Autoimmune thrombocytopenia (AITP) and thyroid autoimmune disease (TAD): overlapping syndromes?

The pathogenesis of thrombocytopenia associated with TAD and the occurrence of overlapping traits between TAD and AITP are still a matter of debate. For this reason, we investigated for the presence and specificity of platelet and thyroid autoantibodies in 18 TAD patients with thrombocytopenia, 19 TAD patients without thrombocytopenia and in 22 patients with primary AITP without clinical signs of TAD. Platelet-associated IgG and/or specific circulating platelet autoantibodies were detected in 83% of patients with TAD and thrombocytopenia, in 10% of patients with TAD without thrombocytopenia and in 86% of patients with primary AITP. The reactivity of serum autoantibodies, assayed by MoAb immobilization of platelet antigens (MAIPA), was directed against platelet glycoproteins Ib and/or IIb/IIIa in 50% of the patients with TAD and thrombocytopenia, as in 46% of the patients with primary AITP. Thyroid autoantibodies were found in 89% of patients with TAD and thrombocytopenia, in 95% of patients with TAD without thrombocytopenia, and in 18% of patients with primary AITP. Thyrotropin (TSH) levels determined in three of four AITP patients with thyroid autoantibodies revealed a subclinical hyperthyroidism in one patient. The present study supports the autoimmune aetiology of thrombocytopenia associated with TAD, since the prevalence and specificity of platelet autoantibodies are similar in TAD and primary AITP. The results indicate also that there exists an overlap between thyroid and platelet autoimmunity with or without clinical manifestations.

Glycocalicin in the diagnosis and management of immune thrombocytopenia

We studied glycocalicin (GC), expressed as plasma GC concentration and as GC index (ratio to platelet count), in 129 thrombocytopenic patients (platelet count < 100 x 10(9)/l) and 60 sex- and age-matched controls. Seventy-two patients had idiopathic immune thrombocytopenia, 32 secondary immune thrombocytopenia, 8 microangiopathic thrombocytopenia and 17 thrombocytopenia secondary to bone marrow aplasia. Patients with immune thrombocytopenia (ITP) were also subclassified, according to their clinical behaviour, as having active disease or being in spontaneous or therapy-induced partial remission. A significant correlation was found between glycocalicin levels and platelet count both in normals and in patients with bone marrow aplasia (r = 0.75). ITP patients showed a GC index significantly higher than controls (6.02+/-7.87 vs. 0.9+/-0.2, p<0.001). When ITP patients with similar platelet count (30-50 x 10(9)/l) were studied, the mean level of GC and the GC index were significantly higher in those patients with active disease than in those in remission (0.97+/-0.38 vs. 0.58+/-0.17 microg/ml, p <0.05; 6.41+/-2.64 vs. 3.44+/-0.94, p<0.05, respectively). A longitudinal study performed in 10 patients with different subtypes of ITP suggested a positive correlation between GC index and the activity of the disease. The GC value and GC index were significantly higher in patients with microangiopathic thrombocytopenia than in controls (1.44+/-0.73 vs. 0.8+/-0.16 microg/ml, p < 0.01; and 18.77+/-22.23 vs. 0.9+/-0.2, p<0.001, respectively). The GC value was significantly lower in bone marrow failure (0.15+/-0.04 microg/ml, p<0.01) compared to controls, while no difference was observed in the GC index. Our data confirm that the GC index is helpful in differentiating thrombocytopenia due to increased platelet destruction from the one due to impaired production. In addition, the assay has been proven useful in the differential diagnosis of different ITP subtypes and their follow-up.

Cerebral vascular accidents in young patients with essential thrombocythemia: relation with other known cardiovascular risk factors

BACKGROUND AND PURPOSE

Since the advent of routine automated blood cell counts, an increased platelet count often is detected fortuitously in asymptomatic individuals. In the past, essential thrombocythemia (ET) was thought to be linked to an increase incidence of hemorrhagic complications, whereas thrombosis is now considered more frequently. Actually, the risk of thrombosis cannot be predicted in an asymptomatic patient with essential thrombocythemia.

PATIENTS AND METHODS

A total of 41 young patients (age range, 18 to 45 years) affected by ET and diagnosed in agreement with the Polycythemia Vera Study Group criteria are reported. Common risk factors, such as hypertension, smoke, obesity, dyslipidemia, and diabetes, have been registered. Particular attention has been given to cerebral vascular accidents (CVA) both of the arterial and venous systems. Platelet number, platelet serotonin content, and platelet aggregation under collagen, adenosine diphosphate (ADP), and adrenalin stimuli were evaluated.

RESULTS

Nine out of the 41 patients affected by ET had CVAs, four of which occurred in the venous system. No difference in platelet function tests has been observed between patients with or without CVA. Six out of the 9 patients with ET and CVA had at least one atherosclerotic risk factor: four were heavy smokers, one had hypertension, and one had hypertension and obesity.

CONCLUSIONS

Cerebral vascular accidents are confirmed to be frequent in patients with essential thrombocythemia, even at a young age. However, the presence of at least one atherosclerotic risk factor associated with increased platelet number seems to favor thrombotic complications. In particular, cigarette smoking seems to be related to arterial CVAs in essential thrombocythemia.

