Clinical predictors of fever in stroke patients: relevance of nasogastric tube.

OBJECTIVES: Fever frequently occurs in stroke patients and worsens their prognosis. However, only few studies have assessed the determinants of fever in acute stroke, and no study has specifically addressed the possible prediction of the development of fever. MATERIALS AND METHODS: This investigation included 536 patients with acute stroke and a body temperature <=37°C during the first 24 h of stay. Ninety-two of them (17.2%) subsequently developed fever (defined as a temperature >=37.5°C starting after 24 h). Among the clinical variables available during the first 24 h from admission, those predictive of the subsequent appearance of fever were searched for. One hundred further patients had a temperature >37°C during the first 24 h. RESULTS: In univariate analysis, many variables were predictive of the subsequent development of fever, but in multivariate analysis, only the following four predictors remained significant (odds ratio [95% confidence interval], P value): nasogastric tube (4.0 [2.2-7.4], <0.0001), atrial fibrillation (2.3 [1.4-3.8], 0.001), total anterior circulation syndrome (2.0 [1.2-3.5], 0.01), and urinary catheter (1.9 [1.1-3.3], 0.01). Among the 52 (9.7%) patients with three or four predictors, 31 (59.6%) subsequently developed fever. In addition, the factors independently associated with a temperature >37°C during the first 24 h were as follows: National Institutes of Health Stroke Scale (P < 0.0001), hemorrhagic stroke (P = 0.0008), atrial fibrillation (P = 0.002), and total parenteral nutrition (P = 0.03). CONCLUSIONS: In patients with acute stroke, four clinical variables were found to be independently associated with the risk of developing fever and, of them, nasogastric tube was the strongest and most significant one.

A comparison of risk factors as predictors of cardiovascular and non-cardiovascular mortality in the elderly people--relevance of N-terminal pro-B-type natriuretic peptide and low systolic blood pressure.

BACKGROUND: Many risk factors are known to predict ischaemic events and mortality in the elderly people, but their ranking of importance remains uncertain. This study was designed to identify and compare the main predictors of total mortality (TM), cardiovascular mortality (CVM) and non-cardiovascular mortality (NCVM) in older adults. METHODS: Nine hundred and seventy-nine community resident adults aged ≥ 65 years, free of previous heart failure and cardiovascular events, participated in the study. The univariate and multivariate (Cox regression) relationships of baseline cardiovascular risk factors, treatments and laboratory data with TM, CVM and NCVM were assessed after a median follow up of 6.7 years. RESULTS: Overall, there were 104 deaths (30 because of CVM and 74 to NCVM). In multivariate analysis, the following factors remained independently associated with mortality: NT pro-B-type natriuretic peptide (NT-proBNP) upper quintile (≥ 237 pg/ml for men, ≥ 280 pg/ml for women): hazard ratio (HR) vs. the rest of the population (95% confidence interval) 2.34 (1.52-3.60), p < 0.001 for TM; HR 5.41 (2.32-12.65), p < 0.001 for CVM; systolic blood pressure lower quintile (≤ 130 mmHg): HR 3.06 (1.80-5.21), p < 0.001 for NCVM; diabetes: HR 2.46 (1.29-4.72), p = 0.007 for NCVM; erythrocyte sedimentation rate (ESR) upper decile (≥ 41 mm/h): HR 2.33 (1.16-4.69), p = 0.02 for NCVM; platelet count lower quintile (≤ 177 × 10(9) /l): HR 2.09 (1.20-3.64), p = 0.009 for NCVM; ever-smoker status: HR 2.08 (1.23-3.52), p = 0.007 for NCVM. CONCLUSIONS: In elderly community dwellers, NT-proBNP was the strongest predictor of TM and CVM, while especially low systolic blood pressure, together with diabetes, ESR, reduced platelet count and ever-smoker status, were the main predictors of NCVM.

A simple scoring system for outcome prediction of ischemic stroke.

