Epidemiologic aspects of abnormal ankle brachial index in the HIV infected population.

AIM: HIV infection is strongly associated with accelerated vascular atherosclerosis and increased cardiovascular events. The prevalence of peripheral arterial disease (PAD) in HIV infected patients is not clearly defined and the results of different reports are contradicting. OBJECTIVE: To determine the prevalence of abnormal Ankle Brachial Index (ABI) and associated risk factors in HIV infected population. METHODS: The ABI was measured manually using 5.0 MHz handheld Doppler probe in 173 HIV infected patients. The cohort was categorized according to the ABI measurements as; normal group (ABI 0.9 to 1.3), peripheral arterial disease (PAD) group (ABI<0.9), and High ABI group (ABI>1.3). Several demographic, atherosclerosis risk factors and HIV infection parameters have been evaluated as potential risk factors. RESULTS: Median age of the cohort was 49 years (inter-quartile ranges [IQR]: 42.5 to 54); 63.4% were males. Abnormal ABI was found in 47(27.2%) patients; twenty four (13.9%) had PAD and 23(13.3%) had high ABI. Among the risk factors evaluated, we observed that PAD group is associated with diabetes (Relative risk [RR]: 4.19; 95% confidence interval [CL]: 2.13 to 8.27; P=0.0002) and age above 49 (Relative risk [RR]: 3.96; 95% confidence interval [CL]: 1.56 to 10.0; P=0.002). However, the High ABI group was significantly associated with male gender (RR: 3.94; 95% CI: 1.23 to 12.70; P=0.009). CONCLUSION: HIV infection is associated with increased prevalence of abnormal resting ABI.

An emergency physician activated protocol, 'Code STEMI' reduces door-to-balloon time and length of stay of patients presenting with ST-segment elevation myocardial infarction.

INTRODUCTION: National consensus guidelines recommend that ST-segment elevation myocardial infarction (STEMI) patients achieve a door-to-balloon time of < 90 min. We sought to determine if emergency physician initiated simultaneous activation of the cardiac catheterisation laboratory team and the on-call interventional cardiologist has any impact on reducing door-to-balloon-times at our hospital. METHODS: A total of 72 consecutive STEMI patients were evaluated from January 2007 to December 2007. The emergency physician activated Code STEMI required concurrent activation of cardiac catheterisation personnel and the on-call interventional cardiologist by the emergency physician. These patients were compared with our staff cardiologist activated primary angioplasty protocol from January 2006 to December 2006 for 51 consecutive STEMI patients. The primary outcome was to measure median door-to-balloon time between both groups. Secondary end-points included the individual components of door-to-balloon times (i.e. door-to-ECG time), peak troponin-I level within 24 h, length of stay and all-cause in-hospital mortality. RESULTS: Median door-to-balloon time decreased overall (112 vs. 74 min, p < 0.001). Of the three components of door-to-balloon time analysed, the ECG to cardiac catheterization laboratory time exhibited the largest area of improvement with 16 min absolute reduction in median door-to-balloon time. Median peak troponin levels (50 vs. 25 ng/ml, p < 0.001), and hospital length of stay (4 vs. 3 days, p < 0.01) decreased. We did not see any statistically significant difference in all-cause in-hospital mortality (p = 0.6). CONCLUSIONS: Emergency physician activation of the Code STEMI significantly reduces door-to-balloon time to within national standards of care, and length of stay in STEMI patients.

Statins may reduce episodes of exacerbation and the requirement for intubation in patients with COPD: evidence from a retrospective cohort study.