[Acute confusion in the geriatric patient]

During 1996, 585 patients, aged 55 to 96, were admitted into hospital at the Geriatric Department of Ospedale Maggiore (Turin). Acute confusion was seen in 22.2% of these patients who tended to have more serious clinical condition, were more likely to have chronic cognitive impairment, were treated with a greater number of drugs and suffered more from immobility with pressure ulcer. The confusional state, manifested at admission to Geriatric department, was mostly related with the patient's clinical severity, while the one which developed during hospital stay was linked to situations of physical frailty, as pressure ulcer and low albumin values. The most frequent causes of acute confusional state were acute infectious diseases, heart failure, gastro-intestinal bleeding with secondary anaemia, stroke and dehydration. In many cases the very cause of the acute confusional state could not be identified. Falls, more than 31 days length of stay in hospital and death were more frequent in patients suffering from confusional state. Chronic cognitive impairment, functional dependence, clinical severity and treatment involving a great number of drugs, are the main contributing factors in this syndrome. Thus, a multi-dimensional evaluation which takes into account both clinical-functional and socio-economical aspects, is useful for a correct preventive and diagnostic approach of acute confusional state.

Platelet count, anti-heparin/platelet factor 4 antibodies and tissue factor pathway inhibitor plasma antigen level in chronic dialysis

We studied 50 chronic dialysis patients with end-stage renal disease. Mean platelet count was within normal limits. An inverse linear correlation was observed between pre-dialysis platelet count and serum creatinine (r=0.304, p=0.038). Dialysis caused a decrease in platelet count (216+/-80x10(9)/L, pre; 198+/-68, post; p=0.0001), and the higher the pre-dialysis platelet count, the greater the decrease (r=0.623, p=0.0001). Post-dialysis triglyceride decreased (1.67+/-1.27 mmol/L, pre; 1.23+/-0.96, post; p=0.0001). Tissue factor pathway inhibitor (TFPI) antigen plasma level was higher in uremic patients than in controls (114+/-42 ng/ml vs. 64+/-12, p=0.0001). TFPI increased 2.3 times following dialysis and such an increase was directly correlated with post-dialysis plasma heparin concentration (r=0.571, p=0.0002) and inversely correlated with post-dialysis triglyceride variation (r=0.407, p=0.005). Six of fifty patients (12%) had anti-heparin/platelet factor 4 antibodies (Hab), 3 IgG, and 3 IgM. Female sex and the use of cuprophane membranes were more frequent among Hab-positive patients (p=0.0001), while a lower percentage of them were on anti-aggregating drugs as compared to Hab-negative patients (p=0.002). Only one Hab-positive patient was slightly thrombocytopenic and none showed bleeding or thrombotic manifestations. Serum albumin and y globulin decreased following dialysis in Hab-positive patients, while the opposite was seen in those Hab-negative (-2.47+/-1.72 g/L, vs. 0.21+/-1.77, p=0.001 and -0.48+/-0.60 g/L vs. 0.64+/-0.97, p=0.007, respectively). In vivo factors other than Hab are involved in the development of heparin-induced thrombocytopenia. Besides a blunted immunological response, increased levels of TFPI, the use of anti-aggregating drugs, and the observed behavior of serum proteins might play a role in this regard.

[Cost-effectiveness of hip fracture prevention]

We estimated the Cost Per Avoided Hip Fracture (CPAHF, millions Lira) by osteoporosis treatment, on the basis of a review on randomized controlled trials. Prevention with vitamin D3 in institutionalized elderly women is cost-neutral (CPAHF = -4; 95% CI = -9, +5). Prevention with alendronate in non-institutionalized women screened on bone mineral density generates doubts (CPAHF = 275; 95% CI = 146, 19.426). The cost-effectiveness analyses can strengthen or weaken conclusions of the clinical trials and discourage the use of economically unsustainable preventive treatments whose efficacy is unproven.

Anti-Hepatitis C Virus Serology in Immune Thrombocytopenia: A Retrospective Analysis in 101 Patients

Hepatitis C virus (HCV), an RNA virus, is known to be the major cause of post-transfusion non-A, non-B hepatitis. HCV can induce several expressions of autoimmunity, including both serological abnormalities and clinical disorders. The relationship between the HCV infection and anti-platelet autoimmunity has been occasionally described, but is still far from well-defined. We retrospectively analysed 101 serum specimens, collected between 1988 and 1994, from patients with immune thrombocytopenia (ITP) for the presence of anti-HCV antibodies. Eighty-seven patients were classified as having idiopathic, and 14 secondary ITP (4 systemic lupus erythematosus, 9 non-Hodgkin's lymphoma and 1 Evan's syndrome). Anti-HCV antibodies were determined by second generation tests (ELISA + RIBA). A specimen was considered positive for HCV antibodies in the presence of ELISA reactivity (sample optical density/cut-off > 1.00) accompanied by RIBA reactivity to at least one HCV specific antigen. 20 sera (20%) were positive, with a prevalence higher in secondary than in idiopathic ITP (43% vs. 16%, p < 0.05). No differences were found between anti-HCV positive and negative patients regarding gender, platelet count, platelet associated immunoglobulins, hepatitis B virus serology and liver enzyme profile. On the contrary, mean age was higher in the HCV positive vs HCV negative ones (58±18SD vs. 44±20yrs, p < 0.01), in keeping with the increasing prevalence of HCV infection with ageing. HCV positive patients, showed a poor response to treatment (platelet count lower than 50,000/μl after conventional medical therapy for immune thrombocytopenia) compared to anti-HCV negative ones, (50% versus 7.3%, p < 0.001). When we excluded patients who were exposed to risk factors for HCV infection after ITP diagnosis and before the serum collection, the prevalence of anti-HCV antibodies was not very different (17.6%) from that found in the series as a whole (19.8%). Our results seem to indicate that HCV infection may play a role in triggering several cases ITP, and moreover might constitute a negative prognostic factor for therapy response.