OBJECTIVES: According to most existing models, a computer is usually needed for predicting stroke outcome. Our purpose was to construct a simple and reliable prognostic scale not requiring the use of a calculating machine. MATERIALS AND METHODS: The scale [the Bologna Outcome Algorithm for Stroke (BOAS)] was obtained in 221 patients with ischemic stroke not undergoing thrombolysis and was then validated in a test group of 100 different patients. Outcome was assessed at 9 months as the number of dependent or dead patients (modified Rankin scale - mRS > 2). RESULTS: By a preliminary systematic univariate analysis, 25 of 415 baseline variables were found to be associated with a mRS > 2 independently of stroke severity and age. Subsequent multivariable analyses led to a final model based on five dichotomous risk factors (RF): National Institutes of Health Stroke Scale score ≥10, age ≥78, need of urinary catheter, oxygen administration, and persistence of upper limb paralysis at discharge from stroke unit. The patients with two or more RF (53%) had a mRS > 2 in 91% of cases and were dead in 42% of cases. With 0-1 RF, the two percentages were 24% and 2%, respectively (overall accuracy of prediction 83.9%, area under ROC curve [AUC] 0.891). In the test group, the accuracy was 79.0% and the AUC was 0.839. CONCLUSIONS: The need of urinary catheter, oxygen administration, and persistence of upper limb paralysis, together with stroke severity and advanced age, allow a simple and accurate prediction of dependency or death after ischemic stroke.

The relationship of mean platelet volume with the risk and prognosis of cardiovascular diseases.

BACKGROUND: Mean platelet volume (MPV) is arousing increasing interest as a new independent cardiovascular risk factor. AIM: To provide a comprehensive review on the biological significance, the main determinants and the prognostic implications of MPV. METHODS: A literature search was performed using key terms, such as 'MPV' or 'mean platelet volume', together with 'stroke', 'myocardial infarction' and 'diabetes and 'obesity'. RESULTS: Large platelets are likely more reactive: elevated MPV values are associated with a shortened bleeding time and increased thromboxane B2 plasma levels. Thus, MPV could be considered an indicator of platelet function. Platelet size is mainly determined in the bone marrow during megakaryocytopoiesis, and subsequently does not substantially change. MPV is only partially regulated by thrombopoietin: in fact, growth factors and cytokines may also elicit the production of larger and more reactive platelets in the bone marrow, in the presence of conditions capable of increasing their concentrations, such as obesity, endothelial dysfunction and possibly myocardial and cerebral ischaemia. This phenomenon could play an important role in vascular diseases. In fact MPV is predictive of stroke, acute myocardial infarction (AMI) and restenosis of coronary angioplasty, is increased in the presence of obesity, diabetes mellitus, metabolic syndrome, AMI and stroke and has been shown to have a prognostic significance in patients with stroke and AMI. CONCLUSION: In assessing whole blood count, MPV should not be undervalued, as its increase should suggest a careful assessment of cardiovascular risk.

Association of serum IgA and C4 with severe atherosclerosis.

To assess the possible involvement of humoral immunity in diffuse atherosclerosis, IgG, IgA, IgM, C3 and C4 were measured in the sera of 23 atherosclerotic subjects (at least 3 stenoses greater than 75% in the arteries of the limbs and neck, as assessed by panangiography) and of 20 controls (possible stenoses less than 40% documented by arteriography of the aortic arch and epi-aortic branches and "normal" response to exercise stress testing and Doppler ultrasonography of the arteries of the lower limbs). Age (59-69) and sex distribution did not differ significantly in the 2 groups. The following serum concentrations were higher in the atherosclerotic subjects than in the controls: C4 (28.7 +/- 6.5 (1 SD) vs. 23.4 +/- 3.8 mg/dl; P = 0.0013); IgA (323.3 +/- 155.0 vs. 210.3 +/- 87.9 mg/dl; P = 0.0020); and C3 (126.3 +/- 16.9 vs. 111.0 +/- 18.9 mg/dl; P = 0.0109). To assess whether these parameters were independently associated with atherosclerosis, a multiple logistic regression was performed, also including other variables which differed between the atherosclerotic group and the control group with P values less than 0.20 (cigarette smoking, arterial hypertension, body mass index, serum HDL-cholesterol, HDL-cholesterol/total cholesterol ratio, serum triglycerides, IgG and IgM). In multivariate analysis only IgA (P = 0.0012), C4 (P = 0.0072), cigarette smoking (P = 0.0141) and serum triglycerides (P = 0.0177) were independently associated with atherosclerosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlations between serum lipids and complement components in adults without demonstrated atherosclerotic disease.

