[Cardiovascular prevention: new biochemical plasmatic markers of risk]. / Prevenzione cardiovascolare. Nuovi indici biochimici plasmatici di rischio.

The primary prevention of acute coronary syndromes is an open question. The scientific progress has discovered new biochemical markers of cardiovascular disease risk that may be useful for primary prevention. They are plasmatic markers of inflammation (serum amyloid A, C-reactive protein, phospholipase A2) and of infection (seropositivity to Chlamydia pneumoniae, cytomegalovirus). They are plasmatic markers of endothelial activation (adhesion molecules such as ICAM-1, VCAM-1) immunological markers (autoantibodies against oxydized LDL, hemostatic markers (TFPI, PAI-1) and metabolic indices (Lpa, homocystein). A gap is evident between the scientific progress in the knowledge of the epidemiology of cardiovascular pathology and its application in clinical practice. The priority should become the population approach to primary prevention: the rapidly changing and complex global context presents new challenges for public health practitioners struggling to implement preventive policies and programmes. New risk factors of cardiovascular disease have been pointed out by research. This study shows the situation on the topic with critique and updated analysis.

Plasma platelet activating factor in nephrotic syndrome.

BACKGROUND: The mechanism of proteinuria in nephrotic syndrome is unknown. The plasma behaviour of platelet-activating factor (ng/ml) in nephrotic and normal people has been evaluated. METHODS: A total of 21 patients with nephrotic proteinuria due to glomerular pathology and 20 subjects as normal control people have been studied. Plasma PAF level is evaluated by ((125)I) RIA Kit (Du Pont NEN). RESULTS: Patients with glomerular proteinuria appeared to have a significant increase (p<0.05) plasma PAF bioactivity: 116.28+/-49.6 ng/ml versus 41.4+/-14.9 ng/ml of normal subjects. CONCLUSIONS: The study shows that PAF may be involved in the mechanism of genesis of human glomerular proteinuria.

Hemostatic alterations in patients with acute, unilateral vestibular paresis.

OBJECTIVES: The etiopathogenesis of acute unilateral peripheral vestibulopathy (APV) still remains a matter of debate; ischemic changes in the circulation of the labyrinth may play a role. We consequently looked for possible hemostasis alterations in a group of patients with APV of an unknown nature. METHODS: We evaluated blood parameters known to be involved in circulation disorders, including total and HDL cholesterol, triglycerides, apolipoprotein A and B, lipoprotein(a), homocysteine, folate, prothrombin time, activated partial thromboplastin time, fibrinogen, D-dimer, antithrombin III, protein C, protein S, activated protein C resistance, and anticardiolipin IgG and IgM antibodies. A series of 23 patients affected with APV were consecutively referred to our department, in the acute phase, before treatment, and in the follow-up phase after 4 to 6 weeks of pharmacologic washout. The aforementioned blood parameters were also measured in a series of 15 patients with Menière's disease. RESULTS: The patients with APV in the acute phase compared with the patients with Menière's disease in the acute phase exhibited increased plasma levels of fibrinogen (mean, 338.3 +/- 135.9 SD vs 271.3 +/- 69.8 SD mg/dL, P = 0.05), increased plasma levels of D-dimer (mean, 320 +/- 207.8 SD vs 226.7 +/- 138.7 SD NG/mL), enhanced plasma levels of lipoprotein(a) (41.4 +/- 38.6 SD vs 16 +/- 18.2 SD mg/dL, F = 5.67, P = 0.02), high leukocyte count (9.1 +/- 2.7 SD vs 6.5 +/- 1.3 SD x 10(3)/microL; F = 8.42, P < 0.006), and low serum folate concentration (5.3 +/- 1.8 SD vs 7.1 +/- 2.7 NG/mg; F = 4.34, P = 0.04). During follow-up the prothrombin time was prolonged (F = 4.34, P = 0.04) and leukocyte count decreased (F = 7.39, P < 0.019) in the APV patients, whereas fibrinogen, D-dimer, lipoprotein(a), and folate were unchanged. CONCLUSION: Our results provide evidence suggesting an involvement of the hemostatic system in APV.

Modulation of beta2 integrin phenotype, adhesion, chemotaxis, and oxidative burst of neutrophils by cyclosporine.