[In-hospital mortality of elderly patients with myocardial infarct. Difference between the sexes]

The number of women who become ill and die from acute myocardial infarction (AMI) increases steadily with age. It is not yet clearly defined whether and why women suffer from a higher in-hospital mortality rate after AMI. In this study we evaluated the importance of the female sex as a risk factor for in-hospital mortality in elderly patients suffering from AMI. A retrospective study was performed in 724 patients (429 males, 295 females) aged > or = 65 years (mean age 74.9 +/- 6.3 years) consecutively admitted to San Giovanni Battista Hospital in Turin during the period 1988-1991 with validated primary discharge diagnosis of AMI. In-hospital mortality was significantly higher in females (34.6%) compared to males (25.6%, p > 0.01). After multivariate analysis female sex was not independent predictive for in-hospital death. Multivariate analysis was therefore repeated in the various sections of the history of AMI (anamnestic variables, including age and sex: physical signs on admission, ECG findings, laboratory tests, clinical progress, including complications and treatment) in order to identify the factors responsible for the higher mortality rate in women. These were found to be low hemoglobin values (< 12 g/dl) on admission, development of cardiac failure disorders and rhythm disturbances during hospitalization, and differences in therapeutic procedures. In spite of the absence of an independent unfavourable effect of female sex, elderly women with AMI have a higher in-hospital mortality rate. A more precarious state of health on admission, a peculiar susceptibility to severe complications during hospital-stay and differences in therapeutic procedures appear to be the factors responsible for this increased mortality rate in women.

Estimating the cost per avoided hip fracture by osteoporosis treatment in Italy

OBJECTIVES

A cost-effectiveness analysis on osteoporosis treatment has been carried out as the basis for an estimate of the cost per avoided hip fracture (CPAHF) in Italy.

METHODS

We have assumed as correct, reported data on the efficacy of calcitonin in preventing hip fractures in European women over 50 (Mediterranean Osteoporosis Study). Health-care costs were calculated using Weinstein and Stason's equation.

RESULTS

Given the incidence of such fractures in Italy and their cost to the health service, we calculate that in order to prevent one hip fracture 1285 women need to be treated with calcitonin at a cost of over two million dollars. The introduction of an element of screening (bone mass measurement to select a high risk subpopulation) would reduce the CPAHF by 65%. Choice of a more effective treatment (as the hormone replacement therapy) would be cost-neutral.

CONCLUSIONS

Drug-related costs, selection of high risk subpopulations and drug efficacy have important implications in the estimation of optimal CPAHF.

Free radicals, atherosclerosis, ageing, and related dysmetabolic pathologies: pathological and clinical aspects

An excess of free-radical production has been linked to many diseases and to the ageing process. Oxidant by-products of normal metabolism can cause extensive damage to DNA, protein and lipid. Exposure to ultraviolet light, cigarette smoke and other environmental pollutants may also increase the free radical burden. The accumulation of unrepaired oxidative damage products is likely to be a major factor in cellular ageing. Many repair processes are available to the cell, including enzyme and structural defences. The large group of natural antioxidants is also part of a protective mechanism. High consumption of fruit and vegetables in the diet is associated with a lowered risk of degenerative diseases. At present, however, there are few data to support the routine use of exogenous antioxidants to prevent and treat these diseases.

Free radicals, atherosclerosis, ageing and related dysmetabolic pathologies: biochemical and molecular aspects

In human ageing and with many pathologies correlated to the senile functional decay of cells, membrane damage often occurs in some organ or tissue, which provokes lipid peroxidation in the membrane and accelerates the disorder in structure and function of the membrane. When lipid peroxides accumulate sufficiently, they leak from the organ or tissue into the bloodstream and increase the lipid peroxide level in blood lipoproteins. The increased lipid peroxides in the blood attack the blood vessel and promote atherogenesis. This paper describes the possible involvement of free radicals in this damage, both to tissues and to blood vessels, which contributes to the senile functional decay of the tissues.

Chronic isolated macrothrombocytopenia with autosomal dominant transmission: a morphological and qualitative platelet disorder

We studied 47 subjects belonging to 13 unrelated families with a history of mild haemorrhagic diathesis and chronic thrombocytopenia. 36 patients presented some degree of thrombocytopenia: 7/36 (19%) had slight thrombocytopenia (100-150 x 10(9)/L); 26/36 (72%) had mild thrombocytopenia (50-100 x 10(9)/L) and 3/36 (8%) had severe thrombocytopenia (< 50 x 10(9)/L). No correlation was observed between platelet count and the degree of haemorrhagic diathesis, which was mild in the majority of patients. Transmission was autosomal dominant. Platelet anisocytosis, increased percentage of large platelets and absence of leukocyte inclusions were observed in 26/30 (87%) of the examined blood smears. The ultrastructural appearance of platelets was normal. Megakaryocytes appeared normal in number in 10/10 patients, but showed asynchronous nuclear-cytoplasm maturation and mainly nonlobulated nuclei. Platelet aggregation was studied in 26 patients and either increased or decreased curves were variably observed in response to different aggregating agents. Platelet-associated IgG (PAIgG) was increased in 18/31 (58%) patients, while serum autoantibodies against platelet glycoproteins Ib/IX or IIb/IIIa were demonstrable in only 1 case. An increased expression of platelet surface glycoproteins Ib and IIb/IIIa, as studied by murine monoclonal antibodies binding in 17 cases, was observed. Platelet survival performed by 111Inoxine-labelled autologous platelets was normal in the 3 studied patients. Congenital macrothrombocytopenia confirms to be a distinct clinical disorder for which the name of "chronic isolated hereditary macrothrombocytopenia" is proposed.

