Phylogenetic analysis of variants of the Puumala virus (Hantaviridae: Orthohantavirus) circulating in the Saratov region.

The objective is to determine the complete nucleotide sequence and conduct a phylogenetic analysis of genome variants of the Puumala virus isolated in the Saratov region. MATERIALS AND METHODS: The samples for the study were field material collected in the Gagarinsky (formerly Saratovsky), Engelssky, Novoburassky and Khvalynsky districts of the Saratov region in the period from 2019 to 2022. To specifically enrich the Puumala virus genome in the samples, were used PCR and developed a specific primer panel. Next, the resulting PCR products were sequenced and the fragments were assembled into one sequence for each segment of the virus genome. To construct phylogenetic trees, the maximum parsimony algorithm was used. RESULTS: Genetic variants of the Puumala virus isolated in the Saratov region have a high degree of genome similarity to each other, which indicates their unity of origin. According to phylogenetic analysis, they all form a separate branch in the cluster formed by hantaviruses from other subjects of the Volga Federal District. The virus variants from the Republics of Udmurtia and Tatarstan, as well as from the Samara and Ulyanovsk regions, are closest to the samples from the Saratov region. CONCLUSION: The data obtained show the presence of a pronounced territorial confinement of strains to certain regions or areas that are the natural biotopes of their carriers. This makes it possible to fairly accurately determine the territory of possible infection of patients and/or the circulation of carriers of these virus variants based on the sequence of individual segments of their genome.

[Possibilities of ultrasound methods in diagnostics of eyelid tumors]. / Vozmozhnosti ul'trazvukovykh metodov issledovaniya v diagnostike novoobrazovanii vek.

PURPOSE: To determine the informative value of ultrasound biomicroscopy (UBM) with A-scan for assessment of qualitative and quantitative characteristics of eyelid tumors less than 5 mm in size. MATERIAL AND METHODS: The study included 25 patients (25 eyes) with eyelid tumors less than 5 mm in size. In addition to standard ophthalmic examination, complex ultrasound diagnostics including B-scan, Color Doppler imaging and UBM with A-scan were performed. The localization, size, structure of eyelid tumors and the state of perifocal tissues were evaluated. All patients underwent surgical treatment with following histological examinations of dissected tissues. Due to qualitative analysis of the studied formations and small number of included patients, there was no need in statistical analysis of the data. RESULTS: Complex application of UBM and A-scan allowed specifying the localization, size, structure of the small-sized tumors and detecting typical echographic signs of benign or malignant properties of the pathological process. Ultrasound data (UBM and A-scan) of eyelid tumors was highly correlated to histological features. CONCLUSION: UBM with A-scan can be recommended for differential diagnostics of small-sized tumors and optimizing their management.

Eight per cent leakage of Lyman continuum photons from a compact, star-forming dwarf galaxy.

One of the key questions in observational cosmology is the identification of the sources responsible for ionization of the Universe after the cosmic 'Dark Ages', when the baryonic matter was neutral. The currently identified distant galaxies are insufficient to fully reionize the Universe by redshift z ≈ 6 (refs 1-3), but low-mass, star-forming galaxies are thought to be responsible for the bulk of the ionizing radiation. As direct observations at high redshift are difficult for a variety of reasons, one solution is to identify local proxies of this galaxy population. Starburst galaxies at low redshifts, however, generally are opaque to Lyman continuum photons. Small escape fractions of about 1 to 3 per cent, insufficient to ionize much surrounding gas, have been detected only in three low-redshift galaxies. Here we report far-ultraviolet observations of the nearby low-mass star-forming galaxy J0925+1403. The galaxy is leaking ionizing radiation with an escape fraction of about 8 per cent. The total number of photons emitted during the starburst phase is sufficient to ionize intergalactic medium material that is about 40 times as massive as the stellar mass of the galaxy.

STRUCTURAL ORGANIZATION OF PORIN GENES (INTACT AND DISRUPTED BY IS 100) BORDERING THE PGM LOCUS OF THE YERSINIA PESTIS AND YERSINIA PSEUDOTUBERCULOSIS STRAINS.

