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A patient with multiple myeloma presented with an accumulation of chylomicron-like particles. This rare finding resembled that of the type V hyperlipoproteinaemia phenotype. The lipid and lipoprotein concentration and composition were compared with values obtained from other patients with multiple myeloma, patients with the type V hyperlipoproteinaemia phenotype (accumulation of chylomicrons and very low density lipoproteins), and normal subjects. An immunoglobulin-lipid complex was demonstrated in our patient. This complex was found not to be associtated with the chylomicrons and was detected only in the lipoprotein-dificient plasma. Lipid and lipoprotein concentration and composition differed from the other groups. Very low density lipoprotein concentration was reduced, and there was thus a marked difference from the type V phenotype. The chylomicrons derived from this patient were also richer in apolipoprotein C compared to chylomicrons derived from the patients with type V hypolipoproteinaemia. It appears that the abnormal composition of the triglyceride-rich lipoproteins observed in this patient renders her refractory to the normal pathways of metabolism.

The role of apo E in aspects of reverse cholesterol transport was studied in apolipoprotein E-deficient mice. These animals develop rampant atherosclerosis. The efflux of cholesterol from mouse peritoneal macrophages (MPM) was 40% lower when induced by high density lipoprotein (HDL) from apo E-deficient mice, compared to the effect of HDL from normal mice. On adding apo E to apo E-deficient HDL, cholesterol efflux from the macrophages increased by 35%, approaching the degree of efflux obtained with normal HDL, This HDL (normal or apo E-deficient)-induced cholesterol efflux was similar in peritoneal macrophages derived from both normal and apo E-deficient mice, suggesting that the HDL apo E rather than the macrophage apo E is responsible for the stimulation of cellular cholesterol efflux. On determining cholesterol efflux specifically from the macrophage plasma membrane, the revel of efflux was similar for both HDL preparations, suggesting that apo E in HDL is important for cholesterol translocation to the plasma membrane, the initial step in reverse cholesterol transport. It is concluded that the enhanced atherosclerosis in apo E-deficient mice could be related, at least partly, to the impaired efflux of LDL derived cholesterol from macrophages of the arterial wall.

Aspirin, 250 mg/day, was administered to 14 normolipidemic healthy subjects for 7 days. Platelet lipid composition was determined in washed platelets by quantitating cholesterol to phospholipid molar ratio. Platelet membrane fluidity was measured by steady state fluorescence polarization using the probe diphenyl hexatriene. Upon 7 days aspirin ingestion platelet lipid composition was not altered. There was a sex-dependent effect of aspirin administration on platelet membrane fluidity. Whereas overall platelet membrane fluidity did not change at 37°C, there was a significant decrease in female subjects; the anisotropy parameter which is inversely related to membrane fluidity increased from 0.937±0.043-1.048 ±0.027 (p0.01). In male subjects there was an increase in platelet membrane fluidity, which was significant at 25° C; the anisotropy parameter decreased from 1.350 ± 0.039-1.283±0.023 (p0.05). These results indicate that aspirin alters the membrane dynamics of platelets. This effect results from mechanisms other than alterations in platelet cholesterol or phospholipid content and operates in an opposite direction in men and women.

Neutral lipid storage disease with ichthyosis (NLSDI) is an inherited metabolic disorder characterized by accumulation of neutral lipids, in a wide variety of cells, by a still unknown mechanism. Previous studies have shown normal cholesterol content in NLSDI granulocytes, fibroblasts and skin cells. Monocyte-derived macrophages possess an additional pathway of cholesterol uptake, which is not shared by these cells and which is not regulated by intracellular cholesterol levels. This pathway is thought to play a rôle in the process of atherosclerosis. Three NLSDI patients were studied. The serum levels of triglycerides, cholesterol, high-density lipoprotein cholesterol, and apolipoproteins A-I and B were within normal limits in all three patients. The intracellular levels of free and esterified cholesterol were measured in the monocyte-derived macrophages of one patient and found to be normal, while the triglyceride concentrations were twice as high as normal. The cholesterol esterification rates, which serve as a sensitive indicator of intracellular changes in cholesteryl ester levels, were normal in the monocyte-derived macrophages of all three patients. These findings provide further evidence that cholesterol metabolism is not disturbed in NLSDI, and it may be inferred that in this respect these patients are not at increased risk for atherosclerosis.