Cyclosporine (CsA) is an immunosuppressive drug widely used to prevent allograft rejection, but its action on neutrophil function is not well known. Neutrophils play an important role in tissue damage during allograft rejection; chemotactic recruitment, adhesion to endothelial cells and oxidative burst of neutrophils are early events during allograft rejection. The aim of this work was to evaluate the effect of CsA on beta2 integrins' surface expression, adhesion to human umbilical endothelial cells (HUVECs), chemotaxis and oxidative burst by neutrophils. For any neutrophil function studied, data obtained from activated neutrophils exposed to CsA were compared with those derived from untreated controls. Results show that CsA does not block neutrophil chemotaxis and does not reduce surface expression of CD11 complex and HUVECs' adhesion at all concentrations tested (15, 100 and 500 ng/mL) and at incubation times of 1, 2 and 4 h as compared to controls. On the other hand, the drug affects significantly the CD18 phenotype after two hours of treatment at the maximum concentration (500 ng/mL) (P < 0.05; ANOVA) and the oxidative burst after four hours (P < 0.01; ANOVA). This study provides evidence that in addition to the well-known CsA effects on lymphocyte functions, the drug affects some neutrophil functions with dose- and time-dependent modalities.

The management of idiopathic thrombotic microangiopathy. Changing trends.

Thrombotic microangiopathy, including the two related syndromes thrombotic thrombocytopenic purpura and hemolytic-uremic syndrome, is a rare and severe multisystem disorder, due to widespread deposition of intravascular microthrombi consisting mainly of platelets, with subsequent consumption thrombocytopenia, microangiopathic hemolytic anemia, renal abnormalities, and neurologic disturbances. The epidemic, verotoxin-induced hemolytic-uremic syndrome, typically associated with prodromal diarrhea, mainly affects young children in small outbreaks. By contrast, idiopathic thrombotic microangiopathy generally affects adults in a sporadic form; it has a more devastating course and a less favourable outcome. Over 90% of the reported cases in the adult, when untreated, have progressed to death within three months of diagnosis. Since the introduction of plasma exchange, a dramatic change in the prognosis of the disease has taken place, although the mortality rate still remains considerable. Indeed, improved survival is the most striking feature of adult thrombotic microangiopathy compared to some decades ago. In the present article we will focus on the evolving concepts able to exert a considerable impact in the management of the adult idiopathic form of thrombotic microangiopathy.

Von Willebrand's factor mediates the adherence of human tumoral cells to human endothelial cells and ticlopidine interferes with this effect.

The aim of this study was to explore whether von Willebrand's factor (vWF) plays a role in the adhesion of human colon tumor cells to human endothelial cells in our coculture system. Cell colony density was evaluated basally (endothelial plus colon tumor cells) and following the addition of: purified vWF, vWF plus vWF-blocking antibodies, antibodies against various integrins and adhesion molecules (alpha2 b integrin, beta1 integrin, beta3 integrin, intercellular adhesion molecule-I, intercellular adhesion molecule-II, vitronectin receptor CD61 CD51, laminin alpha6/beta4 receptor), and various drugs inhibiting the hemostatic system (ticlopidine, heparin, acetyl salicylic acid [ASA], defibrotide, indobuphen, dipyridamole, sulfinpyrazone). Furthermore, vWF concentration was measured in the supernatant fluid of the coculture system basally and following the addition of the above-listed drugs. Cell colony density (as measured by light absorption) increased by 33% following the addition of vWF and returned to a value similar to the basal level with antibodies against vWF, while it did not change significantly following the addition of antibodies against the other integrins or adhesion molecules tested. The same parameter was reduced by 35% following the addition of ticlopidine, while it showed a smaller or no change with the other drugs tested. Similarly, vWF concentration in the cell coculture supernatant showed the greatest reduction (from 0.22 to 0.11 mg/mL) following the addition of ticlopidine. These data suggest that vWF mediates the adherence of human tumor cells to human endothelial cells and that ticlopidine interferes with this effect.

[Thrombin]. / La trombina.

A survey of the present knowledge on the relationship between structure and biological activity of thrombin is made. The recent pharmacological research on the block of thrombin function is then evaluated.

[Uremic coagulopathy. Role of thrombin]. / Coagulopatia uremica. Ruolo della trombina.

The recent observation of increased thrombogenesis in chronic renal failure suggest a pathogenetic role of thrombin in hemorrhagic diathesis of chronic renal failure that may link two paradoxical aspects of this diathesis: hemorrhage and thrombosis. Not only: the accelerated atherosclerosis in uremic patient is also underlined. The possibility of thrombin therapeutic inhibition is then discussed.

Large-needle aspiration biopsy for the preoperative selection of palpable thyroid nodules diagnosed by fine-needle aspiration as a microfollicular nodule or suspected cancer.