The variability due to age and sex and the reciprocal relations of serum IgG, IgA, IgM, C3, C4, total cholesterol (TC), HDL-cholesterol (HDL-C) and triglycerides (TG) were studied in 87 subjects (46 men and 41 women, aged 20-75 years) selected for the absence of significant atherosclerotic lesions. Serum IgA and C3 were higher in men than in women (P less than 0.05) mainly in the age group 41-60, while IgM and HDL-C were higher in women than in men (P less than 0.05 and P less than 0.01, respectively), especially in the age group 20-40. Direct univariate correlations with age were found for serum TC (P less than 0.0001), IgA (P less than 0.001), and C4 (P less than 0.01) but the latter correlations was confirmed only in women by multivariate analysis. These 3 variables had the major increment in the age group 41-60 in men, while in women the increase associated with age was more progressive or late. Univariate analysis showed a 'ring' of highly significant correlations (P less than 0.0001) involving serum lipids and complement components (TC-C4-C3-TG-TC). The correlation between TC and C4 was present only in men in multivariate analysis and improved with increasing age. These findings might represent a clue to explain the previously reported association between serum C4 and atherosclerosis.

Association of serum IgA antibodies to milk antigens with severe atherosclerosis.

The presence of antibodies of the IgA class against dietary antigens (bovine IgG (BGG), beta-lactoglobulin, casein, alpha-lactalbumin and xanthine oxidase, chicken ovalbumin and crude gliadin) was checked in the sera of 23 severely atherosclerotic subjects (ATS) and 20 highly selected controls (C). In these subjects an association between serum IgA levels and atherosclerosis had previously been shown. Determinations were performed by a micro-ELISA method and results were expressed as absorbances at 405 nm x 1000. Higher levels of IgA antibodies were found in ATS with respect to C against beta-lactoglobulin (respectively, 113.4 +/- 152.4 (1 SD) vs. 40.0 +/- 34.2; P less than 0.005) and casein (69.8 +/- 35.5 vs. 52.4 +/- 27.5; P less than 0.05). There was no difference in IgG and IgM against these 2 proteins between the 2 groups. Significant differences of prevalence of IgA antibodies were found for the following antigens: beta-lactoglobulin (4 C and 16 ATS over the limit value of 51; P less than 0.002), xanthine oxidase (1 C and 9 ATS over 289; P less than 0.01), BGG (7 C and 17 ATS over 87; P less than 0.02) and casein (5 C and 14 ATS over 60; P less than 0.02). These data suggest an association between anti-milk IgA antibodies and atherosclerosis. Its relevance and significance deserves further investigation.

Association of serum C3 levels with the risk of myocardial infarction.

PURPOSE: Serum complement and IgA levels have been found to be retrospectively associated with the presence of diffuse atherosclerosis. This study was performed to assess whether serum immunoglobulins and complement components are predictive of future ischemic events. PATIENTS AND METHODS: The baseline values of IgG, IgA, IgM, C3, and C4 were measured in the sera from a cohort of 860 inhabitants of the town of Brisighella, Italy. They were 444 men and 416 women, mean age 53.9 years (SD 12.4, range 23 to 84), who had not had any ischemic events (myocardial infarction [MI], angina pectoris, stroke, transient ischemic attack, or intermittent claudication) at the time of blood sampling in 1984. Their baseline values for the main recognized risk factors for atherosclerosis were known at baseline and for 4 years of follow-up. Multiple logistic regression analysis was performed for associations between ischemic events and immunologic variables (including serum IgG, IgA, IgM, C3, and C4) and risk factors for atherosclerosis (including age, sex, diastolic blood pressure, cigarette consumption, Quetelet index, total cholesterol, HDL cholesterol, triglycerides and blood glucose). RESULTS: During follow-up, 57 subjects experienced ischemic events, including 28 cases of coronary heart disease (17 MI and 11 angina pectoris). Of the immunologic variables studied, only serum C3 was found to be independently associated with ischemic events (P < 0.005 for any ischemic events, coronary heart disease, and MI). The population was divided into thirds according to C3 values. The cumulative incidence of MI was 7.1/1,000 in the low third, 10.6/1,000 in the middle third and 40.8/1,000 in the high third (risk ratio for high versus middle plus low = 4.2 after adjustment for age and sex; 95% CI 1.5 to 11.7). A separate analysis for the sexes showed that serum C3 was a particularly powerful predictor of MI in men. Men whose C3 levels were in the top third had a 72.6/1,000 incidence of MI while the incidence in the rest of the male population was 6.2/1,000 (risk ratio 10.7 after adjustment for age; 95% CI 2.3 to 49.0). When similar analyses were performed for angina pectoris, stroke, and intermittent claudication, no significant increase in risk was found to be associated with serum C3. CONCLUSION: C3 levels measured in sera from male subjects without previous ischemic events are independently associated with the risk of MI.