Intralipid infusion into normal volunteers was recently shown to possess anti-atherogenic properties. We studied the effect of intralipid infusion in patients with severe Familial Hypercholesterolemia (FH) refractory to conventional therapy. FH patients and normal subjects, who served as controls, were given an intravenous infusion of intralipid for 6 h. Serum samples taken from both groups before, during and after intralipid infusion were studied for their ability to inhibit cellular cholesterol accumulation by macrophages. A significantly lower rate of cellular cholesterol esterification (of 46%, P less than 0.005 and 44%, P less than 0.005 in patients and normals, respectively) was demonstrated in macrophages incubated with serum obtained during intralipid infusion compared to those incubated with preinfusion serum. The maximal effect was demonstrated with serum samples taken at the end of the infusion, but the inhibitory effect persisted even at 24 h post-infusion. It was found that chylomicron like particles could induce the above-mentioned effects on macrophage cholesterol esterification. A significant decrement of 50% (P less than 0.005) in aggregation of platelets isolated from plasma samples taken during and after intralipid infusion from both groups was demonstrated, when compared to platelets isolated in the preinfusion state. This effect persisted 18 h subsequent to infusion. We conclude that intralipid infusion abolishes serum ability to stimulate cholesterol esterification in cultured macrophages, and exhibits inhibitory effects upon platelet aggregation. If similar events occur in the arterial wall, intralipid might inhibit foam cell formation.

Apo E-deficient mice which are highly atherogenic animals were used in order to study their plasma and lipoprotein lipid peroxidation in the absence or presence of oxidative stress. We have demonstrated that plasma from apo E knockout mice demonstrated increased lipid peroxidation both in the absence and in the presence of a free radical generating substance, 2,2-Azobis-(2-amidinopropane) hydrochloride (AAPH). Similarly, low and very low-density lipoprotein (LDL and VLDL) from apo E-deficient mice, but not their high-density lipoprotein (HDL), demonstrated increased lipid peroxidation. We suggest that in apo E-deficient mice, accelerated atherosclerosis is associated with increased lipid peroxidation of plasma, LDL and VLDL, as well as increased susceptibility of these lipoproteins to undergo lipid peroxidation under oxidative stress.

In patients with essential hypertension, the increased risk for atherosclerosis is related not only to the blood pressure levels per se, but also to other, unknown, factors. Recent observations have indicated that oxidation of low density lipoprotein (LDL) and macrophage uptake of oxidized LDL are implicated in human atherosclerosis. We tested both the susceptibility of LDL, derived from hypertensive patients, to lipid peroxidation as well as its uptake by macrophages, in comparison with control LDL obtained from healthy subjects. The LDL that was derived from 25 patients with essential hypertension demonstrated increased propensity for lipid peroxidation with a 63%, 91% and 69% elevation in the content of the lipoprotein malondialdehyde, peroxides and conjugated dienes, respectively, in comparison with control LDL. Minimally modified LDL (MM-LDL) (prepared by 6 months' storage of the LDL at 4 degrees C) derived from the hypertensive patients also demonstrated increased lipid peroxidation with a 94%, 130% and 96% elevation in lipoprotein malondialdehyde, peroxides and conjugated dienes, respectively, compared with the control LDL. The susceptibility of the patients' LDL to lipid peroxidation decreased by 32% and 44% (measured as malondialdehyde) after 3 weeks of therapy with the angiotensin converting enzyme inhibitors captopril and enalapril, respectively, with no parallel reduction in the patients' blood pressure. The patients' LDL was shown to contain increased content of lipid peroxides and unsaturated fatty acids, which may explain its increased susceptibility to lipid peroxidation. In vitro experiments revealed that LDL can bind angiotensin II, and that angiotensin II has a stimulatory effect on copper-mediated oxidation of LDL, as well as on LDL degradation by macrophages. These results were secondary to cell-mediated oxidation of the LDL and to its cellular uptake via the scavenger receptor. We conclude that LDL derived from patients with essential hypertension is more susceptible to lipid peroxidation than control LDL, and this may be secondary to angiotensin II stimulation of LDL lipid peroxidation in these patients. Furthermore, this LDL demonstrates enhanced cellular uptake by macrophages in comparison with normal LDL which can also be related to angiotensin II-mediated LDL oxidation. Both these phenomena have been shown to be associated with accelerated atherosclerosis, and thus suggest a new mechanism for increased atherogenecity in hypertensive patients.