INTRODUCTION: Statins have diverse anti-inflammatory effects in addition to their lipid-lowering ability. This study assesses the rate of chronic obstructive pulmonary disease (COPD) exacerbation and intubations in patients taking statins. METHODS: This is a retrospective cohort study of 185 patients with COPD exacerbation, with a 1-year follow-up. Outcomes examined were repeat hospitalisation and intubations for COPD exacerbation. Baseline characteristics for which the p-value was < or = 0.10 were considered as covariates for inclusion in a multivariate model. RESULTS: The statin group had fewer episodes of exacerbation and required intubation fewer times than the subjects not receiving statins (p < 0.0001 for both outcomes). Unadjusted odds ratios (OR) for no statin use vs. statin use were 9.54 (95% CI: 4.54-20.02) for exacerbation and 10.47 (CI: 4.56-24.01) for intubation. The OR, adjusted for the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ORa), were 2.35 (CI: 1.01-5.50) for non-statin users exhibiting an exacerbation and 10.36 (CI: 2.77-38.76) for this group requiring intubation, compared with statin users. Similarly, ORa for long-acting beta(2) agonists as a covariate were 3.01 (CI: 1.46-6.10) for exacerbation and 8.89 (CI: 3.67-21.32) for intubation. Time to outcome during the observation period was reduced by statins with the hazard ratio (HR) for exacerbation of 0.19 (CI: 0.06-0.14); HR for statins reducing intubation was 0.14 (95% CI: 0.10-0.30). CONCLUSIONS: These data suggest that the use of statins may be associated with lower incidence of both exacerbations and intubations in patients with COPD.

The influence of lipid composition and divalent cations on annexin V binding to phospholipid mixtures.

Annexin V is a 36-kDa protein which, it has been suggested, is a factor in protecting the vascular endothelium from attack by antibodies to other phospholipid-binding proteins. Competition between annexin V and beta2-glycoprotein I (beta2GPI) for phospholipid surfaces is complicated by empirical observations regarding alterations in binding to anionic phospholipid, primarily phosphatidylserine. In order to elucidate the effect of phospholipid composition and divalent cations (Ca(+2) and Mg(+2)) on annexin V binding to phospholipid, we used biotinylated annexin V and peroxidase-conjugated avidin D to probe the binding of annexin V to phospholipid-coated wells of polystyrene microtiter plates. Binding of annexin V to anionic phospholipid is Ca(+2)-dependent and, in its absence, annexin V was found to bind most avidly to 100% phosphatidylcholine in a saturable manner, followed by decreasing percentages of phosphatidylcholine. Ca(+2) was found to inhibit phosphatidylcholine binding and promote the binding of phospholipid mixtures containing phosphatidylserine. Phosphatidylserine (100%) did not bind annexin V as strongly as mixtures of 50% and 75% phosphatidylserine. The effect with Ca(+2) suggests saturation of Ca(+2)-binding sites on annexin V, reached under our experimental conditions at approximately 1 mM. Under the same conditions, Mg(+2) slightly enhanced the binding of all of the phospholipid compositions studied. Ca(+2)-dependent binding of annexin V was competitively inhibited by Mg(+2); 5 mM Mg(+2) reduced binding significantly (p < 0.0001 by ANOVA, p < 0.05 for post hoc test of 5 mM vs 0 mM). These data suggest that the translocation of membrane phospholipid under the dynamics of ion transport in vascular endothelium may alter annexin V binding.

The hololipoprotein complex of beta(2)-glycoprotein I and dicaproyl phosphatidylserine.

The ability of beta(2)-glycoprotein I (formerly referred to as apolipoprotein H) to act as an autoantigen for antibodies from patients with antiphospholipid syndrome is dependent upon its binding in vivo to anionic phospholipid surfaces or to surfaces in vitro which mimic their surface characteristics. The ability of the autoepitope(s) of beta(2)-glycoprotein I to be exposed by binding a short-chain (6-carbon), anionic phospholipid has not been explored. Here, we describe our studies of the hololipoprotein generated by reacting beta(2)-glycoprotein I with dicaproyl phosphatidylserine. The formation of the complex is accompanied by inhibition of beta(2)-glycoprotein I binding to phospholipid-coated polystyrene surfaces, with 50% reduction in binding occurring at about 10 mM. At concentrations >10 mM, dicaproyl phosphatidylserine also displaces beta(2)-glycoprotein I bound to anionic phospholipid surfaces. Physicochemical studies suggest that at DCPS concentrations >6 mM, the solutions are colloidal and that beta(2)-glycoprotein I forms a supramolecular complex with organized phospholipid structures. Using a standard human autoimmune anti-beta(2)-glycoprotein I plasma, as well as a series of six additional sera from patients with antiphospholipid syndrome, the complex did not generate a detectable epitope. We conclude that lipid binding, per se, is not sufficient for the presentation of the epitope(s) of beta(2)-glycoprotein I or its recognition by autoantibodies from patients with antiphospholipid syndrome.