In highly virulent strains of Yersinia pestis, the porin gene border- ing pigmentation (pgm) locus was observed to be usually broken by IS100. In this case, the pgm locus that carries virulence genes (high pathogenicity island) and biofilm formation genes (hms operon) is flanked by direct copies of IS100, which can cause its destabilization. We studied the prevalence of the intact and dis- rupted porin genes among 240 strains of Y. pestis from 39 natural centers in Russia and abroad, and 68 strains of Yersinia pseudotuberculosis from different geographical regions. The majority of the highly virulent Y. pestis strains and some phylogenetic lines of Y. pseudotuberculosis 0:1 serotype contain disrupted porin genes. At the same time, deletion of the pgm locus by flanking IS100 in Y pseudotuberculosis is impossible, because IS100 is integrated in the porin gene in the reverse orientation as compared to Y pestis. The porin genes are intact in all Y pestis strains with low epidemic importance and some phylogenetic lines of highly virulent Y pestis strains from some desert foci and Caspian sandy focus, as well as most strains of Y pseudotuberculosis 0:1 serotype. Less virulent strains of Y pseudotuberculosis 0:3 serotype revealed extensive deletion, which included the porin gene and a portion of the gene astE. The nucleotide sequence of the porin genes in Y pestis and Y pseudotuberculosis strains from different geographical regions are identical. Three alleles of the porin gene differ solely by the site of integration and orientation of IS 100 or by the lack of integration. The nucleotide sequence of IS 100, embedded in the porin gene of Yersinia, has minor differences only in two Y pestis strains isolated in America. Low frequency of Hms- mutations correlates with the intact condition of the porin gene in Y pestis. This correlation is absent in Y pseudotuberculosis.

[The Analysis of Changes in EEG Patterns in Response to Transmittent Photic Stimulation in Different Disorders of Central Nervous System].

In this study, for the first time, the photic driving reaction in patients with different disorders of the functional state of central nervous system caused by cerebrovascular conditions of different severity was examined by wavelet analysis of electroencephalographic (EEG) fragments. The background fragments of EEG in the group of patients with vegetative-vascular dystonia, are characterized by lower values of the wavelet spectrum energy in the alpha range than the fragments in the control group. In patients from the groups of vertebrobasilar insufficiency and atherosclerotic damage of cerebral blood vessels, the values of energy in delta range is even lower. The wavelet analysis of reactive patterns has demonstrated the different photic driving of beta, theta and alpha ranges in the patients of various groups. The study demonstrates the possibility of quantitative estimation of the human brain lability of light stimulus perception by the wavelet analysis. The results can be used for the adequate choice of treatment for a patient with cerebrovascular disorder.

[Analysis of diversity and identification of the genovariants of plague agent strains from Mongolian foci].

The genetic diversity of Yersinia pestis strains from the Mongolian natural plague foci has been investigated. A total of 32 strains isolated from western, eastern, and central aimaks, as well as from the territory of the Gobi region, have been studied. Twenty-four strains belong to the main Y. pestis subspecies, while eight belong to other subspecies. There is only one strain of biovar medievalis (genovariant 2.MED1) among the strains of the main subspecies, while the rest of the subspecies belong to the biovar antiqua. Biovar antiqua strains are split into three groups. Strains from the eastern part of the country were classified as genovariant 2.ANT3, and those from the western and central regions were classified as genovariant 3.ANT2, which was endemic for Mongolia. One strain from the Bayan-Ulegeiskii aimak had the rare genovariant 4.ANT. None of the strains of the biovar antiqua belonged to its ancient 0.ANT branch, which is inconsistent with the commonly accepted idea that ancient marmot's plague agent race originates from Mongolia. Six out of eight strains of the minor subspecies belonged to the ulegeica subspecies, which are endemic to Mongolia, one strain belonged to the microtus group, and the last belonged to a previously uncharacterized variant of the minor subspecies.

[A study on the taxonomy of soil amoebas from Caspian plague foci based on an analysis of ribosomal operon sequences].

The results of a study on the taxonomy and quantitative abundance of free-living amoebas in soil samples from the Russian plague foci of the northwestern Caspian steppe, the Caspian sand, and the Volga-Ural steppe are presented. Amoebas of the Willaertia and Hartmanella genera, as well as representatives of myxomycetes, were isolated from samples. From these, amoebas of the Acanthamoeba genus predominated and could be as abundantas 300000 cells per 1 g of soil. Sequencing of the 18S rRNA gene region showed that Acanthamoeba from the Volga-Ural steppe focus belonged to the A. castellanii species. Phylogenetic analysis confirmed that amoebas from two other Caspian foci belonged to the species of Acanthamoeba spp.