The lipid composition of whole platelets and the fluidity of platelet membranes, as well as the sensitivity of the cell to aggregation, were studied in type IIA hypercholesterolemic human subjects before and after treatment with lovastatin. Fourteen patients with primary hypercholesterolemia having initial cholesterol levels of 383 +/- 52 mg/dL (mean +/- standard deviation) were studied and compared with 21 control subjects having cholesterol levels of 187 +/- 32 mg/dL. Lovastatin was administered orally at a starting dose of 40 mg daily. The dose was increased to 80 mg daily for eight patients who did not achieve the target cholesterol level of 200 mg/dL at 6 weeks. Serum cholesterol level was decreased by 37% following 20 weeks' administration of the drug. The fluidity of platelet membranes expressed in terms of the fluorescence anisotropy parameter was determined using the probe 1,6-diphenyl-1,3,5-hexatriene (DPH). When compared with platelets obtained from normocholesterolemic controls, platelets from hypercholesterolemic patients had a higher molar ratio of cholesterol to phospholipids ([C/PL] 0.86 +/- 0.15 v 0.57 +/- 0.06 for controls) and of phosphatidylcholine to sphingomyelin ([PC/SM] 2.64 +/- 0.87 v 2.00 +/- 0.15 for controls), enhanced fluidity (anisotropy parameter at 37 degrees C of 0.892 +/- 0.066 v 0.977 +/- 0.065 for controls), and a greater tendency to aggregate (aggregation of 84.2% +/- 6.3% v 78.5% +/- 7.6% for controls).(ABSTRACT TRUNCATED AT 250 WORDS)

Summary A case of adult xanthogranulomatosis was investigated in depth for lipid abnormalities. The xanthogranulomatous lesion was shown to be composed primarily of cholesterol esters and triglycerides. Fasting plasma lipid levels and lipoprotein concentrations were within normal limits. Plasma lipoprotein electrophoresis and immunoelectrophoresis demonstrated normal high-density lipoprotein (HDL) and low-density lipoprotein mobilities. Polyacry-lamide-gel isoelcctric-foeusing electrophoresis revealed increased levels of very-low-density apolipoprotein (apo) E, especially apo E-III. In the HDL fraction, apo-C-III and apo-E levels were both found to be slightly elevated. These findings might imply a causal relationship between the abnormal plasma apolipoprotein levels and the xamhogranulomatous disease.

Oxidized low density lipoprotein (Ox-LDL) is considered to be involved in the atherogenic process. Factors influencing the formation of Ox-LDL are thus of importance. Oxidation of LDL in a cell-free system in the presence of copper ions was significantly increased (up to 60%) by the presence of platelet-conditioned medium, (PCM) obtained from collagen-activated platelets for the duration of the oxidation period. The effect was time- and dose-dependent and was related to hydrogen peroxide and superoxide production, since PCM-induced enhanced LDL oxidation was inhibited by catalase and by superoxide dismutase, but not by protease treatments. PCM also reduced the fluidity of oxidized LDL by 45%. Upon incubation with a J-774 macrophage-like cell line, PCM-treated Ox-LDL enhanced cellular cholesteryl ester synthesis by 47% and lipoprotein degradation by 41%. Thus platelet secretory products appeared to enhance LDL oxidation through the involvement of oxidative agents. The resulting Ox-LDL demonstrated increased atherogenic properties.

Jejunal mucosa is responsible for the absorption of triglycerides and the production of lipoproteins [chylomicrons, very-low-density lipoprotein (VLDL), high-density lipoprotein (HDL)] and apolipoproteins (B-48, A-I, A-II, A-IV, C-II). Mucosal damage is known to cause fat malabsorption and probably also affects the serum lipid profile. To determine lipoprotein production in states of enterocyte dysfunction, we compared the serum lipid profiles in a group of 12 children with untreated celiac disease (flat jejunal mucosa) with the profiles in a control group of 10 children suffering from other intestinal diseases. Statistically significant differences were found in the following parameters (celiac versus control): plasma levels of triglycerides (70 versus 119 mg/dl), cholesterol content in LDL (107 versus 67.7 mg/dl), protein content in VLDL (6 versus 10 mg/dl), and level of apoprotein A-I (112 versus 140 mg/dl). No significant differences were found between the two groups in the serum levels of total cholesterol, the cholesterol content in VLDL and HDL, the protein content in LDL and HDL, and the level of apoprotein B. Following institution of a gluten-free diet, the lipoprotein profile reverted to normal. These data suggest that the changes in the serum lipoprotein profile in celiac disease are secondary to alterations in enterocyte function and not only a reflection of fat malabsorption.

A 10 year old boy with abetalipoproteinaemia is reported. His mother and grandfather suffered from familial hypobetalipoproteinaemia, but his father had a normal lipoprotein profile. This is the first report of abetalipoproteinaemia resulting from compound heterozygosity for abetalipoproteinaemia and familial hypobetalipoproteinaemia.

