Deferred urgency carotid artery stenting in symptomatic patients: clinical lessons and biomarker patterns from a prospective registry.

INTRODUCTION: The aim of this prospective observational registry was to study the outcome of symptomatic patients presenting with recent TIA or minor stroke and severe carotid stenosis, submitted to early percutaneous treatment by stenting. A secondary aim was to evaluate the biological activity of the symptomatic carotid plaques by serial serum and urinary markers (PAPP-A, hs-CRP, MMP-2/MMP-9, IL-6/IL-8, TNF alpha, CD40L) measured by enzyme-linked immunosorbent assay before and after treatment. METHODS: From May 2005 to June 2006, 57 patients were enrolled in this prospective registry. All patients underwent carotid stenting using a concentric filter for cerebral protection. The procedure was performed within 24-48hrs of the last attack in patients with TIA (n=24, 42%) and between 14 and 30 days in patients with stroke (n=33, 58%). RESULTS: Successful stent implantation was achieved in all cases (100%). Adverse events at 1 month were 1 death (1.7%) and 2 TIAs (3.5%). Some of the vulnerability markers, in particular those reflecting an active systemic inflammatory process of the plaque (PAPP-A, hs-CR, and IL-6), were significantly elevated at the time of enrolment, increased after stenting and decreased after 30 days. CONCLUSION: Deferred CAS is feasible and safe in selected patients with symptomatic carotid stenosis. This preliminary study in a limited series of patients with unstable carotid plaques revealed that endovascular treatment has a satisfactory outcome considering the very high risk profile of the patient population. The evaluation of some biomarkers suggested an inflammatory role in the process of an unstable carotid plaque generating an acute cerebral event.

Dipyridamole stress echocardiography and exercise testing for risk stratification after uncomplicated myocardial infarction.

BACKGROUND: Risk stratification for subsequent cardiac events after an acute infarction can be obtained by exercise testing or dipyridamole stress echocardiography. It remains to be determined whether these modalities are equivalent and provide incremental information on top of clinical evaluation. The aim of our study was to compare the prognostic information obtained early after an acute uncomplicated myocardial infarction of high dose dipyridamole coupled with echocardiography (stress echo) or maximal symptom-limited exercise testing. METHODS AND RESULTS: Ninety patients underwent dipyridamole stress echo and exercise testing at a mean +/- SD of 9 +/- 4 days after admission for acute uncomplicated first myocardial infarction. All patients were prospectively followed for 22 +/- 16 months. There were 9 hard events (3 cardiac deaths and 6 acute myocardial infarctions) and 12 soft events due to post MI angina (6 angioplasty and 6 bypass surgery procedures). Univariate predictor of hard events was rest-stress wall motion score index variation (p = 0.009); univariate predictors of all events (hard + soft) were: positive exercise testing (p = 0.001), positive stress echo (p = 0.001), rest-stress wall motion score index variation (p = 0.002), extent of ischemia at echo (p = 0.008). Multivariate analysis by Cox selected a non-Q wave infarction and rest-stress wall motion score index variation as predictors of death or reinfarction (overall chi-square for the model 12.2, p = 0.0022). CONCLUSIONS: Stress echo is superior to ergometric variables for predicting events after uncomplicated myocardial infarction.

Intimal medial thickening of common carotid artery as indicator of coronary artery disease.

The authors investigated the relation between coronary atherosclerosis, angiographically detected, and intimal-medial (I-M) thickening of the common carotid artery (CCA), as measured by high-resolution B-mode ultrasound system. They studied 31 patients with coronary artery disease (CAD) and 23 healthy control subjects. I-M thickening of CCAs and atheromatous plaques at the carotid bifurcation were evaluated. A score system was defined (range 0-20) based on the absence or presence of atherosclerotic lesions at common and internal carotid arteries. A coronary angiography score was defined based on the presence of of atherosclerotic lesions at nine coronary arterial segments (range 0-36). The thickness of CCAs (M +/- SD) in CAD patients was significantly higher (1.45 +/- 0.95 mm) than in controls (0.87 +/- 0.10 mm, P < 0.005), and an I-M thickening of 1.1 mm or more was specific and positively predictive of CAD. A significant positive correlation between coronary and carotid score was observed (P < 0.028, r = 0.373). The study suggests that I-M thickening could be helpful for the identification of patients at risk for CAD.