[Genetic basis of the variability of nitrate reduction trait in Yersinia pestis strains].

The genetic basis of the varying ability to reduce nitrate in strains belonging to different biovars and subspecies of plague-causing microbe has been investigated and the inability to reduce nitrate observed in different intraspecies groups of Yersinia pestis has been shown to stem from mutations in different genes involved in the expression of this trait. The absence of denitrifying activity in strains of altaica and hissarica subspecies was not due to a mutation at position 613 of the periplasmic reductase napA observed in the strains of the biovar medievalis of the main subspecies, but rather was due to a mutation in the sequence encoding the nitrate-binding domain of the ABC transporter protein SsuA; a thymine insertion (+T) was detected at position 302 from the start of the ssuA gene. Five strains of biovar antiqua isolated at different times in Mongolia, China, and Africa were shown to lack the ability to reduce nitrate. A PCR test targeting two chromosomal regions containing deletions of 19 and 24 bp in size has been developed for the identification of strains of the biovar medievalis. This test can be combined with the test for the marker mutation in the napA gene for a more reliable detection of Y. pestis strains belonging to this biovar.

[The availability and quality of the ambulatory polyclinic care].

The article deals with the results of the study of complex of medical demographic and social economic indicators of Nizhny Novgorod oblast during 1989-2010. The results are as follows. The policlinics' net reduced by 2.25 times, including by 10.6 times in rural area and by 12.6 times of ambulatories of community hospitals. The indicators of physicians' supply of oblast population decreased too especially in urban area. The annual number of visits to physicians per capita decreased by 1.36 times. The number of calls of out-patients to physicians of emergency medical care increased by 1.5 times. The morbidity with temporarily disability and primary registration as a disabled person decreased by 1.45 times, including able-bodied citizen by 1.54 times. In Nizhny Novgorod oblast, the rate of decrease of indicators of primary disability during 2006-2009 overpassed the corresponding federal indicators by 1.45 times. The population mortality increased by 1.43 times. The accessibility and quality of ambulatory polyclinic care significantly impacts on the levels of mortality and social security of population and can be used as an indicator of social risks in the region.

[Features of neurohumoral regulation in children with combined dysfunction of the pelvic organs].

During examination of 165 children aged 5 to 15 years (primarily identified during planned monitoring in Petrozavodsk children's institutions) with dysfunctional urination and encopresis without organic lesion of the central nervous system, autonomic dysfunction syndrome (ADS) was revealed. According to the results of urological examination, which was supplemented with the registration of spontaneous voiding rate and counting the radial pulse, overactive bladder syndrome and insufficient relaxation of the pelvic floor muscles during urination and defecation were detected; relationship between the number of heart rate (as a marker of sympathetic nervous system activity) and the effective volume was identified. It was revealed that the children with ADS in the presence of tachycardia show intermittent decrease of effective amounts of urination, and have residual urine. The standard course of treatment using colon hydrotherapy and biofeedback to activate cystic and obturator reflex caused a positive but short-term therapeutic effect; clinically and statistically significant increase in the effective volume of the bladder was not achieved, despite the reduction in residual urine volume. During the course of treatment using methods of biofeedback, bladder volume remained almost unchanged and tachycardia persisted, indicating the continued oppression of the sympathetic activity. The course of treatment using nootropic drug picamilon and alpha-adrenoblocker doxazosin with peripheral actions allowed to restore the reservoir and evacuation functions of the bladder, to achieve a regular bowel movement without encopresis. It was revealed that the combined dysfunction of pelvic organs occur in children with high activity of the sympathetic division of the ANS, which has a direct impact on the accumulation phase of voiding cycle and relaxation of the pelvic floor muscles.

Effect of rosiglitazone on capillary density and angiogenesis in adipose tissue of normoglycaemic humans in a randomised controlled trial.

