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The antiphospholipid syndrome (APS) is defined by the presence of thrombosis and/or pregnancy morbidity in combination with the persistent presence of circulating antiphospholipid antibodies: lupus anticoagulant, anticardiolipin antibodies and/or anti-β2-glycoprotein I antibodies in medium to high titers. The management of thrombosis in patients with APS is a subject of controversy. This set of recommendations is the result of an effort to produce guidelines for therapy within a group of specialist physicians in Cardiology, Neurology, Hematology, Rheumatology and Internal Medicine, with a clinical and research focus on APS. [ABSTRACT FROM PUBLISHER]

The Committee reviewed cardiac involvement in the antiphospholipid antibody syndrome. The Committee's recommendations are: Valve abnormalities: anticoagulation is recommended for symptomatic patients with valvulopathy. Prophylactic antiplatelet therapy may be appropriate for asymptomatic patients (recommended by 13/17 experts in an independent review). Committee members disagreed whether corticosteroid therapy is helpful, but agree that distinguishing among presumptive valvulitis (valve thickening on echocardiogram), valve deformity and vegetations is important, as treatment implications may differ. Occlusive arterial disease (angina, myocardial infarction): the Committee recommends aggressive treatment of all risk factors for atherosclerosis (hypertension, hypercholesterolaemia, smoking) and liberal use of folic acid, B vitamins and cholesterol-lowering drugs (preferably statins). Hydroxychloroquine for cardiac protection in APS patients may be considered. The Committee also recommends warfarin anticoagulation for those who have suffered thrombosis in the absence of atherosclerosis, but recognizes that developing data may support the use of antiplatelet agents instead. Intracardiac thrombi: the Committee recommends intensive warfarin anticoagulation, and consultation with cardiac surgeons when appropriate. Ventricular dysfunction: the Committee has no recommendations on this aspect of cardiac disease. Pulmonary hypertension: the Committee recommends intensive anticoagulation with warfarin and clinical trials of bosentan, epoprostenol and other new agents. [ABSTRACT FROM AUTHOR]

The diagnosis of the antiphospholipid syndrome (APS) requires both a typical clinical event plus a persistently positive test in an assay for either anticardiolipin (aCL) antibodies or a lupus anticoagulant (LA). Enzyme linked immunosorbent assays (ELISA) specific for autoantibodies against β2-glycoprotein I (β2GPI) or prothrombin are also used, but none of the tests are adequately sensitive or specific. A chromogenic assay was developed that measures the effect of test antibody or plasma samples on in vitro thrombin formation. It is able to detect both LA and β2GPI-dependent aCL antibodies and may have greater specificity for APS than currently available tests. Using this method various monoclonal antibodies (MoAbs) were examined, from mice immunized with β2GPI, mice with a spontaneous animal model of APS, and from three humans with APS. Plasma and affinity purified antibodies from patients with APS and control groups were also examined. Thrombin inhibition was more sensitive to perturbation by MoAbs than a combination of tests for LA (P < 0·05) and at lower antibody concentrations (12·5 µg/ml versus 100 µg/ml). There was a significant correlation between inhibition of thrombin generation and the level of MoAb reactivity to β2GPI (r = 0·90; P < 0·001) but not to CL (r = 0·06; P = 0·76). Plasma and affinity purified antibodies from patients with APS also inhibited thrombin generation, and significantly more so than patients with aPL from causes other than APS. APS patient samples showed thrombin inhibition in the presence of anti-β2GPI or antiprothrombin antibodies. All MoAbs binding β2GPI showed inhibition of thrombin generation, while MoAbs binding domain I of β2GPI had more LA effect. [ABSTRACT FROM AUTHOR]

Radioallergosorbent testing (RAST) of sera from subjects sensitized to wheat and rye flour indicated that there is significant reaction with seed extracts of 12 cereals (wheat, durum wheat, triticale, cereal rye, barley, rye grass, oats, canary grass, rice, maize, sorghum and Johnson grass). Results were evaluated in terms of taxonomic relationships and of the electrophoretically determined protein composition of the cereal extracts. RAST uptakes were uniformly low in sera from four rhinitic bakers, yet were significantly above the levels for non-allergic and cord sera. Much higher RAST uptakes were obtained with sera from four asthmatic bakers when tested with wheat and its close relatives, but there was still reasonably high reactivity with more distantly related cereals. RAST inhibition experiments indicated in a more direct way the extent of cross-reactivity between grain extracts of wheat, rye, barley and oats. One baker had a history of more severe attacks of breathlessness following inhalation of rye flour compared with wheat flour. This was confirmed by bronchial challenge testing, but the comparison was not obviously consistent with the results of prick testing or estimation of histamine released from his leucocytes. The results as a whole suggested that the bran layers of cereal grains are at least as allergenic as flour. [ABSTRACT FROM AUTHOR]

We have identified PAF in the blister fluid from a patient with bullous mastocytosis, a rare form of mast-cell disease. We have found a novel endogenous inhibitor of platelet aggregation which obscured the presence of the PAF in unprocessed blister fluid and in ethanol or lipid extracts. The PAF was characterized by the demonstration of chromatographic, mass spectral and biological properties identical to those of authentic PAF. Thus this is the first demonstration of PAF in biological fluid from a patient with mastocytosis. High levels of immunoreactive prostaglandin D2 (PGD2) and histamine were also present in the blister fluid. The interaction between PAF and the inhibitor of platelet aggregation in patients with systemic mastocytosis may provide an explanation for some of the manifestations of the disease, in particular the episodic hypotension, cutaneous flushing and pallor. [ABSTRACT FROM AUTHOR]

The ability of tumour necrosis factor-alpha (TNF-α) to directly stimulate phospholipid turnover from human neutrophils was studied. Stimulation with recombinant human (rH)TNF-α induced the release of significant amounts of radioactivity from [3H]arachidonic acid-labeled neutrophils. This stimulation was equipotent to that induced by the bacterial tripeptide formyl-methionyl-leucyl- phenylalanine (FMLP). The time of maximum stimulated release varied between donors, with the most common maximal stimulation being 45 min. Dose-response experiments indicated that 100–1000 U/ml rH TNF-α were required for the maximum stimulatory effect. High-performance liquid chromatography analysis of the supernatants revealed that the radioactivity was associated with arachidonic acid, but not with its metabolites, indicating that TNF-α stimulates the release of arachidonic acid from cellular phospholipids but does not stimulate its metabolism. A comparison of TNF-α with other cytokines indicated that stimulation of arachidonic acid release paralleled the ‘priming’ of neutrophils for enhanced superoxide production, raising the possibility that phospho-lipid turnover and priming of neutrophils are causally related. [ABSTRACT FROM AUTHOR]