Enhanced platelet activity in patients with hypercholesterolemia and moderate hypertriglyceridemia can be attributed to increased LDL and VLDL and/or decreased HDL concentrations. In marked hypertriglyceridemia, where there is an accumulation of chylomicrons, platelet function is reduced. Treatment, whether by diet, medication, or plasmapheresis, that will result in a change in lipoprotein pattern is accompanied by a parallel change in platelet responsiveness. Incubation of lipoproteins with isolated platelets results in enhancement of platelet activation by LDL and VLDL and suppression of activity by HDL and chylomicrons. These findings have in vivo confirmation. They are even more pronounced and sometimes altered when the lipoproteins are derived from hyperlipidemic subjects. The effects of the lipoproteins on platelet activity appear to be dependent on lipoprotein composition and on factors such as cholesterol:protein ratio, apo C-III0:apo C-III2 ratio, apo B concentration, and triglyceride:protein ratio. The lipoproteins interact with platelets at specific receptor sites. Rapid change in platelet composition, particularly with regard to cholesterol, phospholipid, and fatty acid content, might ensue, with consequent alterations in membrane fluidity and enzyme activities and either suppression or activation of platelet function. This review has indicated that lipoproteins have a clear influence on platelet function. This interaction could be well of paramount importance in determining atherogenic risk.

LDL modified by incubation with platelet secretory products caused cholesterol accumulation and stimulation of cholesterol esterification in mouse peritoneal macrophages. Its uptake by the macrophages was a receptor-mediated process, not susceptible to competition by acetyl-LDL or polyanions suggesting independence of the scavenger receptor. Stimulation of the esterification process in macrophages by this modified LDL was inhibited by the lysosomal inhibitor chloroquine, indicating requirement for cellular uptake and lysosomal hydrolysis of the lipoprotein. Within the cell, the modified LDL inhibited cellular biosynthesis of triglycerides in a manner similar to the action of acetyl-LDL but different to the effect of native LDL. In the presence of HDL, acting in the medium as an acceptor for cholesterol, a low rate of cholesterol efflux from cells incubated with this modified LDL as well as with acetyl-LDL was demonstrated. A small reduction in cholesteryl ester synthesis was found in these cells, compared to a 60% reduction in cells incubated with native LDL. Thus it was demonstrated that LDL modified by platelet secretory products could induce macrophage cholesterol accumulation even though it was recognized and taken up via the regulatory LDL receptor.

The postprandial plasma lipoprotein pattern was studied in 10 normal and 10 hypertriglyceridaemic subjects after consumption of either a saturated or a polyunsaturated fat-rich meal. Plasma triglycerides increased in both groups 3 h after the meal, and this was followed after 5 h by a dramatic reduction in the normal subjects only; the reduction was less after the saturated fat meal than after the polyunsaturated fat meal. This plasma triglyceride pattern was a consequence of changes in the chylomicron and very-low-density lipoprotein (VLDL) fractions. No significant changes were found in high-density lipoprotein (HDL)- and low-density lipoprotein (LDL)-cholesterol, triglycerides or protein concentration. Plasma cholesterol and apolipoproteins (apo) A-I and B were not significantly altered. The VLDL-apo C-III/apo C-II ratio increased 3 h after the saturated fat-rich meal, but decreased after the polyunsaturated fat-rich meal in normals, but not in the patient group. The effect of these postprandial lipoproteins on platelet function was studied by incubating normal washed platelets with the lipoprotein and then determining aggregation and [14C]serotonin release. All chylomicron fractions decreased platelet activity, whereas postprandial VLDL increased platelet activity. Five hours after the meals, the effect of VLDL on platelet activation was reduced in normal subjects only. The effect of postprandial LDL and HDL on platelet function differed little from that of the fasting lipoproteins.(ABSTRACT TRUNCATED AT 250 WORDS)

Summary Plasma lipid and high density lipoprotein (HDL) levels were studied in 20 normal, healthy, non-obese males while fasting (150 kcal/d with free intake of water) for 6 d in a hunger strike. Plasma triglyceride and cholesterol levels were increased by 18% after 6 d of fasting. HDL-cholesterol concentration was not significantly changed for 4 d, but decreased by 22% after 6 d. Platelet aggregation induced by adenosine diphosphate (ADP) or collagen after 6 d of fasting was in the normal range. In 3 subjects fasted for 9 d, a complete plasma lipoprotein analysis was done. Very low and low density lipoprotein (VLDL and LDL) levels were elevated, whereas HDL was reduced after 9 d of fasting. On isoelectric focusing analysis, a marked reduction in apolipoprotein (apo) E concentration in both VLDL and HDL was noted. Liver function tests showed a reduction in hepatic enzyme activity; and since apo E is of hepatic origin also, we suggest that long fasting inhibits liver function in normal subjects.