Antiplatelet glycoprotein autoantibodies in patients with autoimmune diseases with and without thrombocytopenia

The presence and specificity of antiplatelet autoantibodies in 32 patients with primary and 18 patients with secondary autoimmune thrombocytopenic purpura (AITP), as well as 11 non-thrombocytopenic patients with systemic autoimmune diseases, were studied. By means of the direct and indirect monoclonal antibody immobilization of platelet antigen (MAIPA) assay, antiplatelet autoantibodies were detected using monoclonal antibodies specific for platelet glycoproteins (GPs) Ib, IIb/IIIa, Ia/IIa, and IV. Serum antiplatelet autoantibodies were found in 18 of 32 primary AITP patients (56%), 6 of 18 secondary AITP patients (33%), and 5 of 11 nonthrombocytopenic patients (45%). Platelet-associated autoantibodies were detected in five of eight patients with primary (62%) and in four of eight patients with secondary AITP (50%) and in two of four patients without thrombocytopenia (50%). Multiple antibody reactivity, mainly against GPs IIb/IIIa and Ib and, in a few patients, against Ia/IIa, was found. Using MAIPA, platelet xylene eluates from 20 patients were also studied. Antiplatelet elutable autoantibodies were related to thrombocytopenia; autoantibodies against membrane GPs Ib and IIb/IIIa were demonstrable in 84 and 63% of eluates from patients with primary and secondary AITP, respectively, but not in eluates from nonthrombocytopenic patients. The presence of antiplatelet antibodies thus appears to be a common feature of many autoimmune diseases apart from the thrombocytopenia, but the (primary or secondary) etiology of the immune thrombocytopenia cannot be differentiated on the grounds of their specificity.

[Use and misuse of hospital admission in a department of medicine in Padua]

We evaluated retrospectively 357 consecutive inpatients (M = 157; F = 200) 14=93 wars old (mean 60.9 +/- 1.0, SF: M = 59.5 +/- 1.4: F = 61.9 +/- 1.4) treated by a same physician at the 2nd Division of Medicine, Padua University Hospital, from January 1993 to July 1995. Such Division, which is representative of the Internal Medicine of an important Center has a high medical standard, as evaluated on the basis of academical and scientific titles of its staff, but no specific geriatric facilities. Patients had been assigned to the Division and, within it, to a given physician at random. 38.1% of patients were older than 70 (M = 30.0; F = 44.5, p < 0.01). Apart from the previous group, 29.1% of admissions (M = 28.0; F = 30.0) were inappropriate. 4.5% of admissions were terminally-ill cancer patients, already diagnosed and treated at other divisions and not further susceptible of specific therapy. Only 28.3% of patients (M = 38.2; F = 20.5, p < 0.0005) did not fall within any of the previous categories, but 33% of the days of their hospital stay were inappropriate (M = 30; F = 37). The mean hospital stay was 10.2 +/- 0.5 SE days (M = 10.4 +/- 0.6; F = 10.1 +/- 0.6). Considering patients altogether, the mean hospital stay was longer for patients older than 70 than for the others (12 +/- 0.9 vs. 9.3 +/- 0.5 days, p < 0.01) and a significant correlation was observed between age and stay length (r = 0.249, p < 0.0001). The educational level of inpatients was as follows: no education and elementary 65.8%; junior-high 20.7%; high 8.9%; university 4.4% with no difference between sexes, nor as compared to the general population, adjusted for age. It is concluded that a highly qualified division, to which it would appear appropriate applying only for cases not manageable as outpatients or by less qualified institutions, is suboptimally utilized with waste of money and resources. This is due to a deficiency in geriatric and residential facilities as well as in community and domiciliary care, to a noxious culture subordinating internal medicine to specialty branches and to the inadequate use of resources by both physicians and patients, in particular, among them, by females.

[Longitudinal study of fractures in institutionalized elderly]

AIM

Evaluation of fracture incidence in the institutionalized elderly and analysis of associated risk factors.

EXPERIMENTAL DESIGN

Longitudinal and prospective study with 3-year follow-up.

SETTING

Old people's home in Turin for patients who are no longer self-sufficient.

PARTICIPANTS

197 subjects (47 males and 150 females) aged between 61-98 years old, dependent in at least two basic daily activities.

PARAMETERS

At the time of enrollment, the following parameters were evaluated: age, weight, height, degree of walking autonomy, bone mineral density at proximal and distal radius. The number of falls and fractures were recorded during follow-up.

RESULTS

A total of 46 fractures (22 femoral and 24 in other sites) were recorded with an annual incidence of 7.8%. Femoral fractures only occurred in females. The following risk factors were associated with femoral fractures: very old age (relative risk = 2.6; 95% confidence interval = 1.1-6.4), low body mass index levels (RR = 3.3; 95% CI = 1.3-8.7), low bone mineral density levels at the proximal radius (RR = 2.6; 95% CI = 1.1-6.3), autonomous walking capacity (RR = 3.7; 95% CI = 1.1-12.0) and recurrent falls (RR = 2.7; 95% CI = 1.2-6.2). The following risk factors were associated with non-femoral fractures: autonomous deambulation (RR = 5.7; 95% CI = 1.4-23.7) and recurrent falls (RR = 6.4; CI = 2.3-18.3).

CONCLUSIONS

Institutionalized elderly patients present numerous risk factors for femoral fractures. Fractures in other sites are only associated with risk factors that express a tendency to fall.

Atopic dermatitis and allergic diseases with thrombocytosis: a possible link

BACKGROUND

Thrombocytosis can be present in patients with myeloproliferative disorders or can accompany various conditions, in particular chronic inflammatory diseases, namely chronic bowel diseases, rheumatoid arthritis, and nephritis.