The palpable thyroid nodules with a fine-needle aspiration (FNA) diagnosis of microfollicular nodule or suspected cancer usually are excised; however, most of them are proved benign by postoperative histologic examination. We reviewed the clinical and pathologic data for patients with thyroid nodules with an FNA diagnosis of microfollicular nodule or suspected cancer; nodules also were examined by large-needle aspiration biopsy (LNAB) to assess whether the distinction achieved by LNAB into pure microfollicular or mixed microfollicular-macrofollicular nodules could be used preoperatively to better predict malignancy. One hundred fourteen nodules of this type were excised. The prevalence of cancer was 22% (14/63) among the microfollicular and 4% (2/51) among the microfollicular-macrofollicular nodules at LNAB. These data indicate that histologic examination of the LNAB specimen can be used for preoperative selection of thyroid nodules diagnosed by FNA as a microfollicular nodule or suspected cancer.

Antithrombotic and prothrombotic activities of the vascular endothelium.

Vascular endothelium plays a key role in the control of haemostasis and thrombosis. The main reactions involved in the regulation of platelet reactivity, blood coagulation and fibrinolysis take place at the luminal surface of endothelial cells. Following exposure to certain pathological stimuli, remarkable functional changes of the endothelial cells occur, including downregulation of antithrombotic mechanisms and upregulation of prothrombotic activities. Based on the recent knowledge of vascular endothelial function, a better understanding of the pathogenesis of atherothrombosis is expected.

Vestibular disorders in primary thrombocytosis.

OBJECTIVE: Balance disturbances are some of the most common symptoms among the clinical manifestations of chronic myeloproliferative disorders (MPDs) with a high platelet count, such as essential thrombocythaemia (ET) and polycythaemia vera (PV). In this study, we evaluated the vestibulo-oculomotor and vestibulospinal reflexes in a group of patients suffering from these diseases. DESIGN: Evaluation of balance disturbances. SETTING: Department of Neurosciences, ENT Unit, University of Pisa, Italy. METHOD: In this study, we evaluated 43 patients suffering from ET and PV who underwent otoneurologic examination, based on a study of the vestibulo-oculomotor and vestibulospinal reflexes. RESULTS: There was exclusive central vestibular involvement in 26 cases (60.4%), peripheral and central signs were associated in 8 cases (18.6%), and the involvement was purely peripheral in 1 patient. In six patients (14%), the otoneurologic examination revealed no alterations. CONCLUSIONS: The high percentage of balance disorders in cases of ET and PV probably depends upon disorders of the microcirculation due to platelet dysfunction. We also postulate a full explanation of the involvement of the central vestibular system on the basis of a greater availability of central activated serotonin acting as neuromediator.

Protocols for the preoperative selection of palpable thyroid nodules: review and progress.

Modern protocols for the management of patients with palpable thyroid nodules agree that fine-needle aspiration is the first examination to be performed. However, they differ very much in the role attributed to scintigraphy and ultrasound examinations. In some protocols, these two techniques are not considered, whereas in others they are recommended at the end of the diagnostic workup to select for surgery those nodules with nondiagnostic or suspect fine-needle aspiration biopsy results. We report original data and literature showing that such use of scintigraphy and ultrasonography is not cost effective. Furthermore, we report original data showing that large-needle aspiration biopsy can be used to select for surgery those nodules with nondiagnostic or suspect results after fine-needle aspiration. Consequently, we suggest a new protocol for the preoperative selection of palpable thyroid nodules.

Tissue factor pathway inhibitor.

The role of Tissue Factor (TF, thromboplastin) as the major factor in initiation of the blood coagulation process has been known for more than 100 years. Its importance for the development of clinical thrombosis, be it venous or arterial, and the complexity of the cell biology of TF, have however been increasingly appreciated over the past 15-20 years. Acting as a cofactor for coagulation factor VIIa, it is now clear that TF is able to activate factor IX. Aberrant expression of TF seems to play a major role in the intravascular coagulations disorders linked to endotoxemia, malignancies, immunological diseases and atherosclerosis. Tissue Factor Pathway Inhibitor (TFPI) is the natural direct inhibitor of TF/FVIIa complex. In this study the physiological role, mechanism of action and pharmacological potential of TFPI are discussed.

Blood coagulation parameters in retinal arterial occlusion.