Activation of cord T lymphocytes. III. Role of LFA-1/ICAM-1 and CD2/LFA-3 adhesion molecules in CD3-induced proliferative response.

As cord T cells, a model of antigen (Ag)-unprimed cell, display a functional defect when stimulated through the CD3 molecule, the role of lymphocyte function-associated antigen 1(LFA-1)/intercellular adhesion molecule 1 (ICAM-1) and CD2/lymphocyte function-associated antigen 3 (LFA-3) receptor-ligand pairs in cord CD3-triggered T-cell activation was analyzed using specific monoclonal antibodies (mAb) against each adhesion molecule. The addition of anti-CD11a, anti-CD18, or anti-CD2 to both adult and cord peripheral blood mononuclear cells (PBMC) cultures led to a decrease in CD3-induced proliferation. In contrast, CD3-stimulated cord, but not adult, PBMC proliferation was markedly enhanced when anti-CD54 or anti-CD58 were added. Despite the fact that ICAM-1 and LFA-3 molecules were virtually absent on cord resting T cells, mAb against these two molecules boosted both mitogenesis of and interleukin (IL)-2 production by purified cord T cells stimulated with plastic immobilized anti-CD3. Cord T-cell supernatant levels of interferon-gamma (IFN-gamma) were undetectable with CD3 stimulation, slightly raised with CD58/CD3 costimulation, but normal when T cells were preincubated with IL-2 for 24 hr before being costimulated with anti-CD3/CD58. Evidence that IL-2 and IFN-gamma play a pivotal role in fully activating cord T cells came from the demonstration that IL-2 and IFN-gamma are able to bypass the CD3-proliferative defect through differential up-regulation of the adhesion molecules. It would, therefore, seem that ICAM-1 and LFA-3 molecules are crucially implicated in the CD3-activation pathway of Ag-unprimed T cells.

Interleukin-6 is constitutively produced by human CTL clones and is required to maintain their cytolytic function.

Maturation of cytolytic T lymphocytes from nonlytic precursors requires cytokines in addition to IL2. Interleukin-6 is the principal cytokine that cooperates with IL2 in the induction of CTL differentiation from murine and human thymocyte precursors. However, a cytotoxic differentiation factor (CDF) role of IL6 for mature T cells is challenged by data indicating that IL2 alone is sufficient for CTL generation. The aim of this study was to identify a model system in which IL6 acted as a CDF for human peripheral T cells. We noted that IL6 was endogenously produced by CTL clones in the course of their expansion with APC, lectin, and IL2. The majority of several hundred T-cell clones, both CD4+ and CD8+, produced IL6 in response to relatively high doses of IL2. Other experiments that compared the cytolytic function of CTL clones cultured in the presence of IL6 with that of the same clones cultured in the absence of IL6 demonstrated that IL6 contributes to the cytolytic ability of the majority of human CTL clones. Our data suggest that IL6 acts in an autocrine fashion to support CTL differentiation in human T-cell clones.

[Immunotherapy in allergic diseases. Evaluation of short-term efficacy of aluminum hydroxide-absorbed slow-release preparations]. / L'immunoterapia nelle malattie allergiche. Valutazione dell'efficacia a breve termine di preparati ritardo assorbiti su idrossido di alluminio.

Clinical and immunological changes after immunotherapy (ITS) for respiratory allergy were evaluated in 29 subjects during a one year follow up period. No adverse effects were noted with alum-absorbed allergen extracts. However, only patients receiving ITS for grass pollens demonstrated clinical improvement and blocking IgG increase as compared with those with multiple allergen sensitivity.

Basis for defective proliferation of peripheral blood T cells to anti-CD2 antibodies in primary Sjögren's syndrome.

Anti-CD2-induced T cell proliferation was analyzed in the peripheral blood samples of 31 primary and 8 secondary untreated Sjögren's syndrome patients. Anti-CD2-stimulated PBMC proliferation was very low in about one-third of primary Sjögren's syndrome samples, despite the number of CD2+ cells being similar in primary and secondary Sjögren's syndrome and normal PBMC samples. The depressed response to anti-CD2 was mainly found in anti-Ro+/La+ patients. Experiments on purified T cells demonstrated that a defect at the T cell level was responsible for the anti-CD2 unresponsiveness. Cell proliferation failure was associated with poor IL-2 and IL-2 receptor mRNA expression and, consequently, IL-2 and IL-2 receptor synthesis. Since defective anti-CD2-induced mitogenesis could be reversed by phorbol myristate acetate, but not calcium ionophore A23187, it is probably correlated with impaired protein kinase C activation. Comparison of anti-CD2-triggered PBMC proliferation in treated and untreated patients and a long-term study of nine patients showed that the defect is a stable characteristic in primary Sjögren's syndrome patients, but that it can be reversed by pharmacological immunosuppression.