Peripheral blood markers of inflammation and functional impairment in elderly community-dwellers.

The cross-sectional association of functional impairment with several peripheral blood inflammatory markers (increased C-reactive protein (CRP), fibrinogen and leucocyte count, decreased cholesterol and albumin) was studied in 739 elderly community-dwellers. Functional measures included Tinetti test for gait and balance, and basic and Instrumental Activities of Daily Living. When considering each marker individually, only increased CRP was inversely associated with all functional measures independently of demographics, lifestyle, and comorbidity (P < 0.05). When considering the sum of positive markers, having more than one marker was also inversely associated with all functional measures (P < 0.05), but no clear gradient of impairment was found across increasing numbers of markers. When considering specific combinations of markers, having both increased CRP and at least another positive marker had a stronger association with functional impairment (P < 0.01 for all measures) than increased CRP alone (P > 0.05), or other positive markers alone or in combination (P < 0.05). In conclusion, in elderly individuals, peripheral blood markers of inflammation are associated with functional impairment independently of potential confounders. A specific combination of CRP with other markers provides a better correlate of functional impairment than both individual markers or a simple count of positive markers.

Mortality rates and number of deaths from cardiovascular diseases in Italy from 1982 to 1993. A comparison with total and tumour data.

In this study the recent Italian trends in cardiovascular deaths and mortality are described and compared with the trends regarding total and tumour deaths and mortality. The data, collected from the National Institute of Statistics, are presented as total (T), tumour (TU), cardiovascular (CV), cerebrovascular (CVD), ischemic heart disease (IHD) standardized mortality (sm), non-standardized mortality (nsm) and absolute number of deaths (d), according to sex, age, and geographical area. Data on sm were available only for the age group <75 years old. In males, from 1982 to 1993, T-sm fell by 18%, TU-sm by 4%, CV-sm by 30%, CVD-sm by 38% and IHD-sm by 24%. In females, the decrements were generally greater: T-sm 20%, TU-sm 4%, CV-sm 35%, CVD-sm 39% and IHD-sm 28%. Since 1985/87, tumours have been the leading cause of mortality, in both sexes. By 1991/93, the highest rates of CV, CVD, IHD-sm were reported mostly in the South of Italy. Non-standardized mortality rates for tumours increased, and for cardiovascular diseases decreased, in both sexes and age groups (<75 and >/=75 years old). As for sm, in the group <75 years, old tumours have been the leading cause of mortality since 1985/87, but in the older age group CV-nsm has been more than twice TU-nsm. By 1991/93 in comparison with 1982/84, CV deaths have fallen by 6% (-28% in the age group <75 years, +3% in the age group >/=75 years), while TU deaths have grown by 17% (+3% in the age group <75 years, +45% in the age group >/=75 years). Considering all age groups, by 1991/93 the absolute number of CV-d (239.241) was much greater than the number of TU-d (151.908); overall, almost 70% of CV-d and 40% of TU-d took place in the older age group. For the near future, the rapid aging of the Italian population (from 1982/84 to 1991/93 there was a 40% increment in the population older than 75 years) is a relevant variable to take into account. Thus, despite the 'reassuring' fall in CV-sm and nsm, cardiovascular diseases are expected to remain the major cause of death and physical disability in adults.

Different associations of C-reactive protein, fibrinogen and C3 with traditional risk factors in middle-aged men.