BACKGROUND: Thromboembolism is considered a crucial event in the pathogenesis of retinal occlusion, resulting in a severe damage of central or peripheral visual function. METHODS: We evaluated hemostatic system parameters in the plasma of 14 patients (11 males and 3 females aged 59-73 years) affected by acute retinal ischemia (central retinal arterial occlusion or arterial branch occlusion). The diagnosis of retinal arterial occlusion was established according to clinical symptoms, ophthalmoscopic findings and fluorescein angiography. In addition to routine coagulation tests, antithrombin III, prothrombin fragment 1+2 (F1+2), thrombin-antithrombin III complex (TAT), and D-dimer were measured in the plasma both at the moment of diagnosis (before therapy initiation) and 3-6 months later (at least 1 months after antithrombotic therapy discontinuation). RESULTS: We found a marked increase in the plasma levels of F1+2, TAT, and D-dimer during the acute event, compared with healthy control values. F1+2 and TAT significantly decreased during follow-up, whereas D-dimer was unchanged. CONCLUSION: Our data indicate accelerated conversion of prothrombin to thrombin (high F1+2) and an increase in circulating thrombin (high TAT) during retinal arterial occlusion, providing evidence that increased thrombin generation may play a role in acute retinal ischemia.

The role of tumour markers in predicting skeletal metastases in breast cancer patients with equivocal bone scintigraphy.

Bone scintigraphy (BS) is commonly performed in the staging and postoperative monitoring of breast cancer. Nevertheless, due to low specificity it often demonstrates hot spots with equivocal interpretation, which may be misleading in the management of these patients. The aim of this study was to assess the value of a serum tumour marker panel in selecting among the patients with equivocal BS those with bone metastases. Between January 1986 and December 1995, 297 breast cancer patients were followed-up after mastectomy with serial determinations of a CEA-TPA-CA15.3 tumour marker panel, BS and liver echography. The tumour marker panel was used to select patients with equivocal BS for examination of suspicious bone areas by further imaging techniques. Up to December 1995, 158 (53%) patients showed an equivocal BS and 47 patients developed bone metastases. In the 158 patients with equivocal BS, prolonged clinical and imaging follow-up over 45 months (mean; range 12-120) was used to ascertain the presence or absence of bone metastases. In these 158 patients the negative predictive value and positive predictive value of the tumour marker panel to predict bone metastases was 97% and 75% respectively. This study shows that in breast cancer patients the CEA-TPA-CA15.3 tumour marker panel has a high value in selecting those patients with bone metastases, or at high risk of developing clinically-evident bone metastases, among the large number of subjects with equivocal BS.

Aspiration needle biopsy in preoperative selection of thyroid nodules defined at fine-needle aspiration as microfollicular lesions.

The palpable thyroid nodules that are diagnosed as microfollicular by fine-needle aspiration cytologic analysis are usually excised for the low probability that the nodule is a well-differentiated follicular cancer. The authors retrospectively assess the use of aspiration needle biopsy (either 16- or 18-gauge needles) in the preoperative selection of the nodules diagnosed as microfollicular at fine-needle aspiration (either 20- or 22-gauge needles). Aspiration needle biopsy is a type of large needle biopsy that is a relatively easy and innocuous method of obtaining tissue fragments for preoperative histologic examination of palpable thyroid nodules. From 1980 through 1996, 6,314 patients with palpable thyroid nodules were examined by fine-needle aspiration; 29.5% of these nodules were also examined preoperatively by aspiration needle biopsy. Of all the patients with nodules, 6% received a fine-needle aspiration diagnosis of microfollicular nodule. Two hundred sixty of the 380 nodules (68%) that were diagnosed as microfollicular at fine-needle aspiration were also examined by aspiration needle biopsy; inadequate specimens were obtained in 17% of cases; pure microfollicular structure was confirmed by aspiration needle biopsy in 35% of the nodules; and aspiration needle biopsy showed the remaining 48% to contain a macrofollicular component suggesting a benign hyperplastic lesion. Seventeen nodules that were found to be microfollicular at fine-needle aspiration cytologic analysis and micromacrofollicular at aspiration needle biopsy were excised and the postoperative result was benign in all cases. Twenty-five nodules diagnosed as microfollicular either on both fine-needle aspiration and aspiration needle biopsy were excised and the postoperative diagnoses were benign (20 nodules) or malignant (5 nodules). These data indicate that aspiration needle biopsy can be used for preoperative selection of the nodules that are microfollicular at fine-needle aspiration by identifying the nodules with high probability of being malignant and thus contributing to the reduction in the number of surgical operations for benign nodules.

Anti-D treatment for chronic immune thrombocytopenic purpura: clinical and laboratory aspects.