[Cardiovascular effects of coffee consumption in the aged: the CASTEL epidemiologic study]. / Effetti cardiovascolari del consumo di caffè nell'anziano: lo studio epidemiologico CASTEL.

The data obtained from 2240 subjects aged 65 years or more from the general population of Castelfranco Veneto (Italy) included in the CASTEL (CArdiovascular STudy in the ELderly) epidemiological Italian project were analyzed in relation to coffee consumption. Subjects were divided into 3 classes: class 1 (N = 109): non coffee drinkers; class 2 (N = 1554): 1 to 2 cups of coffee per day; class 3 (N = 577): 3 or more cups per day. The results were described by ANOVA, Tukey post hoc test and Pearson correlation coefficient with Bonferroni's conservative correction. In classes 2 and 3 total cholesterol, apolipoprotein B100 and calculated LDL-cholesterol were higher than in class 1. The number of cups of coffee per day directly correlated to both the number of cigarettes per day and the number of drinks per week. Although these data seem to indicate a convergence of risk factors (cholesterol, smoking, alcohol) in coffee drinkers, no increase in the prevalence of cardiovascular events was found in coffee drinkers in comparison with non drinkers. This could be attributed to the fact that prevalence of hypertension and diabetes did not increase with increasing coffee consumption; on the contrary, they were lower in classes 2 and 3 than in class 1.

Activation of cord T lymphocytes. II. Cellular and molecular analysis of the defective response induced by anti-CD3 monoclonal antibody.

Despite the fact that the percentage of circulating CD3-positive cells is similar in cord and adult blood, the proliferative response induced by anti-CD3 monoclonal antibody (mAb) was impaired in the majority of human cord peripheral blood mononuclear cell (PBMC) samples we tested. The cell proliferative defect was associated with low interleukin 2 (IL 2) gene expression and scant IL 2 production. However, interleukin 2 receptor was fully expressed at both the mRNA and protein levels. Such a finding is consistent with the observation that exogenous recombinant IL 2 is able to boost the anti-CD3-mediated response of cord PBMC. Furthermore, when anti-CD3 and phorbol myristate acetate (PMA) were added together, they exerted a very marked synergistic effect on both the proliferation of, and IL 2 production by, cord PBMC. The addition of allogeneic antigen presenting cells plus soluble anti-CD3 or Sepharose-coupled anti-CD3 mAb to the cord T cell cultures had no significant effect on proliferation, whereas both elicited good mitogenesis of adult T cells. Moreover, addition of exogenous recombinant interleukin 1 to anti-CD3-stimulated T cells failed to trigger any proliferation in either adult or cord samples. Since the combination of PMA and calcium ionophore A23187 is effective in triggering optimal proliferation of cord T cells, the defect would seem to be associated with a failure in transmembrane transduction of the activation signals provided by the anti-CD3 stimulus for the cord T cell.

Anti-CD3 and anti-CD2-induced T-cell activation in primary Sjögren's syndrome.

Because T-cell dysfunctions have been reported in patients with primary Sjögren's syndrome (SS), peripheral blood mononuclear cell (PBMC) proliferation obtained with anti-CD3 and anti-CD2 monoclonal antibodies was evaluated in these patients. Anti-CD3-induced mitogenesis, which varied widely among the patients, was lower in subjects with evidence of anti-SSA and anti-SSB antibodies than in controls. Moreover, the anti-CD2-induced response was depressed in about half the patients and the nonresponders were mainly those with anti-SSA and anti-SSB antibodies. Phorbol myristate acetate, a protein kinase C activator, used alone or added to anti-CD3, induced greater proliferation in patients than in control PBMC. In contrast, exogenous recombinant interleukin 2 (rIL-2) did not significantly enhance the anti-CD2-induced response of patients' PBMC, as it did in normal PBMC. Peripheral blood and parotid T cells from a patient with well-defined primary SS and parotid enlargement also responded poorly to anti-CD2 stimulation. Exogenous rIL-2 restored T-cell proliferation only in the salivary gland cultures of this patient. The present findings suggest that there is a T-cell activation defect in subjects with primary SS, particularly in those with circulating anti-SSA and anti-SSB antibodies. In addition, the difference in the response to IL-2 of peripheral blood and parotid-infiltrating T cells would seem to indicate that T-cell subsets are differently distributed in the blood and inflammation site.