AIMS/HYPOTHESIS: Recent reports of decreased capillary density in the adipose tissue of obese individuals suggest that an imbalance of angiogenesis and adipogenesis may, in part, underlie insulin resistance. This study aimed to determine whether the insulin-sensitising peroxisome proliferator-activated receptor γ (PPARγ) activator rosiglitazone affects adipose tissue vascularisation in normal humans. METHODS: A randomised, parallel-group, investigator-blinded placebo-controlled trial was conducted with normoglycaemic volunteers with BMI 27-43, recruited from the community at the University of Massachusetts Medical School, Worcester, MA, USA. Peri-umbilical adipose tissue biopsies were obtained before and after treatment for 6 weeks with rosiglitazone (8 mg once daily) or placebo, which were randomly allocated from a sequentially numbered list. The primary outcomes were adipocyte size and capillary density measured by immunohistochemistry, and angiogenic potential assessed by capillary sprout formation in Matrigel. Secondary outcomes were serum adiponectin, glycaemic, lipid and liver function variables. RESULTS: A total of 35 individuals fulfilling the inclusion criteria were randomised, and complete before-vs-after analyses were achieved in 30 participants (13 and 17, placebo and rosiglitazone, respectively). Significant differences, assessed by paired two-tailed Student t tests, were seen in response to rosiglitazone for adipocyte size (3,458 ± 202 vs 2,693 ± 223 µm(2), p = 0.0049), capillary density (5.6 ± 0.5 vs 7.5 ± 0.5 lumens/field, p = 0.0098), serum adiponectin (14.3 ± 1.5 vs 28.6 ± 3.0 ng/ml, p < 0.0001) and alkaline phosphatase (1.04 ± 0.07 vs 0.87 ± 0.05 µkat/l, p = 0.001). A difference in angiogenic potential before and after treatment between the placebo and rosiglitazone groups was also seen (-23.88 ± 14 vs 13.42 ± 13, p = 0.029, two-tailed Mann-Whitney test). CONCLUSIONS/INTERPRETATION: Significant effects on adipose tissue vascular architecture occur after a short period of treatment with rosiglitazone in individuals with normal glucose tolerance. Improved adipose tissue vascularisation may, in part, mediate the therapeutic actions of this class of drugs. TRIAL REGISTRATION: ClinicalTrials.gov NCT01150981 FUNDING: The study was funded by National Institutes of Health grant DK089101 to S. Corvera, and by pilot funding from the University of Massachusetts (UMASS) Center for Clinical Translational Sciences (M. Thompson, S. Malkani and S. Corvera). Morphology core services were supported by UMASS Diabetes Endocrine Research Center (DERC) grant DK32520.

[Standard algorithm of molecular typing of Yersinia pestis strains].

AIM: Development of the standard algorithm of molecular typing of Yersinia pestis that ensures establishing of subspecies, biovar and focus membership of the studied isolate. Determination of the characteristic strain genotypes of plague infectious agent of main and nonmain subspecies from various natural foci of plague of the Russian Federation and the near abroad. MATERIALS AND METHODS: Genotyping of 192 natural Y. pestis strains of main and nonmain subspecies was performed by using PCR methods, multilocus sequencing and multilocus analysis of variable tandem repeat number. RESULTS: A standard algorithm of molecular typing of plague infectious agent including several stages of Yersinia pestis differentiation by membership: in main and nonmain subspecies, various biovars of the main subspecies, specific subspecies; natural foci and geographic territories was developed. The algorithm is based on 3 typing methods--PCR, multilocus sequence typing and multilocus analysis of variable tandem repeat number using standard DNA targets--life support genes (terC, ilvN, inv, glpD, napA, rhaS and araC) and 7 loci of variable tandem repeats (ms01, ms04, ms06, ms07, ms46, ms62, ms70). The effectiveness of the developed algorithm is shown on the large number of natural Y. pestis strains. Characteristic sequence types of Y. pestis strains of various subspecies and biovars as well as MLVA7 genotypes of strains from natural foci of plague of the Russian Federation and the near abroad were established. CONCLUSION: The application of the developed algorithm will increase the effectiveness of epidemiologic monitoring of plague infectious agent, and analysis of epidemics and outbreaks of plague with establishing the source of origin of the strain and routes of introduction of the infection.

[Sialic acids and O-acetyl groups as markers of biological activity of microbial polysaccharides in plague and cholera agents].