OBJECTIVE

We report our experience in 55 patients younger than 45 years of age with increased platelet counts (over 500 X 10(9)/L). Thirty-three were affected by essential thrombocytemia in agreement with polycytemia vera study group criteria and 22 by reactive thrombocytosis. Serotonin concentration has been determine in all the patients.

RESULTS

Serotonin was decreased as expected in 23 out of the 33 patients with essential thrombocytemia. In the remaining ten subjects, serotonin was within normal limits as in reactive thrombocytosis. Eight of these subjects had positive histories for allergic rhinitis and two for atopic dermatitis.

CONCLUSIONS

Chronic inflammation, present in patients with diseases of the immune system may cause an increased platelet number. One should consider with caution patients with thrombocytosis and positive histories for diseases of the immune system; probably a diagnosis of essential thrombocytemia is not justified.

Health and functional status in elderly patients living in nursing homes

Socio-economic background, functional status, multiple pathology and medical conditions requiring care have been evaluated in 506 elderly subjects living in nursing homes in Turin (Italy). In the sample 78.8% are women, mean age 84.2 years, only 21.2% are men, mean age 76.3 years. Particularly in the oldest age classes women are more represented than men. Most subjects (94.3%) require help in at least one Activity of Daily Living (ADL). Part of the sample (21.2%) comes from home, 13.2% from acute wards, 9.1% from long term care wards, 6.3% from mental hospitals, 26.3% from residential homes. Education level is rather low. Before retirement, many men were workmen (38.3%), while many women were housewives (46.6%). Multiple pathology is very common: 23.7% of patients suffer from 4 pathologies, more than 5 diseases are present in 18.8%, while only 4.7% of subjects have less than two pathologies. Half of the sample (52.6%) is affected by dementia, 37.6% by cardiovascular diseases, 29.1% by chronic obstructive lung disease and 25.5% by stroke. Bone fractures are present in 22.1% of the subjects. Severe impairments in strength and/or motility in at least two limbs affect 43.7% of patients, double incontinence 49.2%, severe disturbances in speech and communication 35.4%. The prevalence of care needs is higher in women compared with men. More females than males need aid in walking, help in eating, diapers, pressure sores prevention and bedposts.

[Course of peripheral arterial diseases]

During January and November 1983 we examined 230 patients by means of doppler evaluation for suspect of peripheral arterial disease. We identified 105 subjects with peripheral arterial disease. During September and November 1993 we tried to convoke again all 230 subjects. Altogether we followed 215 subjects (95 with peripheral arterial disease and 120 without). Sixty-three patients died and we analysed the cause of death. Forty-seven out of 95 patients (49.5%) with peripheral arterial disease died and only 16 out of 120 subjects (13.3%) without peripheral arterial disease. Twenty-five out of 47 deaths (53.2%) happened among the patients with peripheral arterial disease. Age, severity of peripheral arterial disease (measured by ankle-arm pressure ratio) and the presence of a carotid bruit were associated with death. The natural history of peripheral arterial disease has been characterized by a worsening of the intermittent claudication in 52.1% of patients but only 18.6% presented a progression toward a superior class of the Fontaine classification. In conclusion, the peripheral arterial disease, despite his apparently benign course, represents a clinical event that must not be overlooked, because the risk of cardiovascular mortality is high. The measurement of ankle-arm pressure ratio allows a good definition of the severity of peripheral arterial disease and therefore represents a valid prognostic criterion.

Biotin-avidin immobilization of platelet glycoproteins (BAIPG): a new capture assay for the detection of anti-platelet antibodies

Several 'capture' assays are currently employed to identify specific platelet antibodies, but all require the use of murine monoclonal antibodies (MoAbs) against the antigen of interest. We have developed a new antigen capture assay for the detection of platelet reactive antibodies, based on platelet surface sialoglycoprotein labelling with biotin hydrazide, and a following immobilization of the biotinylated platelet proteins to microtiter wells that had been coated with streptavidin. The resulting solid phase can then be used in a simple ELISA to detect serum and platelet associated antibodies. We describe here two versions of this biotin-avidin immobilization of platelet glycoproteins (BAIPG) assay. In BAIPG assay type I, the test sera are directly incubated in microtiter wells previously coated with streptavidin plus biotinylated platelet proteins. The BAIPG type II procedure involves the incubation of sera with biotinylated platelets before platelet solubilization, and, after platelet lysis, the immobilization of the immune complexes to streptavidin-coated wells. In both cases, the bound antibodies are determined by alkaline phosphatase conjugated anti-human IgG. Using BAIPG type I, positive results were obtained in 7/33 patients with idiopathic thrombocytopenic purpura (ITP), 1/10 patients with secondary immune thrombocytopenia (SIT) and 4/17 with non-immune thrombocytopenia (NIT). The BAIPG type II test was positive in 13 out of 33 patients with ITP, in six out of ten patients with SIT, and in three out of the 17 patients with NIT. A comparison between BAIPG and monoclonal antibody immobilization of platelet antigens (MAIPA) assays showed a high degree of correlation between the two methods. These results suggest that the BAIPG assay is a valuable new tool for the detection of anti-platelet antibodies.