Activation of cord T lymphocytes. I. Evidence for a defective T cell mitogenesis induced through the CD2 molecule.

A study was carried out on cord blood T cell activation via the CD2-mediated pathway. Despite similar percentages of circulating CD3+ and CD2+ cells in adult and cord blood, the proliferation of cord PBMC to the anti-CD3 mAb and cord T cells to anti-CD2 mAb were defective. The T cell CD3-surface structure was normally able to control CD2-mediated activation, as its modulation by a non-mitogenic anti-CD3 mAb blocked cord PBMC proliferation induced by anti-CD2 mAb. CD2-stimulated cord T cells did not proliferate and did not produce a significant amount of IL-2 in culture, although they expressed the IL-2R. This observation was confirmed by the optimal proliferation of CD2-induced cord T cells when rIL-2 was added. Despite the alternative T cell activation pathway is monocyte-independent in adults, the defective cord T cell activation via the CD2 molecule could also be bypassed by the addition of PMA, small amounts of either autologous or allogeneic adult and cord AC or simply rIL-1 alone. Our findings provide evidence for an intrinsic functional defect in cord CD2-mediated T cell activation, which is linked to an impaired increase of free cytoplasmic calcium, as confirmed by the effectiveness of calcium ionophore A23187 in restoring a good CD2-induced cord T cell proliferation and by measurement of cellular calcium uptake after activation via the CD2 molecule. The characteristics of cord T cells revealed by this study recall the thymocyte functional pattern and may represent functional expression of the previously described phenotypic immaturity of cord T cells.

X-ring Turner's syndrome with combined immunodeficiency and selective gonadotropin defect.

A rare association of chromosomal, immunological and endocrine defects is described in a young woman with short stature, recurrent pulmonary infections and primary amenorrhea. Cytogenetic studies showed a 45, X karyotype in 65% of peripheral blood lymphocytes and 46,Xr(X) (p22q27) karyotype in the remaining 35%. Severe immunodeficiency was revealed by phenotypical and functional studies and a selective gonadotropin defect was disclosed by endocrinological investigations. An attempt is made to explain the coexistence of the three abnormal pictures.

Interleukin 6 is the principal cytolytic T lymphocyte differentiation factor for thymocytes in human leukocyte conditioned medium.

The formation of CD8+ killer cells from nonlytic thymocyte precursors is mediated by interleukin 2 and a cytokine termed CTL differentiation factor (CDF). While several reports have focused on the effects of recombinant molecules on the development of CTL, the natural protein responsible for CTL development that is produced by normal leukocytes has not been conclusively identified. A 24 kD native protein with CDF activity was enriched from leukocyte conditioned medium and neutralizing antibodies were produced. Utilizing immunoaffinity chromatography and reverse phase chromatography, we purified this CDF to homogeneity. All 21 amino acid residues at the NH2-terminus of CDF were found to be identical to that of IL-6. Natural CDF and IL-6 share many of the same biological properties, including costimulation of thymocyte proliferation with IL-1. Antibodies against CDF or IL-6 can block the activity of either cytokine, and anti-CDF blocks the activity of bulk leukocyte conditioned medium. These results indicate that IL-6 is the principal CTL differentiation factor produced by stimulated human leukocytes.

Analysis of CD4-positive T cell subpopulation in sarcoidosis.

Double-labelling immunofluorescence analysis within the CD4+ cell subset was carried out in 27 bronchoalveolar lavage fluids and 11 peripheral blood samples of sarcoidosis patients with anti-TQ1, anti-2H4 and anti-4B4 monoclonal antibodies. Helper/inducer CD4+TQ1-/4B4+ cells were strongly increased in the lung and slightly, but significantly, decreased in the blood of sarcoidosis patients with respect to normal controls. No differences were found in the number of both lung and blood CD4+2H4+ cells between sarcoidosis patients and controls. The findings are further evidence for a compartmentalization of T cell subsets in sarcoidosis.

