Management of Raynaud's phenomenon. Focus on newer treatments.

Current thinking on the general approaches to handling patients with Raynaud's disease is briefly described, and the principles of management discussed. The various categories of drug treatment available - vasodilators, especially those active on the smallest blood vessels, drugs acting on endothelium and platelets and their products, rheologically active drugs and some whose action it is difficult to classify - are mentioned. By far the most widely tested drugs in this field are the dihydropyridine-like slow calcium channel antagonists, of which nifedipine is probably the best known. Side effects are common and the optimal dosage and drug formulation are yet to be achieved. Serotonin antagonists (naftidrofuryl, ketanserin) look promising, although ketanserin is not generally available yet. Drugs active in the sympathetic control of vascular tone may well be best reserved for the most severe forms of Raynaud's, especially perhaps those associated with tissue loss in the secondary disease. Older vasodilators, such as glyceryl trinitrate (nitroglycerin) and some of the nicotinic acid derivatives, have not been studied of late but the transdermal applications of glyceryl trinitrate at least sound attractive. Drugs active in the cyclo-oxygenase systems, especially those with prostacyclin-like activity or thromboxane antagonists, are obviously promising; however, their unavailability in oral, sublingual or transdermal forms limits comment on them at present. Non-drug approaches such as biofeedback control of vascular responses may be interesting in a small number of patients, but the advice to 'keep warm' (and how to achieve this) is probably the most valuable suggestion that can be given to patients with Raynaud's disease.

The relationship between cyclic AMP changes and histamine release from basophil-rich human leucocytes.

Histamine release and changes in cyclic AMP levels induced by a variety of stimuli have been measured in isolated human leucocytes from a patient with 40-70% basophilia. Adenosine and sodium fluoride induced early monophasic rises in cyclic AMP which peaked at 1 min, but they did not release histamine. 2',5'-Dideoxyadenosine (DDA) caused a transient fall in cyclic AMP levels. Anti-IgE, polylysine and calcium ionophore A23187 induced a slow release of histamine commencing 2-5 min after addition of secretagogue. With polylysine and A23187, release was still proceeding 45 min after challenge. In contrast, the chemotactic peptide formyl-methionyl-leucyl-phenylalanine (f-met-leu-phe) induced a rapid secretion of histamine which was complete within 2 min. Anti-IgE induced a rapid monophasic rise in cyclic AMP which reached a maximum at 45 sec and was inhibited by pretreatment with DDA. Cyclic AMP rises induced by polylysine and f-met-leu-phe were kinetically similar but smaller in magnitude. A23187 caused a later rise in cyclic AMP which peaked 3 min after challenge. A high concentration (50 microM) of compound 48/80 induced a slow cytotoxic release of histamine which was not accompanied by changes in cyclic AMP levels. The inconsistent quantitative and kinetic relationships of histamine release and cyclic AMP production suggest that changes in cyclic AMP levels may not play a key role in the biochemical events leading to mediator secretion from human basophil leucocytes.

Impairment of neutrophil chemotaxis by serum from patients with chronic lymphoproliferative disease.

The sera of 74 individuals with chronic lymphoproliferative disease were screened for the presence of inhibitory activity against neutrophil chemotaxis. This was present in more than half the patients with IgA myeloma and Hodgkin's disease but was less common in chronic lymphocytic leukaemia, lymphocytic lymphoma and non-IgA paraproteinaemia. Heating the sera prior to testing frequently enhanced inhibitory activity particularly in myeloma and lymphoma.

Evaluation and comparison of neutrophil bipolar shape formation with a migration assay.

The neutrophil shape change response to a chemotactic formylpeptide was assessed. Neutrophil bipolar shape formation (BSF) was also simultaneously assessed with a Boyden chamber-based neutrophil migration assay. Both assays were precise and relatively reproducible; the average coefficient of variation for the BSF assay was 9.6% and 9.2% for the migration assay. In a blind study the BSF assay showed 100% sensitivity at detecting subjects with known abnormal neutrophil migration. Unlike the migration assay, the BSF assay does not require isolated neutrophils, reducing possible cell activation and monitoring the cell response under more physiological conditions. Small blood samples--1 ml or less compared with 20-40 ml for the migration assay--are used, and the method is technically simple. Results are available within 40 minutes, and routine (EDTA) blood samples are used. It is concluded that the BSF assay is a suitable motility screening test for both the clinical and pharmacological examination of the movement of polymorphonuclear leucocytes.

Granulocyte chemotaxis: multiple assay screening using a raft technique.

The assessment of granulocyte chemotaxis is complicated by the difficulty of precisely reproducing results in serial estimations and deciding on the best end point which would reflect most accurately the degree of travel taken by the cells under observation. The methods in use are generally based on the Boyden chamber, following this, we have further developed the principle of the "raft" technique of chamber based migration. In order to overcome the problems associated with reproducibility of results when performing multiple assays of chemotaxis, especially when sera of widely differing activity are encountered in the screening procedure, we have used a "batching" system and a simple method of presenting the results so that they are comparable.