Site-specific relative risk of fractures in the institutionalized elderly

A 3-year prospective study was performed to evaluate the incidence of fractures in institutionalized elderly and associated risk factors. A total of 197 subjects (47 males and 150 females, mean age 81.5 +/- 8.0 years) were included in the study. The annual fracture incidence was 7.8%. All hip fractures occurred in female subjects (annual incidence = 3.7%). As expected, the incidence of fractures is higher in walking subjects. In walking subjects (n = 128) logistic regression analysis showed falls [adjusted relative risk (RR) = 3.3; 95% confidence interval (CI) = 1.3-8.4] and age (adjusted RR = 1.7; 95% CI = 1.1-2.3) to be variables independently and significantly associated with fractures, after adjusting for baseline bone mineral density (BMD) and sex. Hip fractures were associated with age (RR = 1.6; 95% CI = 1.1-2.3), and non-hip fractures with falls (RR = 4.1; 95% CI = 1.3-13.4). The importance of low BMD as a risk factor for fractures is reduced in the institutionalized elderly. However, other fracture-site-specific risk factors exert a greater influence.

[Changes in the electrocardiogram in the elderly patient. The limits between normality and pathology]

Normal electrocardiographic criteria in the elderly are not well defined. The prevalence of electrocardiographic abnormalities is three times higher in subjects over 85 years than in subjects 65-69 years old. With aging the heart rate does not vary during rest and sinus rhythm is prevalent, although sinus pauses, overall at night, are frequently seen. First degree atrio-ventricular block is present in 8.1%-19% of the elderly. 11% of subjects over 70 years suffer from left anterior hemiblock. 4.3% of subjects over 65 years and 7% of those over 85 present a right bundle branch block. 1.7% of subjects older than 65 years and 9% of those older than 85 are affected by a left bundle branch block. Atrial ectopic contractions are present in 8.8% of subjects over 60 years and in all older subjects. Atrial fibrillation is more common as age increases, being found in 2% of under 75s, in 5% of all subjects over this age, in 14% over 85 years and in 27% of patients hospitalized or institutionalized aged over 90 years. The prevalence of ventricular ectopic contractions varies from 76% in studies performed with baseline electrocardiogram to 96% in studies performed with portable monitoring electrocardiogram. Major ST-T wave alterations are present in 6.3%-13% of the elderly. In 340 patients over 80 years, hospitalized for diseases, other than cardiovascular, we found atrial fibrillation in 27.9% of subjects, ectopic beats in 26.2%, first degree atrioventricular block in 8.5%, right bundle branch block in 11.2%, left bundle branch block in 5.9%, left anterior hemiblock in 8.2%, ST-T wave alterations in 23.8% of the population.

Specific antiplatelet autoantibodies in patients with antiphospholipid antibodies and thrombocytopenia

By means of immunoblotting and monoclonal antibody immobilization of platelet antigens (MAIPA) we have studied the specificity of antiplatelet antibodies in patients with antiphospholipid antibodies and thrombocytopenia defined as presence of anticardiolipin IgG and a platelet count below 100 x 10(9)/l. The study group consisted of 10 patients with systemic lupus erythematosus (SLE), 8 patients with primary anti-phospholipid syndrome (PAPS) and 16 patients with idiopathic thrombocytopenic purpura (ITP). The comparison group was formed by 17 patients with classical chronic ITP without anticardiolipin IgG. We identified the 80-100, 130-150 and 150-170 KD surface proteins that comigrate with GPIIIa, GPIIb and GPIb and a 50-70 KD cytoplasm band by immunoblot. In patients with classical chronic ITP, the prevalence of the antiplatelet antibodies against GPIIIa was 53% on immunoblot assay and 47% on MAIPA. In ITP patients who had also anti-phospholipid antibodies in serum, the percentage of reactivity to GPIIIa declined to 37% on immunoblot and 21% on MAIPA but it was not statistically different from the percentage observed in patients with classical ITP. Autoantibodies to platelet surface glycoproteins were almost absent in SLE and PAPS patients, who showed a significant prevalence (78%) of IgG reactivity to the 50-70 KD internal platelet protein which was frequently encountered also in patients with ITP and aPL (56%). Our study provides additional evidence that platelet antigens in patients with phospholipid-associated secondary immune thrombocytopenia are different from those of primary ITP, and that surface glycoproteins were not involved.

[Health demands in adolescence. The results of 2 epidemiological studies in the Padua area in 1990-1992]

In order to make a detailed analysis of the specific requirements of adolescent health in this country, local health unit n. 19 in Padua performed an epidemiological survey with the collaboration of 15 general physicians who were asked to record all ambulatory visits by 13-24 year olds on a special form. The survey, which lasted two years, revealed that of a total of 4748 records, 2112 (44.48%) were male and 2636 (55.51%) were female. The age at which the greatest number of visits was recorded was 18. The majority of adolescents attended alone (68.48%) and this pattern tended to increase with age. The frequency of annual attendance was 86.64%. In order of frequency, diagnoses included: requests for certificates and prescriptions (21.76%); respiratory disease and influenza (21.61%); obstetric and gynecological problems (8.61% of the total and 15.52% of female attendance) which together with auxoendocrinological problems amounted to a frequency of 10.55%; psychological problems (6.53%); dermatological diseases (6.324%); problems involving the osteomuscular structure, problem of the digestive tract (4.93%); nervous disorders and diseases of the sense organs (4.87%); medication and requests for information (3.60%); nephro-uro-andrological problems (3.26%).

IN CONCLUSION

the high rate of attendance at medical clinics does not show that adolescents are an often ill population but that the doctor has been selected as the prime interlocutor for all health-related problems. It should also be pointed out that the majority of problems tend to be reported as somatic, whereas only a minimum part (6.53%) are classified as psychological. This analysis confirms, however, that the health requirements presented as somatic often involve a psychological component.