BACKGROUND: Some acute phase proteins are associated with both ischemic events and traditional risk factors. Since they are strongly interrelated, each of them partly reflects the characteristics of other proteins. This study was carried out to ascertain the specific preferential associations of some acute phase proteins with traditional risk factors for atherosclerotic disease. METHODS: High-sensitivity C-reactive protein, fibrinogen and C3-complement were assessed in 288 unselected men aged 55-64 years. Three multiple linear regression analyses were performed, in which each of the three acute phase proteins was considered the dependent variable of both traditional risk factors and the other two proteins. RESULTS: The three acute phase proteins strongly correlated with each other. Moreover, C-reactive protein was independently associated with triglycerides (P<0.0001), age (P=0.0130), body mass index (P=0.0179), and acute (P=0.0280) and chronic (P=0.0582) inflammations (R2=0.17). Fibrinogen was associated with alcohol consumption (inversely, P=0.0001) and smoking (P=0.0598) (R2=0.06). Finally, C3 was associated with insulin (P<0.0001), cholesterol (P=0.0001), sedentarity (P=0.0028), glucose (P=0.0077), and systolic blood pressure (P=0.0124) (R2=0.28). CONCLUSIONS: When simultaneously studied in multivariate analysis, acute phase proteins have different preferential associations with traditional risk factors, a probable consequence of their involvement in different cellular activations and metabolic processes.

Coronary and cerebrovascular atherosclerosis: two aspects of the same disease or two different pathologies?

Cerebrovascular and coronary disease are characterized by some common aspects. Indeed the same risk factors relate to coronary heart disease and to cerebrovascular disease. However, there may be differences in the pathogenesis of atherosclerotic lesions in coronary and cerebral arteries. In fact some populations are characterized by a high incidence of ischaemic stroke and a low incidence of myocardial infarction, while in other populations there is an opposite trend. These differences could be explained on the basis of: genetic risk factors; a different prevalence of risk factors; a different reactivity of the coronary and cerebral arteries to risk factors; anatomical differences concerning coronary and extracranial cerebral arteries with respect to intracranial cerebral arteries. Atherosclerosis is undoubtedly a systemic disorder and its genetic and environmental causal factors are only partly known. The variable incidence of cerebrovascular and coronary heart disease in the same population or in different populations as well as the different nature of atherosclerotic plaques are probably related to the different prevalence of the causal factors, even though these may not always be identified.

Current thinking in statin therapy.

The HMG-CoA reductase inhibitors (statins) are now considered the most potent lipid-lowering drugs. Treatment with statins reduces both morbidity and mortality rates due to coronary artery disease. There is now increasing evidence that the clinical benefits obtained with statins cannot be solely attributed to a decrease in low-density lipoprotein (LDL) level. These drugs may also have beneficial effects on endothelial dysfunction, LDL oxidation, rheological and thrombogenic factors, cellular inflammation and plaque formation and stability. Further, there are differences among the various statins on these non-lipid variables. The biochemical effects of statins, as well as their clinical benefits, should be taken into consideration.

Endothelial dysfunction in hypertension.

Endothelial cells release both relaxing and contracting factors that modulate vascular smooth muscle tone and also participate in the pathophysiology of essential hypertension. Endothelium-dependent vasodilation is regulated primarily by nitric oxide but also by an unidentified endothelium-derived hyperpolarizing factor and by prostacyclin. Endothelium-derived contracting factors include endothelin-1, vasoconscrictor prostanoids, angiotensin II and superoxide anions. Under physiological conditions, there is a balanced release of relaxing and contracting factors. The balance can be altered in cardiovascular diseases such as hypertension, atherosclerosis, diabetes and other conditions, thereby contributing to further progression of vascular and end-organ damage. In particular, endothelial dysfunction leading to decreased bioavailability of nitric oxide impairs endothelium-dependent vasodilation in patients with essential hypertension and may also be a determinant for the premature development of atherosclerosis. Different mechanisms of reduced nitric oxide activity have been shown both in hypertensive states and several cardiovascular diseases, and endothelial dysfunction is likely to occur prior to vascular dysfunction. Thus, the strategies currently used to improve endothelial dysfunction may result in decreased morbidity and mortality in hypertensive patients.

Relationship between serum C3 levels and traditional risk factors for myocardial infarction.