We used low-dose anti-D immunoglobulins for home treatment of Rh+ adult patients with chronic immune thrombocytopenic purpura (ITP). After informed consent, 15 unselected outpatients (ten males and five females, aged 22 to 72), affected by chronic ITP with negative HIV test, were given intramuscular injection of 900-1500 micrograms of anti-Rh0 (D) IgG over 3 days every month for 2 or 3 consecutive months. Platelet count (mean +/- SD) significantly increased from basal value of 17,000 +/- 9,000/microL to 72,000 +/- 55,000/microL at the end of treatment. Eight patients achieved a rise in platelet count above 50,000/microL (five above 100,000/microL) and two of them maintained the increase longer than 6 months without further anti-D administration. Three patients responsive to the first cycle responded to further treatment with substantially identical results. Seven patients had no response. Four of them had not responded to previous glucocorticoid and intravenous IgG therapy. Direct antiglobulin test became strongly positive in all patients and mean serum haptoglobin decreased from a basal value of 118 +/- 59 to 61 +/- 43 mg/dL; nevertheless no clinically overt hemolysis was observed in any patient, there was no rise of serum indirect bilirubin and hemoglobin level was unchanged (mean +/- SD basal level 13.6 +/- 2.2 g/dL; after anti-D 13.9 +/- 1.2 g/dL). No hematoma developed at the injection site, and no other side effects occurred. Our results show that anti-D therapy is effective in the majority of patients well tolerated, and feasible as home treatment: thus it can be recommended as a cheap and safe alternative treatment in ITP Rh+ patients.

Uremic medium increases cytokine-induced PAI-1 secretion by cultured endothelial cells.

The overall fibrinolytic activity is depressed in patients with chronic renal failure where a prothrombotic state is described, thereby enhancing the risk of vascular occlusive events. The mechanism responsible for fibrinolysis derangement has not yet been elucidated. To evaluate the effect of the uremic environment on the fibrinolytic activity of endothelial cells, we studied plasminogen activator (t-PA) and plasminogen activator inhibitor type 1 (PAI-1) production by human umbilical vein endothelial cells (HUVEC) in culture, exposed either to uremic or normal sera, before and after cytokine stimulation. Twenty uremics were studied: 11 were on conservative dietary treatment and nine were on maintenance hemodialysis. Eight healthy subjects served as controls. Before cytokine stimulation, no difference in the HUVEC supernatant concentration of t-PA and PAI-1 was found among the groups studied. After stimulation with interleukin (IL)-1 and tumor necrosis factor (TNF)-alpha, the HUVEC supernatant levels of PAI-1 in the uremics were higher than in the controls, whereas the supernatant levels of t-PA did not differ. Our data provide evidence that uremic serum, in concert with IL-1 or TNF-alpha, can enhance PAI-1 secretion by endothelial cells, thereby depressing the fibrinolytic system. This impaired endothelial fibrinolytic response to hypercoagulation could favor vascular events, which are the major cause of morbidity and mortality in patients with chronic uremia.

Large needle aspiration biopsy for reducing the rate of inadequate cytology on fine needle aspiration specimens from palpable thyroid nodules.

From 1980 to 1996, 1,907 consecutive euthyroid subjects with palpable thyroid nodules were examined by fine needle aspiration (FNA) cytology plus large needle aspiration biopsy (LNAB) histology. There were 1,630 (85%) women and 277 (14.5%) men aged from 17 to 80 years. A single nodule was palpated in 1,419 subjects (74.4%) while 488 (25.6%) showed multiple nodules. The nodule size ranged between 1 and 7.5 cm. The number of inadequate specimens at the first examination, FNA cytology of LNAB histology, were 261 (13%) or 398 (20.8%), respectively. LNAB performed on the 261 nodules with nondiagnostic cytology showed findings which were adequate for diagnosis in 130 (49.8%) and inadequate in 131 (50.2%). Among the 261 patients with inadequate initial cytological findings 61 were subjected to repeated FNA and 36 repeated LNAB. More than 60% of the nodules on which FNA was repeated achieved a cytological diagnosis; more than 80% of the nodules reinvestigated by LNAB were finally diagnosed by histology. The mean nodule size was larger in the group with inadequate result than in that with adequate FNA or LNAB result. Among the 261 patients with inadequate cytological finding at the first FNA 28 were operated on; 20 were in the group with adequate LNAB histological findings and eight in the group with an inadequate LNAB. Two papillary cancers, one per group, were found at postoperative histology. However, one was diagnosed by LNAB and one at the second FNA. The remaining 26 nodules were all found to be benign postoperatively. This study shows that the addition of LNAB to FNA leads to a histological diagnosis in 50% of the palpable thyroid nodules with inadequate cytology at the first FNA and that LNAB can be used even for those nodules which remain uncharacterized after repeat FNA.