The Italian version of the Alzheimer's Disease Assessment Scale (ADAS): psychometric and normative characteristics from a normal aged population

The Alzheimer's Disease Assesment Scale (ADAS) was specifically proposed for the clinical assessment of patients suffering from dementia and is used in different countries. The Italian version of ADAS is presented in this paper together with the description of criteria used in transforming the American edition in the Italian edition. Psychometric and normative data are illustrated and discussed. A sample of 95 healthy volunteers of both sexes ranging in age from 50 to 79 years were recruited from the general population in different parts of Italy and from different social and educational levels. Their performance on the ADAS was analysed by sex, age, and educational level. Results indicated a specific influence of subjects' educational level on the Cognitive Subscale Total Score of ADAS and the need for an adequate correction was evidenced. The two objective measures of memory which constitute, together with the Cognitive Subscale Total Score, the cognitive subscale of ADAS were sensitive to both age and educational level, requiring corrections. The factor structure of the cognitive subscale of ADAS confirms the validity of distinguishing between the clinical-functional scores, which are summarized by the Cognitive Subscale Total Score (CSTS), from those of the objective memory tasks, which are kept separate and used to quantify specific memory characteristics. The main components of the CSTS were 3 factors. The first factor was

Carotid plaque, aging, and risk factors. A study of 457 subjects

BACKGROUND AND PURPOSE

The aim of this study was to assess the prevalence of extracranial carotid artery atherosclerosis and its relation to principal cardiovascular risk factors at different ages in a sample of the general population.

METHODS

B-mode ultrasonography was used to investigate the carotid district in 457 subjects (231 men and 226 women; mean age, 55.4 +/- 18.7 years; range, 18 to 97 years) in the metropolitan area. The ultrasonographic findings were then related to risk factors.

RESULTS

Carotid plaques were found in 178 subjects (38.9%). The prevalence of atherosclerosis, number of plaques, and severity of stenosis were observed to increase with age. Age (P < .0001), cigarette smoking (P < .0001), male sex (P < .001), total cholesterol (P < .05), and, inversely, the ratio of high-density lipoprotein cholesterol to total cholesterol (P < .05) were found to be independently associated with carotid atherosclerosis. Stratified analysis by sex and age showed effect modifications by age on cigarette smoking, total cholesterol, and the ratio of high-density lipoprotein cholesterol to total cholesterol. After multivariate analysis including interaction terms, cigarette smoking and cholesterol levels were not longer found to be associated with carotid atherosclerosis in elderly subjects. Age (P < .01), total cholesterol (P < .05), and diabetes (P < .05) were positively related to the severity of vascular narrowing.

CONCLUSIONS

There is a high prevalence of asymptomatic carotid atherosclerosis in the general population, particularly among the very old. The association between risk factors and carotid atherosclerosis is less pronounced in the elderly than in younger subjects.

Myeloproliferative disease in patients with a history of multiple blood donations: a report of 8 cases

BACKGROUND

The clonal origin of myeloproliferative disorders has been clearly demonstrated and it is known that reactive thrombocytosis occurs as a non specific response to various inflammatory or neoplastic conditions. Only a few papers have discussed the topic of myeloproliferative diseases in blood donors.

MATERIALS AND METHODS

We report 8 cases of myeloproliferative diseases (3 polycythemia vera and 5 essential thrombocythemia) in blood donors out of a total of 44 myeloproliferative disorders diagnosed in our Department during the last 5 years on the basis of the criteria established by the Polycythemia Vera Study Group criteria. As controls we considered 61 patients with reactive thrombocytosis referred to our Department in the same period of time. The estimated odds ratio was calculated according to standard methods.

RESULTS

The prevalence of blood donors with myeloproliferative disorders was 18.1%, while that of donors with reactive thrombocytosis was 3.2%. The estimated odds ratio was 6.56 with a 95% confidence interval between 1.07 and 17.3. No other single factor except blood donations was frequent in the past history of these patients.

CONCLUSIONS

Our data seem to indicate that both thrombocytosis and erythrocytosis resembled primary forms in these subjects; however, none of them suffered serious thrombotic and/or hemorrhagic symptoms. Our study indicates the importance of paying due attention to the blood cell counts of blood donors.

Risk factors for atherosclerosis and aging

In order to investigate the association between atherosclerosis and risk factors in aged subjects, Doppler ultrasound scans were used to identify the presence and severity of carotid and femoral atherosclerosis in a sample of 457 community living subjects (mean age 55.4 +/- 18.7 years) of the metropolitan area; the ultrasonographic findings were then related to primary cardiovascular risk factors. Carotid and femoral plaques were found respectively in 178 (38.5%) and in 180 (39.4%) subjects. Prevalence of atherosclerosis, number of plaques and percentage of stenosis have been observed to increase with age. All the main cardiovascular risk factors (age, male sex, hypertension, cigarette smoking, diabetes and hypercholesterolemia) resulted significantly associated with both carotid and femoral atherosclerosis in the total series and, more strongly, in subjects aged under 65. On the contrary, most of these associations disappeared in subjects aged 65 or more. Multiple logistic regression analysis confirmed that in this age group only age and male sex were independently associated with carotid and femoral atherosclerosis; of the other risk factors cigarette smoking alone was an independent risk factor for femoral atherosclerosis. We conclude that in the elderly, in spite of the age-related increase in carotid and femoral atherosclerosis, the association between risk factors and atherosclerotic disease is less relevant than at younger ages.

Hemodynamic, hemorheologic, and hemocoagulative changes after treatment with picotamide in patients affected by peripheral arterial disease (PAD) of the lower limbs

Effects of picotamide on platelet activity and on some hemorheologic, coagulative, and hemodynamic parameters were investigated in a randomized, double-blind, placebo-controlled study for eighteen months. Twenty patients, average age 61.5 +/- 9.6 (SD) years, with peripheral arterial disease (PAD) at functional stage 2 of the Fontaine classification and with intermittent claudication for at least six months were studied. Ten patients received tablets of picotamide, 300 mg three times a day, and 10 subjects received three identical placebo tablets each day. Similar atherosclerotic disease risk factors were present in both groups. Picotamide induced a significant decrease of plasma viscosity, fibrinogen, and beta-thromboglobulin and an increase of amplitude of the photoplethysmographic wave.