AIM: To determine sialic acids and O-acetyl groups content in Yersinia pestis and Vibrio cholerae antigens in order to establish their association with biological activity. MATERIALS AND METHODS: The following antigens of Y. pestis EV NIIEG strain--capsular antigen (F1), major somatic antigen (MSA), lipopolysaccharide (LPS), Pla-protease, allergen pestin PP--as well as O-antigens (O-AG) of V. cholerae serogroups O1 and O139 were used in the study. Sialic acids were identified by the thiobarbituric method, and O-acetyl groups--according to Alicino. Specific polysaccharides in the MSA and O-antigens were detected by the immunodiffusion assay. RESULTS: Sialic acids were found in LPS, Pla-protease, allergen pestin PP, and all cholera O-AG; their absence was demonstrated in MSA and F1. O-acetyl groups were identified in cholera O-AG of both studied serogroups as well as in LPS, Pla-protease, MSA and pestin PP of Y. pestis. Tendency to correlation between O-acetyl groups content in MSA and serological activity titer was observed. CONCLUSION: Sialic acids and O-acetyl groups identified in carbohydrate-containing antigens of Y. pestis and V. cholerae could be characterized as reaction-active markers of pathogenetic mechanisms of cholera and plague infections as well as immunochemical activity of microbial polysaccharides.

[Analysis of insect toxin complex gene variability of Yersinia pestis and Yersinia pseudotuberculosis strains].

The nucleotide sequences of the Tc's insect toxin complex genes have been analyzed in 18 natural strains of the main and non-main subspecies of Yersinia pestis isolated in different natural foci in the Russian Federation, as well as neighboring and more remote countries, as compared to the data on Y. pestis and Y. pseudotuberculosis strains stored in the NCBI GenBank database. The nucleotide sequences of these genes in plague agent strains have been found to be highly conserved, in contrast to those of the pseudotuberculosis agent. The sequences of two genes, tcaC and tccC2, have been found to be almost identical in Y. pestis strains, whereas other three genes (tcaA, tcaB, and tccC1) contain a few mutations, which, however, are not common for all strains of the plague agent. Exceptions are only strains of the Y. pestis biovar orientalis, whose tcaB gene is in a nonfunctional state due to a nucleotide deletion. The results suggest that the formation of the species Y. pestis as an agent of a natural focal infection with a transmissive mechanism has not resulted in degradation of the Tc's complex genes. Instead, these genes are likely to have been altered as the plague agent have been adapting to the new environment.

[The formation of social professional skills of students with limited possibilities].

The education of children and adolescents with limited possibilities is a system of economic, public, legal and individual personal measures supporting the optimal conditions to overcome this defect up to a degree of participation in public life on par with other citizen. In the Nijny Novgorod academic boarding school for the disabled the organization of activities forming the social professional skills are differentiated on terms and targets of education. The students of first course need the optimization of communication, enhancement of self-consciousness, formation of educational information perception, reasoning, involuntary memory voluntary logical memory attention, will, educational general intellectual expertise. The students of second course need more attention to making and optimization of various types of activity, activation of labor activity, forming of labor attitudes, communicative skills and enhancement of emotional and motivational sphere. The students of third course need to develop the skills of self-reliant work, motoric activity, dexterity labor skills, working discipline skills, rational attitude to group work, professional knowledge.

[The role of medical social expertise in the social protection of disabled patients].

The dynamics of disability level in the Nijegorodskaya oblast was analyzed. The decrease of number of patients admitted as disabled for the first time and its causes was revealed. The drastic decreasing of number of patients examined in 2007 brings to consider the existence of expertise barriers in outpatient and polyclinic institutions which make the expert care less accessible. The share of persons accepted as the disabled in the total number of examined decreases too. The adequate rehabilitation services net in the oblast factually don't exist. Artificial decreasing of disability rate always leads to the decrease of social protection of patients and to the increase of mortality rate in population.

[Structural and functional analysis of araN gene in the Yersinia pestis strains of various origin].

Structural and functional analysis of the araN gene involved in regulation of expression of diagnostically significant symptom (arabinose fermentation) was performed in the Yersinia pestis microorganism. Lack of arabinose fermentation in the Altai substrain, Hissar substrain, and Talas strains was shown to be due to solitary nucleotide insert into the araN gene. The insert is in the position 763 bp. The strains of the main, Caucasian, and Ulege substrains do not contain this mutation of the araN gene. The absence of the mutation correlates with ability to ferment arabinose.

Autologous progenitor cell implantation as a novel therapeutic intervention for ischaemic digits in systemic sclerosis.