Patients with myeloproliferative disorders demonstrate decreased plasma cholesterol and apolipoprotein B concentrations, and this has been related to the presence of a large spleen. Patients that underwent splenectomy in the past demonstrated normal plasma cholesterol levels. Plasma high-density lipoprotein (HDL) cholesterol and apolipoprotein A-I were also reduced in these patients, but were normal after splenectomy. To study the immediate effect of splenectomy on the plasma lipid pattern, three patients with myeloproliferative disease and a large spleen who were undergoing splenectomy were compared with two control groups, one undergoing orthopedic operations and the second, cholecystectomy. In the control groups, plasma lipids tended to decrease for the first 2 days after surgery and then returned to preoperative levels. After splenectomy, however, plasma cholesterol, low-density lipoprotein (LDL), and apolipoprotein B significantly increased, reaching maximum levels after 4 days. Plasma HDL as well as apolipoprotein A-I decreased 1 day after splenectomy, but then increased over and above their preoperative concentrations. These results suggest an important role for the spleen in cholesterol metabolism in these patients. The spleen appears to be an important site for LDL catabolism in these patients.

The binding of low-density lipoproteins (LDL) as well as LDL modified by cyclohexanedione (CHD-LDL) to gel-filtered platelets (GFP) and its effect on platelet function were studied in normal and in homozygous familial hypercholesterolaemic (HFH) subjects. Only normal-derived LDL could significantly compete with normal 125I-labelled LDL for binding to normal platelets. When GFP from normal subjects were incubated with normal LDL at concentrations of 25-200 micrograms of protein/ml, platelet aggregation in the presence of thrombin (0.5 i.u./ml) was increased by 65-186%. CHD-LDL, at similar concentrations, caused the opposite effect and decreased platelet aggregation by 26-47%. Both LDL and CHD-LDL (100 micrograms/ml) from HFH patients, when incubated with normal GFP, caused a significant reduction in platelet aggregation (33 and 50% respectively). When HFH-derived platelets were used, both patient LDL and CHD-LDL (but not the normal lipoprotein) could markedly compete with the patient 125I-labelled LDL for binding to the platelets. LDL and CHD-LDL (100 micrograms/ml) from normal subjects decreased aggregation of HFH-platelets by 52 and 85% respectively, while corresponding concentrations of LDL derived from HFH subjects (HFH-LDL) and CHD-LDL derived from HFH subjects (CHD-HFH-LDL) increased platelet aggregation by 165 and 65% respectively. The present results support the following conclusions: platelet activation by LDL in normal subjects is through the arginine-rich apoprotein-binding site; more than one binding site for LDL exists on platelets; under certain circumstances, LDL binding can cause a reduction in platelet activity; specificity for LDL binding to the platelets resides in different regions of the lipoprotein in HFH and in normal subjects. We have thus suggested a model for LDL-platelet interaction in normal and in HFH subjects.

Thrombin-induced platelet activation is enhanced by very low and low density lipoproteins but decreased by high density lipoprotein. Plasma lipoproteins maximally affect platelet aggregation and 14C-serotonin release in a gel-filtered platelet preparation within 10 min of incubation at 37 °C. This effect is saturable and physiologic concentrations of lipoproteins are required in order to attain this saturation. When no aggregating agent is added to the incubation medium, the lipoproteins alone did not alter platelet aggregation. However, 14C-serotonin release is increased by very-low- and low-density lipoproteins alone more than by high density Hpoprotein. On removal of the lipoproteins after incubation with the platelets, and subsequent testing of platelet function, minimal influence of these lipoproteins on the platelet function remains. Arachidonic acid causes similar results to thrombin when added to the platelet suspension after incubation with the lipoprotein. Our results further emphasize the Opposing effects’ of very low and low density lipoproteins as compared to high density lipoproteins on platelets and/or platelet-thrombin interaction.

Fourteen patients with established hypertension followed a double-blind crossover-styled trial to study the effects of 100 mg/day atenolol compared to placebo. Atenolol was found to be an effective antihypertensive agent, reducing both systolic and diastolic blood pressure. Hypertensive patients appear to have increased in vitro platelet adhesion and aggregation. Atenolol significantly reduced platelet adhesion, but had little effect on aggregation. This may be important in contributing towards the now-recognised cardio-protective effect of the beta-adrenoceptor blocking agents. Blood chemistry and haematological parameters were unchanged; but whereas plasma cholesterol and plasma triglyceride levels remained normal, there was a significant fall in plasma high-density lipoprotein cholesterol levels. Side effects were very few.