Carotid plaques, aging, and risk factors for atherosclerosis

The prevalence of extracranial carotid artery atherosclerosis and its relations to principal cardiovascular risk factors at different ages was evaluated in a sample of general population. High resolution B-mode ultrasonography was used to investigate the carotid district in 457 subjects (231 males and 226 females, mean age 55.4+18.7 years, range 18-97 years) of the metropolitan area. The ultrasonographic findings were then related to primary risk factors. Carotid plaques were found in 178 subjects (38.5%). Prevalence of atherosclerosis, number of plaques and percentage of stenosis have been observed to increase with age. The main cardiovascular risk factors resulted significantly associated with carotid atherosclerosis in the total series and, more strongly, in subjects under 65 years. In the group aged 65 years and over, most of these associations were no longer found. In the multiple logistic regression model, analysis of subjects under 65 years showed positive and independent associations between carotid atherosclerosis and age (p<0.0001), cigarette smoking (p< 0.001), number of cigarettes smoked each day (p<0.01), and a negative association with HDL/total cholesterol ratio (p<0.001). The analysis of subjects aged 65 years or more showed positive independent associations only with age (p<0.001) and male gender (p<0.01). In conclusion, there is a high prevalence of asymptomatic carotid atherosclerosis in the general population, particularly in advanced age. In the elderly the association between risk factors and carotid atherosclerosis has not yet been found.

[Ischemic stroke and transient ischemic attacks: a case-control study of the risk factors in elderly hospitalized patients]

We have evaluated in a case-control study the association of the main risk factors with cerebrovascular ischemic accidents in elderly patients. Two hundred and twenty patients aged 65 year or more (average age 77.3 +/- 7.3 yr, 93 males and 127 females) admitted to our Division for stroke (122) or transient ischemic attacks (TIA) (98) were enrolled: 220 hospitalized patients, age and sex-matched, without actual or previous cardiovascular clinical manifestations were the control group. Advanced senile decay, hepatic or renale failure and malignancies were considered exclusion criteria for both groups. The following risk factors have been considered: family history, obesity, cigarette smoking, diabetes, hypercholesterolemia, hypertriglyceridemia, atrial fibrillation, left ventricular hypertrophy, and related continuous variables. After logistic multiple regression analysis, atrial fibrillation, hypertension and blood cholesterol concentration above 240 mg/dl were significantly and independently associated with stroke, while only hypertension and hypercholesterolemia were associated with TIA. The unexpected finding of a significant association between hypercholesterolemia and cerebrovascular ischemia seems attributable to the choice of hospitalized patients as control group. These results indicate that hypertension and atrial fibrillation are independently associated with ischemic stroke even in advanced age.

Risk factors for atherosclerosis: ultrasound evaluation of carotid and femoral arteries in patients examined by coronary angiography

The carotid and femoral arteries of 209 subjects (161 men and 48 women), consecutively tested by coronary angiography during the first four months of 1990, were examined using a B-Mode Echo-doppler. The angiographic examination was performed for suspected ischemic disease or to complement hemodynamic tests for valvular cardiopathy. The relationship between the main risk factors and the degree of atherosclerotic vascular involvement in the coronary, carotid and femoral districts was examined using standardised partial correlation coefficients. Cigarette smoke (expressed as number of cigarettes per day or as duration of exposure to smoke), total blood cholesterol concentration and age were positively correlated with the degree of atherosclerotic involvement in all three vascular regions; triglyceridemia values were correlated only in the coronary region. These relations were observed both in patients below and above 65 years of age; in the elderly group no correlation was found between blood cholesterol concentration and coronary involvement and between triglycerides levels and atherosclerotic disease in the three districts. Our results suggest that some risk factors (high blood cholesterol concentration and history of smoking) correlate with severity of atherosclerotic involvement even in advanced age.

The effect of a single course of alpha-2B-interferon in patients with HIV-related and chronic idiopathic immune thrombocytopenia

13 patients with HIV-related immune thrombocytopenia (HIV-ITP) and 10 patients with chronic idiopathic thrombocytopenic purpura (C-ITP) were treated with a single course of alpha-2b-Interferon (IFN 3 x 10(6) IU subcutaneously for 12 d). The patients had platelet counts lower than 40 x 10(9)/L and thrombocytopenia persisting for over 1 year (range 1-22 years); 7 patients were refractory to previous conventional therapy, 5 were responsive, and 11 had not been previously treated. The response to IFN was complete in 8 patients (platelets > 100 x 10(9)/L), partial in 7 (platelets 50-100 x 10(9)/L); 8 patients showed no response. The treatment with IFN was stopped after 4 d in one patient due to a fall in platelet count. The maximal platelet count (median peak 116 +/- 55 SD x 10(9)/L platelets) was obtained after 13.7 +/- 2.98 d and the improvement in platelet count was maintained for 22.8 +/- 8.6 d. No difference in platelets response was observed between HIV-ITP and C-ITP. The response to IFN seems to be related to the one obtained with previous treatments. Indeed 80% of the patients who were responsive to previous steroids, high dose immunoglobulins or azidothymidine (HIV-ITP) showed a complete or partial response while only 43% of the refractory patients showed a partial response; the positive response rate in previously untreated patients was 73%.