Binding of complement component C1q to anti-beta2 glycoprotein I antibodies from patients with antiphospholipid syndrome.

OBJECTIVE: To determine if anti-beta2 GPI reactive with surface-bound beta2 GPI can bind C1q, i. e. to determine whether surface-bound beta2 GPI-anti-beta2 GPI immune complexes can initiate the classical pathway of complement activation. METHODS: Beta2 GPI was bound to chemically-activated microtiter plates which had previously been shown to promote anti-beta2 GPI reactivity with bound beta2 GPI. Wells with surface-bound beta2 GPI (capped with bovine serum albumin) were then reacted with complement-inactivated sera from antiphospholipid syndrome patients (APS) or with control sera. Following removal of unbound serum components, the wells were incubated with biotinylated C1q and probed with peroxidase-conjugated avidin D. Bound C1q was detected at 450 nm using tetramethyl benzidine/peroxidase as a substrate system and expressed as absorbance units (Abs). RESULTS: The identified 20 APS with elevated anti-beta2 GPI: 4 with IgG only, 4 with IgM only, 1 with IgA only, 1 with IgG and IgA, 6 with IgG and IgM and 4 with IgG, IgA and IgM. C1q binding from 20 healthy controls was 0.039 +/- 0.029 (SD). Of the APS, 17/20 (85%) had Abs >5 SD above controls. The 3 APS with C1q Abs within normal limits had, respectively, IgM only (1), IgA only (1), and both IgG and IgM (1). Statistical analyses (Kruskal-Wallis followed by Dunn's post test) suggest differences in IgG and IgG + IgM groups compared to con (Kruskal-Wallis: p = 0.0002; Dunn's: con vs. IgG, p < 0.05; con vs. IgG + IgM, p < 0.01). CONCLUSIONS: Anti-beta2 GPI from APS appear to have a variable degree of C1q affinity. Those patients with strong C1q binding responses are likely to have an inflammatory component to their disease processes.

Modification of beta 2glycoprotein I by glutardialdehyde. Conformational changes and aggregation accompany exposure of the cryptic autoepitope.

Autoantibodies from patients with antiphospholipid syndrome (APS) recognize an epitope on beta 2glycoprotein I (beta 2 GPI) only when native beta 2 GPI is adsorbed on surfaces composed of anionic phospholipids or oxidized polystyrene. beta 2 GPI was modified with the crosslinking agent, glutardialdehyde (GDA), which induced exposure of the anti-beta 2 GPI epitope at GDA:beta 2 GPI mol ratios in the range of 500-2000. A second crosslinking agent, dimethyl-suberimidate (DMS), did not expose the epitope, which may be a consequence of its having less tendency than GDA to form intermolecular links. SDS-PAGE experiments demonstrate that GDA does promote extensive intermolecular crosslinking of beta 2 GPI, and DMS does not. Formaldehyde also reacts with the lysine residues of beta 2 GPI, but does not expose the epitope. The circular dichroism spectra of native and modified beta 2 GPI confirm that GDA induces changes in conformation that are qualitatively different from those caused by formaldehyde. These data provide evidence that binding of lysine residues is not a sufficient condition for exposure of the autoepitope, and also support the likelihood that anti-beta 2 GPI antibodies bind only to aggregates of the protein. Thus, by synthesizing an active holoantigen of beta 2 GPI, conditions were defined that are necessary for binding of human autoantibodies.

Inhibition of beta 2glycoprotein I binding to anionic phospholipids: a strategy for the development of antiphospholipid syndrome-specific drugs.