A 30-year-old female presenting with arterial occlusions of the lower limbs was discovered to have a markedly abnormal thrombin time and reptilase time. Further investigations revealed the presence of a qualitatively abnormal fibrinogen. Two other family members who were completely asymptomatic had similar defects. The abnormal fibrinogen has been characterized and found to be a new variant and as such designated fibrinogen ‘Haifa’.

Summary Plasma lipid and lipoprotein pattern and platelet activity were studied in blood samples derived from veins and arteries of 10 healthy male subjects. A significant reduction in plasma high-density lipoprotein (HDL) cholesterol, triglyceride and protein levels, as well as in plasma apolipoprotein A-I, was found when lipoproteins were derived from arterial blood in comparison to venous blood. All other lipoproteins were not significantly changed. Platelet activity measured as plasma beta-thromboglobulin levels and as collagen-induced platelet aggregation and 14C-serotonin release in platelet-rich plasma was markedly elevated when platelets were derived from arterial blood. Since reduced plasma HDL concentration and platelet activation are known risk factors for atherosclerosis, our study may suggest a further explanation for the presence of atherosclerotic lesions in arteries but not in veins.

Platelet adhesion was studied in whole blood using a simple stagnation flow method in patients at high risk for the development of atherosclerosis. Fourteen patients with hypercholesterolemia, 26 with hypertriglyceridemia and 25 normolipidemic hypertensive subjects were compared with 75 normal (normotensive and normolipidemic) subjects. Increased platelet adhesion was found in hypercholesterolemic (but not hypertriglyceridemic) patients only when native blood with no anticoagulants was used. In hypertensive patients, platelet adhesion was signficantly elevated, but remarkably reduced by beta-blocker drugs. Propranolol and atenolol significantly reduced platelet adhesion, but this effect was found to take a longer time than that required for significant blood pressure reduction.

Gel-filtered platelets (GFP) from normal human subjects bound both low density lipoproteins (LDL) and high density lipoproteins (HDL). This binding was saturable and 125 I-labelled lipoprotein uptake was inhibited by plasma. Platelets are also able to degrade lipoproteins but only to a limited extent. LDL appeared to compete with 125 I-labelled HDL for platelet uptake, whereas the ability of HDL to displace 125 I-LDL was limited. Cyclohexanedione-treated LDL (CHD-LDL), unlike CHD-HDL, did not compete with [ 125 I]LDL for platelet accumulation, suggesting that arginine residues are necessary for LDL but not HDL binding. Addition of HDL or LDL to GFP did not alter platelet aggregation. However, in the presence of thrombin (0.5 U/ml), 1 mg/ml LDL incubated for 1 h at 23°C enhanced platelet aggregation (215% increase) whereas HDL under similar conditions decreased aggregation by 53%. LDL also shortened the time of maximal aggregation whereas HDL had the opposite effect.

Elevated plasma lipid concentrations and increased platelet activation are risk factors in the development of atherosclerosis. Nine patients with type IIa hyperlipoproteinemia and nine patients with type IV hyperlipoproteinemia were given soya lecithin, 12 g/day, for 3 months. Plasma cholesterol and triglycerides were reduced by 15 and 23%, respectively, and HDL-cholesterol increased by 16% in the hypercholesterolemic patients. Platelet function was unchanged. In the hypertriglyceridemic patients, total cholesterol fell by 18%, triglycerides by 36%, and HDL-cholesterol increased by 14%. There was a 27% reduction in platelet aggregation (P less than 0.01). Seventeen hypertriglyceridemic patients then received increasing doses of soya lecithin for 1-month periods (6, 12, and 18 g/day). The optimal lipoprotein-lowering effect was achieved with a daily dose of 12 g soya lecithin per day. Both low-density lipoprotein and very-low-density lipoprotein levels were reduced, and HDL-cholesterol and apolipoprotein levels were reduced, and HDL-cholesterol and apolipoprotein A-I concentrations were increased. Platelet aggregation in response to collagen and ADP was significantly reduced, parallel with the reduction in triglyceride level. Soya lecithin supplementing the diet may be useful in the management of the hypertriglyceridemic patient.