Identification of a 24-kDa cytokine that is required for development of cytolytic T lymphocytes.

It is known that the production of cytolytic T lymphocytes requires growth factors such as interleukins 2 and 4 (IL-2 and IL-4). Elsewhere we have described bioassays that detect a cytokine that operates in concert with growth factor to generate cytolytic T lymphocytes. The factor that is termed cytolytic T-lymphocyte differentiation factor (CDF), together with IL-2 and lectin, mediates the formation of CD8+ killer cells in 2 days from thymocyte or peripheral lymphoid precursors. CDF is not mimicked by natural or recombinant sources of interferons, colony-stimulating factors, and IL-1 to IL-4. Here we use these bioassays to isolate and further characterize a single 24-kDa CDF protein from the conditioned medium of stimulated human blood mononuclear cells. CDF is first enriched by three successive chromatographic procedures that utilize anion exchange, hydroxyapatite, and phenyl-Superose. A single 24-kDa band with CDF activity is then isolated on 12% NaDodSO4/PAGE and clearly distinguished from the 17-kDa band of IL-2. The apparent molecular mass is similar under reducing and nonreducing conditions. After elution from NaDodSO4/PAGE the cytokine is maximally active at 0.25 nM in the CDF assay and has no growth factor activity for T lymphoblasts. To generate cytolytic CD8+, CD4- cells from spleen and lymph node T lymphocytes, IL-2 and small numbers of accessory dendritic cells must be applied together with CDF.

Thymic hormone modulation of CD38 (T10) antigen on human cord blood lymphocytes.

We studied the in vitro effect of three different thymic factors on the expression of CD38 (T10) antigen on cord T-lymphoid cell surface. The results showed that cord mononuclear cell populations contain variable percentages of CD38+ cells. The CD38 molecule was expressed on cord T and B lymphocyte and monocyte surfaces. Incubation with thymic agents induced a significant increases in the CD38+ cell percentage only in the samples with low CD38 antigen expression, and this modulation was mainly attributable to the T-cell subset. The effect seems to be specific and not correlated with the known high spontaneous DNA synthesis rate of cord mononuclear cells.

Phenotypic and functional abnormalities of T lymphocytes in pathological hyperprolactinemia.

The phenotype and function of T cells circulating in patients with pathological hyperprolactinemia were analyzed and compared to those in sex- and age-matched control subjects. Two-color immunofluorescence study revealed an increased number of CD4+ TQ1+ cells and the presence of phenotypically immature CD1+ T cells, also exhibiting transferrin surface receptor, in peripheral blood of the hyperprolactinemic patients. After chronic treatment with the dopamine agonist bromocriptine, T-cell abnormalities disappeared. In addition, some untreated patients showed enhanced T-cell suppressor activity in an in vitro pokeweed mitogen-driven B-cell transformation assay. These immunological findings confirm a link between neuroendocrine and immune systems in humans.

Bioassays for the detection of a cytokine that enhances the development of cytolytic T lymphocytes.

Interleukin 2 (IL-2) is an important growth factor for cytolytic T lymphocytes (CTL). Other factors here termed cytolytic differentiation factor(s) (CDF) may be required for CTL responses, but it has been difficult to identify suitable bioassays. We report a polyclonal assay in which lytic activity develops after 2 days of culture with lectin and lymphokines. CDF is required for the development of Thy-1+, CD8+, CD4- CTL in this assay. The responsive T cells are thymocytes from certain strains of mice (A, Swiss NCS, B6.H-2k) or peripheral T cells cultured in the presence of high doses of hydrocortisone acetate. If these precautions are taken, little or no lytic activity develops in the presence of rIL-2 alone. CDF is present in the media of mitogen-stimulated mouse spleen or human blood mononuclear cells, but not in the conditioned media of a number of mouse and human cell lines. It is immunologically distinct from IL-2, but only acts in concert with IL-2 to induce CTL. A large panel of available mouse and human cytokines do not synergize with Il-2 in the bioassay. These include interferons, colony-stimulating factors, lymphotoxin/tumor necrosis factor, and IL-1, -3, and -4. Therefore a distinct CDF(s) seems essential for the induction of at least some CTL. The assays described here should be useful in purifying the molecule responsible for this biological activity.