The binding of beta 2glycoprotein I (beta 2GPI) to anionic phospholipids (PL) leads to the presentation of one or more epitopes recognized by autoantibodies from patients with antiphospholipid syndrome (APS). The inhibition of beta 2GPI binding to PL mixtures coated on polystyrene microtiter wells (MTW) and to large, multilamellar PL vesicles (LMV) was examined. Inhibitors included phosphorylated monosaccharide metabolites, myo-inositol monophosphate (IMP), hexaphosphate (IHP) and hexasulfate (IHS), pyrophosphate (PPi), methyl bisphosphonate (MBP) and phenyl phosphonate, and a series of carboxylic and aromatic sulfonic acids. Inhibitors were incubated with beta 2GPI at 37 degrees C for 2 hr either with dimyristoylphosphatidic acid, 80%/dimyristoylphosphatidyl choline, 20% (DMPA/DMPC) coated on MTW or in a suspension of LMV. Phospholipid-bound beta 2GPI to PA/PC on MTW was detected using an immunoassay based on rabbit anti-beta 2GPI; free beta 2GPI (not bound to LMV) was detected by fluorescence spectroscopy. Inhibition was studied over the range 0.01-9.0 mumoles/10(-4)L (0.1-90 mM). Inhibition at maximum concentration in the MTW system ranged from 0.1% (for ADP) to > 94% (for IHP). IHP also provided the greatest inhibition in the LMV system (76%) and was also effective in displacing beta 2GPI already bound to PL surfaces (approximately 50% displaced at 0.25 mM). These data suggest that a strategy for development of therapeutic agents for APS may be based on the use of small cyclic, organic oligoanions such as inositol derivatives to act as ligands for lysine residues at the PL binding site of beta 2GPI.

Standardized measurement of major immunoglobulin class (IgG, IgA, and IgM) antibodies to beta2glycoprotein I in patients with antiphospholipid syndrome.

Patients with the antiphospholipid syndrome (APS) have autoantibodies directed against epitopes on beta2 glycoprotein I (beta2GPI). We describe herein the performance characteristics of standardized enzyme-linked immunosorbent assays (ELISAs) for anti-beta2GPI of the three major immunoglobulin classes: IgG, IgA, and IgM. All three assays generated highly linear standard curves (5 points, r > or = 0.993 for each); precision was excellent both intra-assay and run-to-run, with coefficients of variation (CV) ranging from 2.3% to 6.6%. Values for IgG anti-beta2GPI correlated strongly with those obtained by an earlier method (r = 0.80, P< 0.0001). A study group consisting of 203 healthy subjects was used to generate percentile-based reference intervals for all three classes of anti-beta2GPI. APS subjects' anti-beta2GPI were found to differ significantly (P <0.0001 for each) from those of the control population. All three assays correlated well with beta2GPI-dependent anticardiolipin antibody (aCL) measurements; IgG: r = 0.94 (P <0.0001), for IgA: r = 0.82 (P<0.001) and for IgM: r = 0.84 (P<0.0001). We suggest that these ELISAs may provide valuable standardized measurements of IgG, IgA, and IgM anti-P2GPI.

A stable, multi-subunit complex of beta2glycoprotein I.

Beta2glycoprotein I (beta2GPI) is a 54-kDa plasma protein which is recognized as an autoantigen for antibodies from patients with antiphospholipid syndrome (APS). SDS-PAGE (under reducing conditions) of beta2GPI from three sources indicates that the 54-kDa beta2GPI band is accompanied by a band corresponding to an 8-kDa protein. In the absence of detergent and reducing agents (native PAGE), beta2GPI demonstrated a large complex (molecular mass approximately 320 kDa) which is dissociable by boiling in 6-8 M urea, yielding several lower molecular mass bands, one of which corresponds to the 8-kDa protein observed in SDS-PAGE. Sera from five healthy adults demonstrated native beta2GPI migration equivalent to the commercially purified protein. Atomic force microscopy (AFM) images of native beta2GPI show aggregrates of particles each having a diameter of 30-35 nm. This is consistent with a globular unit the size of which would be substantially larger than that expected for a 54-kDa protein. These experiments suggest that the 54-kDa beta2GPI monomer subunits exist as a multimeric complex with the 8-kDa protein.