Dibutyryl cyclic AMP, forskolin, dipyridamole and butyl imidazole inhibited platelet aggregation (induced by ADP or collagen) in washed platelets more than in platelet-rich plasma preparations. Aspirin, indomethacin and epoprostenol (prostacyclin, PGI2) showed no preferential inhibition of these platelet preparations. When platelet-rich plasma from either normal or familial hypercholesterolaemic (FH) subjects was used, aspirin, indomethacin and dipyridamole (but not forskolin) inhibited platelet aggregation in normal subjects more than in FH patients. When low doses of aspirin (75 mg daily for 7 days) or dipyridamole (250 mg, single dose) were administered in vivo, platelet aggregation was inhibited more in the normal subjects in comparison to the patient group.

The composition and concentration of remnant lipoprotein particles accumulating in the plasma of patients with chronic renal failure (CRF) was determined. Ten patients on chronic hemodialysis were compared with 8 controls. The patients' very low density lipoproteins (VLDL) were abnormal and contained more of the dense VLDL subfraction (VLDL3). The concentration of intermediate density lipoproteins (IDL) was increased 3-fold in CRF plasma, whereas the amount of low density lipoprotein (LDL) was decreased by 25%. On electrophoresis of plasma lipoproteins the beta-band from the patients' samples demonstrated increased anodal mobility, indicating an abnormality in composition of the patients' LDL. These abnormalities were present regardless of whether patients were hyperlipidemic or not. These findings suggest defective conversion of VLDL to LDL in CRF, allowing for the accumulation of lipoprotein particles usually absent from plasma. The latter may account for the accelerated atherosclerosis reported in patients with CRF.

Lead poisoning remains one of the hazards of industrialized civilization. CaNa2 EDTA and dimercaprol, the usual therapeutic measures, have many side effects and can be given by parenteral route alone. The authors present a case of chronic lead poisoning caused by ingestion of contaminated flour ground in a primitive flour mill. The diagnosis was confirmed by the CaNa2 EDTA provocative test. Dimercaptosuccinic acid (DMSA) was given orally as a further provocation and resulted in an 11-fold increase in urinary lead excretion. A 5-day course of treatment with DMSA was instituted, during which symptoms abated, urinary lead excretion increased and the blood lead level decreased. No side effects were noticed. There has been no relapse over several months of follow-up. The authors conclude that the oral use of DMSA is effective, safe and convenient both as a provocative test in establishing the diagnosis of lead poisoning and as a therapeutic tool.

Plasma lipid and lipoprotein patterns were determined in 54 female patients with rheumatoid arthritis (RA). The patients were divided into four groups, on the basis of the treatment that was being administered (gold, penicillamine, hydroxychloroquine and nonsteroidal anti-inflammatory drugs). Plasma cholesterol levels were significantly reduced in all groups. The reduced plasma cholesterol level was a result of 26% and 36% reductions in low- and high-density lipoproteins (LDL and HDL), respectively. Very-low-density lipoprotein cholesterol was reduced only in the group receiving hydroxychloroquine, and this was associated with decreased plasma triglycerides in this group. Plasma apolipoprotein (apo) B, the LDL protein moiety, demonstrated a pattern similar to that shown for LDL cholesterol. Plasma apo A-I, the major HDL protein, was, however, in the normal range, suggesting an abnormal HDL fraction. Even though reduced HDL cholesterol was found in RA patients, the HDL/LDL ratio was normal and the apo A-I/apo B ratio was increased, suggesting that these patients are not at increased risk for atherosclerosis.

Plasma lipoprotein concentration and composition were studied in 7 female patients with primary biliary cirrhosis and compared with 6 normal, age-matched controls. The effect of the lipoproteins derived from these patients on the function of normal platelets was also tested. High levels of plasma cholesterol and phospholipids and a raised free/esterified cholesterol ratio were found. In 4 of the patients, both HDL cholesterol and HDL protein were increased, and high levels of plasma apoprotein A-I and A-II were evident. This abnormal HDL did not contain excess apolipoprotein E. The VLDL and LDL fractions were also abnormal, as evidenced by a high cholesterol/protein ratio. Little correlation between lipoprotein disorders and clinical condition was found. Platelet function was reduced in all patients. LDL from the patients reduced aggregation of normal platelets, whereas HDL had a minimal effect. The abnormal lipoproteins in these patients may contribute to their abnormal in vitro platelet aggregation.

Uremic patients undergoing chronic hemodialysis demonstrate a secondary systemic carnitine deficiency. We studied the effect of carnitine replacement with high doses ( L -carnitine, 3

The occurrence of otosclerosis and hyperlipidemia in four generations of a single family is described. The lipid abnormality fulfilled the characteristics of combined familial hyperlipidemia. Whereas a genetic linkage between combined hyperlipidemia and otosclerosis is feasible, our study indicates that both conditions are inherited through autosomal but unlinked genes.

