Unstable angina: individualized stratification and prognosis.

OBJECTIVE: To analyse the methodology of risk stratification and the prognosis of patients admitted with unstable angina. POPULATION AND METHODS: This retrospective study involved a population of 68 patients (43 males and 25 females with a mean age of 65.8 +/- 9.8 years) consecutively admitted for suspected unstable angina during the year of 1996. Thirty six patients (52.9%) had angina at rest, 13 patients (19.1%) had both exertional and rest angina, 9 patients (13.2%) crescendo angina, 6 patients (8.8%) new onset exertional angina (less than 1 month), and 4 patients (5.8%) post-infarction angina (less than 2 weeks). The risk stratification was individualized. The coronary angiography (35 patients) was only performed when the medical therapy failed in patients with recurrent angina, or with proved ischemia after an exercise test and/or thallium 201 stress scintigraphy. Thirteen patients (19.1%) did not undergo these tests (advanced age and or bad general condition, or refusal). The follow-up of patients with and without ST-T changes was compared, as well as those revascularized versus non-revascularized. It was possible to achieve a mean follow-up of 13.7 +/- 6.2 months (3 to 25 months). RESULTS: The exercise test and/or thallium-201 stress scintigraphy were positive for myocardial ischemia in 28 pts (41.1%) and negative in 7 patients (10.2%). The coronary angiography revealed three-vessel coronary artery disease in 18 patients (26.4%), one vessel disease in 11 patients (16.1%) and two-vessel disease in 5 patients (7.3%). One patient had normal coronary arteries. Medical therapy was the initial approach. Coronary surgery was urgently performed in 3 patients and coronary angioplasty in 5 patients for refractory unstable angina. In the whole group coronary artery surgery was undertaken in 14 patients (20.5%) and coronary angioplasty in 12 patients (17.6%). A mean follow-up of 13.7 +/- 6.2 months was obtained in the 68 patients. During this period 6 patients (8.8%) died due to cardiac causes and 16 patients (23.5%) were readmitted: 8 patients (11.7%) for unstable angina, 5 patients (7.3%) for congestive heart failure and 3 patients (4.4%) for myocardial infarction. Fifty two patients (76.4%) remained free of cardiac events. The patients with transitory ST-T changes had more cardiac events (unstable angina, myocardial infarction, mortality) than the patients without ECG changes (13/30 vs 2/30, p = 0.003). When the revascularized patients were compared to the non revascularized no significant differences were observed regarding myocardial infarction and mortality, however revascularized pts had a less significant incidence of rehospitalization for unstable angina (0/26 vs 8/42 p = 0.02). CONCLUSIONS: An individualized strategy can be effective in pts with unstable angina. In this study 76.4% of patients remained free of cardiac events during the follow-up, 23.6% had severe cardiac events and the cardiac mortality was 8.8%. The patients with transitory ST-T changes had more cardiac events and worse prognosis. No patients significant difference was observed in the revascularized versus non revascularized patients for myocardial infarction and mortality; however, the revascularized patients had less significant incidence of rehospitalization for unstable angina.

Effects of sulglycotide on inflammation and epithelial cell turnover in active Helicobacter pylori+ chronic gastritis. A pilot study.

The effects of Sulglycotide were evaluated in a pilot study of active H. pylori+ atrophic gastritis. Ten informed patients (mean age 51 +/- 13 years) entered a double-blind study. Five received Sulglycotide 400 mg three times a day for one year, the other 5, placebo. At 0, 30, 90, 270, and 360 days of treatment, patients underwent endoscopic examinations with multiple biopsies. Morphometric studies (number of inflammatory cells and percent gland volume), morphologic studies (according to the Sydney system), and flow cytofluorimetry were performed in all cases. Compared to findings in the placebo group, patients treated with Sulglycotide showed a reduced number of inflammatory cells and an increase in gland volume 120 days after treatment. While the difference was not statistically significant, the trend was confirmed by the morphologic patterns. Flow cytofluorimetry revealed an increase in the percentage of cells in the G2 phase (full maturation) and a parallel drop in the S phase (premitotic synthesis) in the Sulglycotide group only in the first three months. These data would appear to indicate an acceleration of gastric epithelial cell maturation and a decrease in the inflammatory infiltrate under the effect of Sulglycotide.

Multiple cerebral infarcts associated with an atrial septal aneurysm. Superimposed thrombus detected by transesophageal echocardiography.

The authors describe the case of a patient referred for evaluation of multiinfarct dementia. Conventional echocardiography revealed an aneurysm of the interatrial septum. A transesophageal echocardiogram demonstrated superimposed thrombus. This rare cause of systemic emboli can be diagnosed only by transesophageal echocardiography and is of major interest to avoid recurrence of ischemic strokes.

The relevance of flow-cytometric DNA content in the evaluation of lung cancer.