Phospholipid-independent binding of beta 2glycoprotein I by IgA from patients with antiphospholipid syndrome.

beta 2glycoprotein I (beta 2GPI) is a phospholipid-binding protein of the coagulation system. In patients with the antiphospholipid syndrome (APS), antibodies to beta 2GPI contribute to the population of "antiphospholipid antibodies" measured in the anticardiolipin antibody (aCL) assay. In fact, both IgG and IgM antibodies from patients with APS bind beta 2GPI in the absence of anionic phospholipids if the antigen is bound to a suitable surface, i.e., one which exposes the epitope. The binding of IgA was studied from patients with APS, using an enzyme-linked immunosorbent assay (ELISA), and significantly higher binding of IgA was observed from 39 patients compared to a control group of 50 healthy individuals (p < 0.0001). Moreover, 15 out of 39 APS subjects (38 percent) exhibited binding greater than 5 standard deviations (SD) above the mean of the control group. All 39 APS patients had elevated IgG anti-beta 2GPI; however, depletion of IgG from two APS sera diminished, rather than enhanced, binding of IgA. Pre-incubation with purified IgG from a subject with APS led to inhibition of IgA binding at inhibitor levels > 125 micrograms IgG/well. These data demonstrate that patients with APS have IgA anti-beta 2GPI autoantibodies and that the epitope(s) which are recognized by these antibodies can be presented in the absence of cardiolipin or other anionic phospholipids.

The association of antibodies to beta 2 glycoprotein I with the antiphospholipid syndrome: a meta-analysis.

The precise target of marker autoantibodies in the antiphospholipid syndrome (APS) has been controversial. Recently, the theory that surface-bound beta 2 glycoprotein I (beta 2 GPI) presents a normally encrypted autoepitope and that antibodies to beta 2 GPI (anti-beta 2 GPI) are associated with APS, has been prominent. The literature has been searched from 1990 to 1995 (inclusive) to find studies in which: (1) anti-beta 2 GPI antibodies were measured and, (2) adequate clinical data describing the patients were included. These conditions were met in four studies, from August 1992 to December 1995, in which patient samples ranged from 15 to 39 cases, the total of the four studies being 90 cases. Applying the diagnostic criteria of > or = 2 clinical manifestations of APS, 65 cases had APS while 25 did not. For the group with APS, 58/65 (89 percent) were anti-beta 2 GPI (+); among those who did not meet the criteria, 11/25 (44 percent) were anti-beta 2 GPI (+) (p < 0.0001). The presence of either the primary (1 degree) or secondary (2 degrees) form of APS made no difference in association with anti-beta 2 GPI; 13/16 (81 percent) patients with 1 degree APS and 45/49 (92 percent) with 2 degrees APS had anti-beta 2 GPI. The presence of lupus anticoagulant (LAC) did not predict APS: 25/58 (38 percent) APS (+) cases were LAC (+); 11 APS (-) were all LC (+) (p < 0.0001). IgG anticardiolipin also showed a closer association with APS absence (25/25 cases; 100 percent) than with APS presence (40/65; 62 percent, p < 0.0001). These data support the contention that anti-beta 2 GPI antibodies are closely associated with APS and that their measurement may facilitate the diagnosis.

Antibodies to beta 2 glycoprotein I: standardized immunoassay and a reference interval for healthy controls.

Patients with antiphospholipid syndrome (APS) demonstrate an antibody reactivity with beta 2 glycoprotein I (beta 2 GPI) independent of the anionic phospholipids that previously had been believed to be the relevant autoantigens associated with this syndrome. Immunoassays for IgG anti-beta 2 GPI have, however, suffered from a lack of standardization. In this article, we describe an assay based on reference standards that we developed recently. The assay exhibits excellent linearity, with regard to both application of the standards and dilution of out-of-range specimens. Precision was assessed both within the between run and was judged to be satisfactory. A reference interval was developed on the basis of a control group consisting of 111 men and 93 women, yielding a range of 0-19 standard IgG anti-beta 2 GPI units (SGU) for the ninety-fifth percentile of values. These data suggest that this standardized anti-beta 2 GPI assay may be useful in the clinical diagnostic laboratory.

Analytical and clinical relationships between human IgG autoantibodies to beta 2 glycoprotein I and anticardiolipin antibodies.

