to promote beneficial effects of HIF-1 related genes (e.g. expression of vascular endothelial growth factor (VEGF)) may derive. © 2004 Elsevier Ireland Ltd. All rights reserved.

Aims: Unfavourable cardiac remodelling often complicates acute myocardial infarction (AMI) as a result of increased cardiomyocyte apoptosis. It is currently unclear whether ongoing or recurrent ischaemia is an independent determinant for increased apoptosis in peri-infarct viable myocardium. Methods and results: In order to assess the link between infarct-related artery (IRA) occlusion, ischaemia, and apoptosis, 30 subjects dying 7-120 days after AMI (16 with IRA occlusion and 14 with patent IRA) and five control subjects were selected at autopsy. Cardiomyocytes were defined as apoptotic if co-expressing TUNEL and activated caspase-3. Expression of both hypoxia-inducible factor-1 and cyclo-oxygenase-2 was assessed in the peri-infarct myocardium and considered as tissue markers of ischaemia. Evidence of ischaemia was significantly more frequent in cases with IRA occlusion (53%) than in cases with patent IRA (15%) or control hearts (0%, P = 0.026). The finding of IRA occlusion and markers of ischaemia identified cases with higher apoptotic rates (ARs) in the peri-infarct viable myocardium [12.2% (8.2-14.0), P < 0.001 vs. others], whereas IRA occlusion without ischaemia was associated with lower AR, not significantly different from patent IRA [3.0% (1.0-7.9) vs. 2.2% (1.0-5.8), respectively, P = 0.42] Conclusion: Ischaemia in the peri-infarct viable myocardium is present in over 50% of subjects dying late after AMI with IRA occlusion, and it is associated with increased apoptosis. Relief of ischaemia after AMI may prove of benefit in preventing apoptosis and its consequences. © The European Society of Cardiology 2005. All rights reserved.

Background: Cyclo-oxygenase-2 (COX-2) is induced in cardiomyocytes only in response to stress, such as ischaemia. Objective: To assess COX-2 expression at the site of recent myocardial infarction. Methods: COX-2 expression was evaluated by specific immunostaining in cardiomyocytes from 23 subjects who died 10–60 days after acute myocardial infarction. The relation between COX-2 myocardial expression and apoptotic rate was investigated. Cardiomyocyte apoptotic rate was defined as the number of cells co-expressing in situ end labelling of DNA fragmentation (TUNEL) and immunostaining for activated caspase-3. Results: COX-2 expression was found in cardiomyocytes at the site of infarction in nine of 23 cases (39%). It was associated with fivefold higher apoptotic rates (median 17.9% (interquartile range 11.0–25.4%) v 3.7% (0.6–12.8%); p = 0.016), and apoptotic rate increased progressively from mild to intense COX-2 staining (p for trend 0.009). COX-2 expression co-localised with TUNEL nuclear staining in myocytes, and there was a high concordance between COX-2 and hypoxia induced factor 1-α staining (78%, p = 0.021) and between COX-2 and bax (83%, p = 0.014). Subjects showing myocardial COX-2 expression were more likely to have enlarged hearts (p = 0.050), and intense COX-2 staining was strictly associated with symptomatic heart failure (p = 0.035). Conclusions: COX-2 is expressed in cardiomyocytes in nearly 40% of cases at the site of recent acute myocardial infarction, even late after the index event. Its expression was associated with extremely high apoptotic rates. These findings suggest a potential cause–effect link between COX-2 expression and enhanced myocardial apoptosis in ischaemic cardiomyopathy.

The effects of retinoic acid (RA) on cell replication, fibronectin and laminin synthesis, integrin expression and haptotactic migration of three mesothelioma cell cultures of different histotype, one epithelioid, one fibromatous and one biphasic, were evaluated. Cell growth was not affected by RA, while RA treatment decreased the synthesis of fibronectin and laminin and inhibited the migration of all three mesotheliomas on substrates of fibronectin and laminin; on the contrary, the expression of some integrins was not significantly modified by RA. These data indicate that RA may lead to a decrease of mesothelioma cell local invasion; this can correlate with a modification induced by RA on mesothelioma tumor progression in vivo.

Purpose of the present study was to investigate in human neuroblastoma (NB) cell lines the effects of GTP depletion induced by mycophenolic acid (MPA) (the most specific IMP dehydrogenase inhibitor): 1. on biopterin biosynthesis, using cytotoxic drug concentrations in short-term experiments; 2. on cellular differentiation and extracellular matrix remodelling, using drug concentrations below those inducing apoptosis.1

Six human neuroblastoma (NB) cell lines of different type: three neuronal, one mixed and two epithelial, were studied for their responsiveness to interferon gamma (IFNgamma). The effects of IFNgamma on cell growth rate and morphology were first evaluated: the replication was significantly inhibited in five out of six NB, while a neural morphological maturation was evident only in the three neural NB. Whether IFNgamma could also control the synthesis of two extracellular matrix glycoproteins, often involved in NB differentiation, laminin (LM) and fibronectin (FN), was then analyzed. Both glycoproteins increased after IFNgamma treatment in all neural and in the mixed NB, while they slightly decreased in one and did not change significantly in the other epithelial NB. Therefore, IFNgamma determines the up-regulation of FN and LM, while inducing NB cell growth inhibition and neural differentiation. These data support the hypothesis that the expression of the two extracellular matrix glycoproteins is controlled by IFNgamma during the complex event of NB terminal maturation.

The expression of the extracellular matrix-related genes, such as fibronectin, laminin and tenascin C, and apoptosis-related genes, such as bax, bcl2 and survivin, was evaluated by reverse transcription-polymerase chain reaction (RT-PCR) and by immunohistochemistry in normal breast tissue and benign and malignant breast tumors and then correlated to several clinical parameters: estrogen and progesterone receptors, Ki67, ErbB2, tumor size, lymph node status and grading. Seventy-three breast tissue samples were examined. After RNA extraction, an RT-PCR was performed to detect fibronectin, laminin, tenascin C, bax, bcl2 and survivin gene expression. Thirty-two samples were evaluated also by immunohistochemistry at the protein level to detect fibronectin, laminin, tenascin C, bax and survivin. We found a significant correlation (P=0.025) between fibronectin gene expression and lymph node status, and a significant negative correlation (P=0.049) between laminin gene expression and Ki67. In addition, we found a statistically significant increase in survivin transcription in malign tumors compared to fibroadenomas (P=0.024). The negative correlation between laminin transcription and Ki67 could suggest that laminin impacts negatively on tumor proliferation, and the positive correlation between fibronectin and lymph node status may lead to consider fibronectin as predictive of long distance metastasis.