OBJECTIVE: Serum C3, a complement component produced by macrophages, the liver and the adipose tissue, is associated with the risk of myocardial infarction in men. This study was performed to ascertain the relationships between serum C3 and traditional risk factors in an unselected population sample. METHODS AND RESULTS: A random population of 1,068 subjects (537 men and 531 women, 23 to 90 years old) was examined for risk factor assessment. Serum C3 was measured by nephelometry. C3 was independently associated with body mass index (P < 0.0005, especially in women), LDL-cholesterol (P = 0.0014 in men and 0.0215 in women), systolic blood pressure (P < 0.05) and, in women, with triglycerides (P = 0.0133) and blood glucose (P = 0.0383), as assessed by multivariate analysis (multiple linear regression). The overall R2 were 0.07 and 0.21 for men and women, respectively. Women over 50 years of age had significantly higher C3 levels, LDL-cholesterol and body mass index than younger women. The correlation of C3 with LDL-cholesterol was present after the age of 40 in men, and 2 decades later in women. CONCLUSIONS: These data show that serum C3 correlates with a cluster of conventional risk factors for myocardial infarction resembling insulin resistance. Such correlations may be either independent of, or mediated by the development of coronary atherosclerosis.

Conditional risk factors in men with previous myocardial infarction: relevance of C3 and homocysteine.

OBJECTIVE: To establish which traditional and conditional risk factors were effectively treated, and which remained active, in patients with previous myocardial infarction (PMI). METHODS AND RESULTS: In 47 PMI patients recently submitted to cardiological assessment and in 42 controls (50-70 years old men), traditional risk factors (total cholesterol, high-density lipoprotein cholesterol, blood glucose, blood pressure, cigarette smoking and body mass index) and the following variables were measured: fibrinogen, plasminogen activator inhibitor-1 (PAI-1), lipoprotein(a) [Lp(a)], total homocysteine, plasma folates, vitamin B12, high sensitivity C-reactive protein and C3 complement. Most patients were taking beta-blockers, ACE inhibitors and statins. Accordingly, patients had lower blood pressure and cholesterol values than controls. Moreover, they consumed less alcohol and coffee and did not differ from controls in cigarette smoking and body mass index. Conversely, patients had higher levels of homocysteine, fibrinogen, C3 complement and Lp(a), although of these factors only C3 and homocysteine remained significantly associated with PMI in multivariate analysis. C-reactive protein, PAI-1 and especially C3 often correlated with traditional risk factors in controls, but these correlations tended to disappear or reverse in PMI patients. Fibrinogen inversely correlated with alcohol consumption. Homocysteine correlated (inversely) with plasma folates only. Lp(a) did not correlate with any variable. CONCLUSIONS: Forty-seven patients with previous myocardial infarction displayed an excellent control of traditional risk factors, but they had higher mean C3 and homocysteine levels than the control group.

[Cardiac pacemaker and radiotherapy: a growing association. Report of a clinical case]. / Pacemaker cardiaco e terapia radiante: un'associazione in crescita. Descrizione di un caso clinico.

Cardiac pacing is increasingly common. In 1986, in the USA there were more than 500,000 pacemaker-implanted patients and at least 100,000 new pacemaker implants were performed, for a total of 3,000 pacemakers for million inhabitants. The increment in cardiac pacing is due to: a fall in cardiovascular mortality; increased elderly population, in which bradyarrhythmias are frequent; and the introduction of implantable cardioverter defibrillators (ICD). In 1992, in Italy, there were 30,500 deaths due to lung tumours and 10,900 deaths for breast malignancies. Both malignancies are more common in patients older than 65. Lung and breast cancer therapy involves the use of surgery, radiation, or chemotherapy, and often a combination of two or all three. In particular 40% of cancers are managed with radiotherapy. It is therefore likely that cancer patients may require radiotherapy at sites (lung, breast) where a pacemaker is implanted. The authors describe the finding on a chest radiogram of a one centimeter nodular mass at the right superior lobe almost completely hidden by the pacemaker. The modalities to proceed to radiotherapy, without damaging the sensitive pacemaker, are discussed.

Serum IgA antibodies to apoproteins and milk-proteins in severe atherosclerosis.