OBJECTIVE: To examine IgG anti-beta 2 glycoprotein I (anti-beta 2 GPI) binding in 82 sera referred for anticardiolipin antibody (aCL) testing and to develop preliminary clinical correlations with antiphospholipid syndrome (APS). METHODS: Immunoassay of IgG cofactor dependent aCL and IgG anti-beta 2 GPI antibodies and retrospective chart review. RESULTS: Forty-four sera exhibited normal (< or = 22 GPL units) aCL activity, 18 had moderate binding activity (23-45 GPL units), and 20 had high (> or = 46 GPL units) binding activity to cardiolipin. Among these groups, 6 of the 20 sera in the high GPL group had elevated anti-beta 2 GPI. This correlated strongly with 2 or more clinical manifestations of APS. CONCLUSION: Anti-beta 2 GPI activity may be a more valuable indicator of APS than aCL.

Biphasic response of complement to heparin: fluid-phase generation of neoantigens in human serum and in a reconstituted alternative pathway amplification cycle.

We describe a study of the effects of heparin on complement activation through the use of assays for fragment C4d, fragment Bb, and the S-C5b-9 complex (S-MAC). In sera from healthy volunteers, virtually no change was observed in C4d either as a function of time or of heparin concentration, whereas changes in Bb and S-MAC were biphasic. This observation was explored in greater detail in the heparin concentration range 0.001-5.0 u/ml (5 x 10(-3) to 25 micrograms/ml). For both Bb and S-MAC, a significant (P < 0.05) increase in production was noted in the heparin concentration range, 0.01-0.5 u/ml (5 x 10(-2) to 2.5 micrograms/ml). At higher heparin concentrations, Bb and S-MAC production decreased markedly (P < 0.05). We reconstituted the alternative pathway amplification cycle (C3, factor B, and factor D) and studied Bb generation. With reactants at concentrations one tenth those of normal serum, we observed a maximum generation of 13.2 micrograms/ml Bb. Control and heparin at 5 x 10(-4) micrograms/ml generated Bb concentrations of 6.8 and 6.1 micrograms/ml, respectively, for a 2-min incubation; at 5 x 10(-3) micrograms/ml heparin, Bb was increased to 9.8 micrograms/ml. Using isoelectric focusing to study anionic pI shifts in heparin-bound factors B and D, it was found that factor B bound heparin only at the highest heparin concentration studied, i.e., 50 micrograms/ml; factor D, however, bound heparin at a much lower concentration (0.05 micrograms/ml). We conclude that, at low concentrations, heparin activates complement due to potentiation of the alternative pathway amplification cycle in the fluid phase.

Binding of beta 2 glycoprotein I to activated polystyrene and its recognition by human IgG autoantibodies.

Beta 2 glycoprotein I (apolipoprotein H, beta 2GPI) is involved in the formation of epitope(s) recognized by clinically relevant autoantibodies from patients with antiphospholipid syndrome. We studied the binding of beta 2GPI to chemically activated polystyrene in a microtitre plate format. Adsorption isotherms (at 37 degrees C) were generated for beta 2GPI on activated polystyrene and on unactivated polystyrene, with both human serum antibodies and rabbit polyclonal IgG antibodies as probes, and horseradish peroxidase (HRP)-tagged anti-IgG to detect binding. Additionally, beta 2GPI was biotinylated and isotherms were developed by using HRP-streptavidin as the recognition sequence. Human serum autoantibodies, which did not precipitate beta 2GPI in solution, yielded a characteristic chemisorption isotherm on activated polystyrene but did not recognize beta 2GPI bound to untreated polystyrene. The rabbit IgG, which did precipitate beta 2GPI in solution, detected beta 2GPI bound to both activated polystyrene and, to a lesser extent, to untreated polystyrene. The binding of beta 2GPI to untreated polystyrene was confirmed by the use of biotinylated beta 2GPI. To assess the prevalence of IgG anti-beta 2GPI autoantibodies, we surveyed 113 sera submitted to our laboratory for anticardiolipin antibody (aCL) testing. Only nine (8%) had anti-beta 2GPI activity greater than two standard deviations above the mean for those sera in which aCL activity was within normal limits. We conclude that epitope presentation of beta 2GPI for human autoantibody binding is dependent on surface properties of the polystyrene, and that beta 2GPI autoantibodies are found only in a subpopulation of sera positive for aCL.