Cells from a group of 185 patients suffering from malignant tumours (160 non-small-cell lung carcinoma, 13 small-cell lung carcinoma, and 12 non-epithelial tumours) and 6 with benign lung tumours were studied by flow cytometry in order to detect the prognostic value of DNA content. A total of 144 (90%) non-small-cell lung carcinomas (NSCLC) and 8 (62%) small-cell lung carcinomas (SCLC) exhibited aneuploidy. Furthermore 52% (83 patients) NSCLC, 24% (3 patients) SCLC and 50% (6 patients) non-epithelial tumours demonstrated multiclonality. Benign cases showed diploid DNA content. For actuarial survival analysis using the Bergesson and Gage method and the Greenwood variance, 142 patients were selected. Statistical comparisons were made by the use of the t-test for unpaired data between fixed times. No correlation was observed between ploidy and stage, histological grading or treatment modality. A statistically significantly better survival was observed after 12, 18 and 24 months of follow-up for diploid and monoclonal (with the exclusion of hypo- and hypertetraploid) patients. Thus, flow-cytometric DNA analysis may be useful in prognostic assessment of human lung tumours.

Subclavian angioplasty: immediate and late results in 50 patients.

In order to assess the therapeutic outcome of percutaneous transluminal angioplasty for subclavian stenosis, 50 patients were followed up clinically as well as with a velocimetric Doppler after attempted angioplasty. A minimal clinical follow-up of 9 months was expected. Subclavian stenoses were due to atheroma in 49 patients and to Takayasu's disease in 1 case. Indication of angioplasty was curative in 34 (68%) symptomatic patients (posterior fossa ischemia and/or upper limb ischemia) and preventive in 16 (32%) asymptomatic patients (severe difference of blood pressure between the 2 arms and/or association with carotid stenosis or axillo-femoral bypass). Angioplasty was successful in 45 patients (primary success rate = 90%). Three (6%) thrombosis occurred due to the percutaneous approach, one of the axillary and one of the brachial artery without any significant sequelae, and one of the aorta requiring an aorto-bifemoral bypass. A complication occurred in 2 unsuccessful angioplasties (4%): an ischemic stroke occurred in 1 case and a thrombosis of the dilated site requiring a surgical bypass. Clinical follow-up over a period of 9-101 months (mean = 41) was performed in 43 out of the 45 patients who had undergone angioplasty successfully. Two patients had a follow-up shorter than 9 months: one died after 5 months, the other was lost to follow-up. By the end of the clinical follow-up, 37 (84%) out of the 44 followed-up patients had benefitted from the procedure. Doppler study performed in 35 out of the 44 followed-up patients (80%) over a period of 2-90 months (mean = 39) showed 5 restenosis (14%). This study demonstrates the good long-term results of angioplasty in case of subclavian artery stenosis. Though there are complications, angioplasty could be proposed as a first choice treatment for subclavian stenosis as compared to surgery. Indications in asymptomatic patients should be carefully weighed as complications may occur.

[Familial scimitar syndrome]. / Le syndrome du cimeterre à forme familiale.

The authors report a new case of a familial form of the scimitar syndrome: father and son. Both presented an adult form which was well tolerated. Another familial form has been reported in the medical literature: father and daughter. The authors discuss the possible genetic mode of transmission in the light of these two cases.

[Angioplasty of the subclavian arteries. Immediate and mid-term results]. / Angioplastie des artères sous-clavières. Résultats immédiats et à moyen terme.

The authors report the immediate and mid-term results of a retrospective study concerning 30 attempted angioplasties in 30 patients with tight stenosis of the subclavian artery. The cohort consisted of 23 men with a mean age of 57.5 and 7 women with a mean age of 57.7. Twenty three patients had symptoms and 7 were asymptomatic. There were 2 technical failures related to impossibility of passage through the stenosis. There were two complications during the immediate postoperative period in the form of obstruction at the arterial puncture site with no long term functional consequences. Clinical evaluation after a mean follow-up of 32.5 months showed that 25 (89.2%) of 28 patients with a good primary result were improved from a clinical and/or blood pressure after a mean follow-up of 34.5 months in 19 (82.6%) of the 23 patients undergoing this investigation. This study confirms the satisfactory efficacy of subclavian angioplasty with a low complication rate. It would seem legitimate to suggest angioplasty as first line treatment of stenosis of the subclavian artery and to reserve surgery for failures or contraindications to the technique.

[Malignant fibrous histiocytoma of the pancreas]. / Istiocitoma fibroso maligno del pancreas.

The authors report a case of pancreatic malignant fibrous histiocytoma (approximately 22 cm). Clinical and instrumental approach for preoperative diagnosis is discussed and the anatomopathological features of the lesion, which is rarely localized in the pancreatic gland, are stressed. Surgical treatment is outlined as well.