Total serum IgA and IgA antibodies to some milk antigens are often associated with severe atherosclerosis. In the present study we examined the same serum samples to evaluate the possible involvement of serum IgA antibodies to apoproteins and lipoproteins and their relationship to IgA antibodies to milk antigens. We studied 23 subjects with angiographically assessed atherosclerotic lesions (ATS group) and 20 healthy control subjects with a similar age range (59-69 years) and sex distribution. Anti-ApoB, Apo A-I, Apo A-II and anti-LDL, VLDL and HDL antibodies were measured with the ELISA method. All antibodies tested except those to anti-Apo A-I were significantly higher in the ATS group with respect to controls with a maximum significance for anti-Apo B IgA (p = 0.0018). When, for each antibody, a threshold of positivity was set to the mean + 2 SD of values in the control group, 12 ATS subjects (52%) and 1 control (5%) were found to be positive for either anti-Apo B or anti-Apo A-II IgA. Most of the correlations of anti-apoprotein and anti-lipoprotein IgA with anti-milk protein IgA and total IgA were significant. The association of these antibodies with atherosclerosis might either be specific or represent part of a polyclonal IgA response. Whether this association is a cause or an effect of atherosclerotic disease is presently unknown.

[Treatment of pulmonary embolism. Current status and future prospects]. / Il trattamento dell'embolia polmonare. Attualità e nuove prospettive.

Although still severe, the prognosis of pulmonary embolism has recently improved due to considerable progress in the therapeutic field. This paper concerns the various therapeutic tools, both pharmacologic and surgical, which are already available or under evaluation. Despite the introduction of thrombolytic drugs, heparin remains an indispensable drug. The rationale for its use comes from the need of preventing further clot formation, while endogenous fibrinolysis or thrombolytic drugs are dissolving the already existing clots. Thrombolytic drugs, such as streptokinase, urokinase or rt-PA, have changed the therapeutic strategy of pulmonary embolism, due to their ability to accelerate the normal fibrinolytic mechanisms and to facilitate pulmonary reperfusion. This often allows an early disappearance of symptoms and a reduced incidence of invalidating complications involving the respiratory function. rt-PA seems to be most effective and fast in inducing reperfusion (angiographic signs of clot dissolution are obtained in 82% of the patients within 2 hours). The administration of rt-PA by intravenous bolus has recently been proposed, which would induce an even faster thrombolysis and fewer hemorrhagic complications. The role of surgical therapy has declined after the diffusion of thrombolytic drugs, being reserved only for the most serious cases. When anticoagulation is counter-indicated or not effective, the prevention of embolic relapses can be achieved by percutaneous insertion of caval filters of different types. Some new catheters provided with rotating metallic tips, which allow the mechanical fragmentation of the emboli, are presently under evaluation. Although some improvements are needed, this technique is expected to become soon of general use, especially in cases in which thrombolytic therapy is counter-indicated.

Immunologic changes in circulating leukocytes in the presence of atherosclerotic disease.

To assess the numeric and functional changes in circulating white blood cells in the presence of severe atherosclerosis, 25 subjects with marked, angiographically assessed, atherosclerotic lesions and 29 selected controls were studied. Of the differential leukocyte counts, only monocyte count was significantly higher in the atherosclerotic than in the control subjects (449.0 +/- 115.6 (1 S.D.) vs. 344.1 +/- 138.8/mmc; P = 0.0016). By flow-cytometry no significant differences concerning monocyte surface antigens were found, except a feeble decrease in beta 2-microglobulin in the atherosclerotic subjects. As to lymphocytes, an increase in the CD8 population (33.4 +/- 6.8 vs 28.6 +/- 6.5%; P = 0.0144) and decreases in class I HLA antigen (96.6 +/- 7.3 vs 99.4 +/- 0.7%; P = 0.0049), beta 2-microglobulin (97.9 +/- 2.1 vs 99.3 +/- 1.0%; P = 0.0055) and especially in vivo DNA synthesis (3.8 +/- 1.2 vs 5.3 +/- 2.1%; P = 0.0102) percent expressions were found in the atherosclerotic patients with respect to the controls. This study shows that circulating monocytes are increased in atherosclerotic disease, possibly due to their participation in the phagocytosis of lipids in the arterial wall, with no further immunologic involvement. Conversely, the replicative activity of T lymphocytes is decreased, which might be a consequence of or a factor predisposing to atherosclerosis.