OBJECTIVES: The effects of local stem cell implantation on clinical and functional characteristics of peripheral vascular disease were studied in two SSc patients with non-healing ischaemic ulcers. METHODS: The local injections of CD34(+) cells from peripheral blood (PB) after mobilization by G-CSF (Case 1) and bone marrow (BM) (Case 2) were used for ischaemic skin ulcers in hands, while mononuclear cells (MNCs) were implanted in lower extremities of the same patients. Ischaemic status was evaluated by measuring ulcer healing, Raynaud's condition score (RCS), visual analogue pain, RP and ulcer scales. To evaluate vasculoprotective action of the implanted cells, we studied weekly the changes in endothelial function, using measurement of flow-mediated brachial artery reactivity by high-resolution ultrasonography, circulating endothelial precursors (CD34(+)VEGFR2(+), CD133(+)VEGFR2(+) CEP) by FACS analysis, cutaneous blood flow (laser Doppler flowmetry), skin surface temperature (thermograph), peripheral arterial diameter and blood flow characteristics by Duplex ultrasonography. RESULTS: CD34(+) cells and MNCs both from BM and PB showed rapid and evident beneficial effect on vascular symptoms resulting in ulcer healing, remarkably decreased daily frequency and duration of RP attacks, RCS, visual analogue scale for RP, ulcers and pain. Physical function and disability measured with HAQ and SHAQ improved. Therapeutic efficacy of stem cell therapy was associated with restoration of endothelial function, augmentation of microcirculatory blood flow and significant increase in circulating CD133(+)VEGFR2(+) progenitors, known as cell effectors of angiogenesis. CONCLUSION: This first open-label pilot study demonstrates the feasibility and short-term safety of local CD34(+) cell therapy for SSc ischaemic complications.

[Overlap syndromes in rheumatology].

Overlap syndromes in rheumatology present a challenging problem reflecting clinical and immunogenetic heterogeneity of rheumatic disorders. Current statistics refers 25% of the connective tissue diseases to "overlap syndromes". There are three main groups of them, viz. (1) overlap forms of systemic connective tissue diseases, (2) mixed connective tissue disease (Sharp's syndrome), (3) undifferentiated rheumatic disease. Characteristics of these groups are presented based on the published studies and the original data on 100 patients with the most frequent forms of systemic connective tissue pathologies, such as systemic sclerodermias with polymyositis/dermatomyositis (68 patients) and rheumatoid arthritis (32 patients).

[Endothelial dysfunction in scleroderma systematica: clinicopathogenetic correlations].

AIM: To evaluate disturbances of vascular tonicity regulation in scleroderma systematica (SS) patients using laser Doppler flowmetry (LDF) with calculation of amplitude-frequency blood flow fluctuations (variability) basing on the mathematical model wavelet-transformation. MATERIAL AND METHODS: The trial included 101 patients with verified SS aged 21-60 years (mean 52.3 years, 97 females). In addition, 15 and 10 patients with primary and secondary Raynaud syndrome diagnosed by ACR criteria, respectively, entered the trial. The control group consisted of 20 healthy subjects. Cardiovascular patients were not included in the study. Microcirculation was investigated with laser analyzer of capillary circulation in the tip of left hand finger III and external surface of the left arm. Endothelial motor function was studied in the tests with reactive hyperemia and nitroglycerin. RESULTS: SS patients were found to have a significantly higher variability and endothelial rhythm amplitude index in arm skin, reduced microcirculation, the variation index and high neurogenic tonicity in the hand finger tip. A direct correlation was found between severity and area of skin lesion (of the arm, in particular) and their amplitude of endothelial fluctuations (r = 0.38, p = 0.03) of circulation in the arm skin. Persistent correlations between skin count and LDF values were not registered. There was a significant regression of flow-dependent dilation of the brachial artery in SS patients independent of classic cardiovascular risk factors. CONCLUSION: SS patients have defects in regulation of vascular tonicity both in microcirculation and middle-caliber arteries. Vasomotor activity of the middle-caliber vessels is low in the absence of conventional cardiovascular disease risk factors. LDF detects changes in local regulation in cardiovascular patients confirming the role of neuroendothelial disorders in its pathogenesis. The trend to systemic DE in cardiovascular patients is associated with both disease-mediated vascular lesions (ulcers of finger tips, pulmonary hypertension) and cardiovascular disease markers.