Cellular heterogeneity of DNA/total-protein content in human lung tumors, as determined by flow cytometry.

With the aim of distinguishing neoplastic cell sub-populations of different prognostic and diagnostic significance, dual-parameter measurements (DNA/protein) have been simultaneously determined in a (256, 256) channel matrix in lung samples derived from 110 patients affected by neoplastic and non-neoplastic lung diseases. Biparametric analysis demonstrated that cells with abnormally high red fluorescence (i.e., protein content), which is indicative of unbalanced growth, were often observed in malignant tumors as compared with normal lung samples. Furthermore, the dual-parameter analysis allowed recognition of additional aneuploid tumor-cell lines, indicating that the frequency of cytometrically determined diploid tumor is lower than that previously described by DNA monoparametric analysis. The recognition of aneuploid subpopulations by dual-parameter analysis in clinically and histologically negative one-parameter flow-cytometric "diploid" samples assumes important diagnostic value. The results have also shown the presence of multiple protein sub-populations in clones with the same ploidy value, indicating a higher level of cellular heterogeneity than demonstrated by DNA monoparametric measurements.

Cytokinetic investigation of lung tumors using the anti-bromodeoxyuridine (BUdR) monoclonal antibody method: comparison with DNA flow cytometric data.

In order to investigate the cytokinetics of malignant tumors and non-malignant lesions of the lung, tissue samples from 57 patients affected by non-small-cell carcinoma (NSCLC), small-cell carcinoma (SCLC), and benign and inflammatory lesions have been analyzed using the BUdR monoclonal antibody (MAb) method. This method is based on the preparation, at the time of surgery, of viable monocellular suspensions (using collagenase and DNase treatment) and the concomitant administration of BudR. The percentage of BudR-labelled cells was monitored by fluorescent microscopy using an FITC-labelled second antibody. In NSCLC, each histological group showed a wide range of labelling index (LI) values. On the contrary, SCLC exhibited a more homogeneous kinetic behaviour as evidenced by a narrowly distributed, higher LI. Tumors shown to be diploid by flow cytometry did not show a lower LI than aneuploid tumors. Furthermore, differences were constantly observed between the S-phase percent calculated using BUdR and that calculated using the DNA flow cytometric (FC) histogram, the latter always showing higher S-phase values. In an attempt to study the intra-tumor proliferative heterogeneity, multiple-site sampling was performed. Proliferative heterogeneity seemed to be higher inter-tumor than intra-tumor. Finally, a positive correlation (p less than 0.05) was found between LI and the actual doubling time (DT) of the primary tumor mass, evaluated using sequential radiographs. In conclusion, the present BUdR method can be considered a useful source of relevant information on in vivo cell growth, in parallel to other clinical (DT) and biological (DNA content) approaches.

Profile of sequential determinants in tissue polypeptide antigen BrCN:B fragment.

A synthetic approach has been applied to determine the profile of sequential determinants of one immunodominant region of Tissue Polypeptide Antigen (TPA). Five overlapping peptides, covering 30 of the 32 amino acid residues of this fragment, were chemically synthesized, and their antibody-binding activities for rabbit anti-TPA antibodies determined by enzyme-linked immunoadsorbant assays. Anti-TPA reacted with two overlapping fragments at the COOH-terminal end of the fragment, but not with peptides that include Arg 15 considered as essential for the antigenicity of the whole fragment. This might suggest that this critical residue is involved in the formation of a complex conformational determinant.

Do monoclonal antibodies recognize linear sequential determinants?

A group of 19 anti-class II monoclonal antibodies produced in different laboratories were tested in ELISA for their ability to bind to a panel of synthetic peptides selected from HLA-DQ alpha and beta chains. No one of the antibodies tested was found to react with the synthetic fragments, thus confirming the common finding that MoAbs generally fail to recognize fragments of the native antigen. The possibility that this result might be partly due to the procedure used for screening hybridoma supernatants is discussed.

14C-labeling of synthetic peptides.

Two methods are described for the labeling of synthetic peptides using iodo[14C]acetic acid. The first procedure may be employed when the synthetic fragment contains a cysteine with a free sulfhydryl group. Alternatively, a commercial amino-protected cysteine may be carboxymethylated using radioactive iodoacetic acid. This derivative can be added to the growing peptide chain in the manual or automatic solid-phase synthesis of the fragment.

Restriction of anti-peptide antibody specificity by enzyme-modified Sepharose-peptide immunoadsorbents.

Sepharose-peptide immunoadsorbents, employed for the isolation of specific antibodies from the sera of rabbits immunized with carrier protein-peptide conjugates, were digested with suitable proteolytic enzymes, in order to obtain the splitting of a part of the peptide bound to the gel. This new modified immunoadsorbent can be advantageously used for the isolation of antibody subsets, that do not cross-react with related peptides exhibiting high sequence homology with the immunogens.