Whole blood procoagulant activity in breast and colorectal cancer.

Whole blood procoagulant activity was determined by measuring the recalcification time of citrated blood, with and without the addition of bacterial endotoxin, in patients with breast cancer (n = 39), colorectal cancer (n = 20), benign breast disease (n = 15), benign colorectal disease (n = 11), normal volunteers (n = 15) and inpatients with non-malignant disease (n = 22). The median clotting times of those samples incubated with endotoxin were significantly shorter in the patients with breast and colorectal cancer compared with normal controls. Furthermore, significant differences between the median clotting times of stimulated and unstimulated samples within each subject group were observed only in the two cancer groups. There was no correlation between whole blood procoagulant activity and absolute monocyte counts, with histological staging or with plasma concentrations of plasma fibrinopeptide A. The results suggest that blood from patients with cancer is more sensitive to endotoxin stimulation than that from normal or benign controls, but that in its present form the technique cannot be used to distinguish between malignant and non-malignant disease.

Procoagulant activity in whole blood from patients with breast and colorectal cancer.

Whole blood procoagulant activity was determined by measuring the endotoxin-induced shortening of the celite-activated whole blood recalcification time in patients with breast cancer (n = 29), colorectal cancer (n = 18), benign breast disease (n = 26), benign colorectal disease (n = 10), normal volunteers (n = 17) and surgical in-patients with non-malignant and non-inflammatory conditions (n = 18). Using this method, patients with breast and colorectal cancer produced significantly more procoagulant activity than normal controls (P less than 0.001), surgical in-patients (P less than 0.005) and patients with benign breast (P less than 0.001) and benign colorectal (P = 0.05) disease respectively. The difference between subjects classified as 'cancer' or 'non-cancer' was highly significant (P less than 0.0001). There were no significant differences in total white cell or absolute monocyte counts between subject groups, and in individual patients, there was no correlation between these parameters and the procoagulant activity. It is concluded that the activated whole blood recalcification time is a more reproducible way of measuring whole blood procoagulant activity than the original technique, and that using this method, patients with cancer show higher procoagulant activity than corresponding benign controls.

Assessment of therapeutic control of anticoagulation.

The control achieved in two anticoagulant clinics over 1 year was studied. The result of 430 patient years of treatment in 732 patients was assessed. Overall, the patients were maintained in the therapeutic range (British ratio 2.0-4.0) 85% of the time, 'under-anticoagulated' 10% and 'overtreated' 5% of the time. Patients on long-term treatment had better control than those on short-term treatment (87 and 72% of time in therapeutic range, respectively). Short-term patients were 'undertreated' one quarter of the time. Assessment of the percentage of time individual patients spent within the therapeutic range was a useful index: 77% short-term patients and 99% long-term patients were controlled more than half the time; and 30% short-term plus 40% long-term patients were controlled all the time. Two complementary methods of assessing therapeutic control are used. The standard of control compares favourably with other reports, but shows areas where improvements can be made. For assessment of clinical benefit from anticoagulants, close quality control of treatment by such methods is essential.

The evaluation of neutropenia: the use of the granulocyte mobilization test.

Ten individuals with idiopathic neutropenia and similar numbers of normal and abnormal controls were tested for mobilization of their marginal granulocyte pools and bone marrow reserve by using epinephrine and hydrocortisone intravenously. Individuals with 'benign' idiopathic neutropenia appeared to have a normal response while half the abnormal controls responded poorly. It is suggested that granulocyte mobilization tests are valuable in the assessment of individuals with neutropenia.

Leucocyte numbers and quality: their effect on viscosity.

Leucocyte suspension viscosity was measured using cells from a number of leukaemias. Samples from individuals with acute myelomonocytic and myeloid leukaemias, and chronic myelogenous and chronic lymphatic leukaemias were examined for their viscosity and flow properties. Leucocytes were suspended in native plasma and the effect of variable leucocyte numbers in the ranges seen in some leukaemias (100-600 x 10(9)/l) examined at different shear stresses. The effect of MCV was also determined in relation to viscosity. The results showed an increasing order of viscosity from the leucocytes of chronic lymphatic leukaemia through chronic myelogenous and acute myeloid leukaemia to the acute myelomonocytic variety. This bears some relation to the mean corpuscular volume, but confirms the fact that at high numbers of cells, patients with acute myelomonocytic, and to a lesser extent the myeloid leukaemias, are at considerable risk of blood hyperviscosity.

The morphology and viability of blood components processed by high-gradient magnetic separation.

The effect of high-gradient magnetic separation on blood components has been investigated. For erythrocytes there is no significant change in the morphology, size distribution and in the in-vivo survival times at the confidence level P = 0.05. For neutrophils stimulated nitro-blue tetrazolium reduction is maintained after HGMS. No change in chemotaxis and yeast cell phagocytosis was observed. Platelet distribution curves show no detectable changes before and after filtration. It is concluded that blood separated by HGMS is suitable for diagnostic analysis and may be considered for return to the patient.