Summary A severe form of acute thrombotic thrombocytopenic purpura (TTP) developed in a patient with systemic lupus erythematosus (SLE). Infusions of large amounts of fresh frozen plasma (FFP) were added to steroid therapy and resulted in a rapid improvement and remission. Further episodes of thrombocytopenia and abdominal pains during a two-year follow-up were successfully treated with plasma alone and this indicates the important role of FFP infusions in the recovery of this patient.

Both venous and arterial thrombosis can be a feature in some patients with Behcet’s Syndrome. The pathogenesis of the coagulopathy is as yet ill understood. We have examined platelet adhesion and platelet aggregation in 14 patients with proven Behcet’s Syndrome and compared them with matched controls. Platelet adhesion was measured by two techniques recently developed in our laboratory. In the first platelet adhesion is determined when platelet rich plasma is applied to a glass slide while applying a predefined centrifugal force. In the second method citrated whole blood is pumped through an inert silicone tube and applied to a glass slide in the form of a stagnation point flow field. The number of platelets adhering to the slide per unit area is determined. The conditions of blood flow through this system were similar to those prevailing in arteries of similar size. Adhesion is found to be significantly greater in Behcet’s patients by both methods. There was a 30% increase in platelet adhesion in the Behcet patients. Platelet aggregation was determined by the Born method. Platelet rich plasma was used and 5HT, epinephrine, ADP, and collagen were the aggregating agents. In our hands platelets from the Behcet’s patients are more sensitive to aggregation induced by epinephrine and ADP than platelets from our controls.It appears that disturbed platelet function may play an important role in the coagulopathy of Behcet’s Syndrome.

High-density lipoprotein (HDL) levels were studied in 10 male patients with severe coronary atherosclerosis and in 10 well-matched controls. All subjects were normolipidemic, and the presence of a disease or other factor influencing HDL levels were excluded. Very low density lipoprotein and low-density lipoprotein levels were similar in both groups, but HDL concentration was significantly lower in the patient group. Analysis of HDL subfractions revealed that both HDL2 and HDL3 concentrations were significantly lower in the patient group. The composition of both HDL subfractions was also altered in the patient group: an increased cholesterol-to-protein ratio was found. These data strengthen the evidence in support of an important and independent role for HDL in the pathogenesis of coronary atherosclerosis. It appears that both HDL2 and HDL3 are implicated and that both the concentration and composition of HDL are important.

Two patients with splenic abscess successfully diagnosed and treated are described. The first case, a diabetic, developed a pyogenic abscess caused by klebsiella, while the other suffered a splenic infarct complicated by splenic abscess. Although relatively easy to treat, solitary abscess of the spleen is a potentially lethal condition due to diagnostic difficulties. In both present instances the final diagnosis was easily achieved before surgery by the aid of computerized tomography (CT). This investigation seems to be more accurate than 99Tcm-sulphur colloid scan and ultrasound scan, which failed in both cases to diagnose splenic abscess clearly. The use of this investigation is suggested in every suspected case and will, no doubt, confirm the diagnosis at an early stage of the disease. Splenectomy with antibiotic cover will usually result in cure.

Increased platelet activation has been shown to be a feature of patients with familial hypercholesterolaemia. Plasma lipoprotein concentration and composition were studied in eleven male patients with familial hypercholesterolaemia and in ten age-matched healthy controls. Increased levels of cholesterol were found in very-low- and low-density lipoproteins (53 and 275%, respectively), whereas in high-density lipoprotein, both cholesterol and apolipoprotein A-I were decreased by 21 and 26%, respectively. On incubation of gel-filtered platelets derived from normolipidaemic controls with identical concentrations of lipoproteins derived from either nomolipidaemic controls or hypercholesterolaemic patients very-low- and low-density lipoproteins from the patients caused significantly greater thrombin-induced platelet aggregation (P less than 0.01). High-density lipoprotein from normal subjects reduced platelet release by 22%, whereas the patients' high-density lipoprotein had no significant effect on platelet release. Lipoprotein-deficient plasma from both groups augmented platelet function to a similar extent. Lipoprotein composition has an important effect on platelet function in vitro. The abnormal lipid and protein composition of the lipoproteins derived from hypercholesterolaemic patients appears to be the cause of platelet hyperactivity observed in these patients.

We determined serum high-density lipoprotein cholesterol content and analyzed the approtein structure of the various lipoprotein fractions in 21 patients on chronic hemodialysis. High-density lipoprotein cholesterol was significantly reduced in all patients as compared with 11 normal persons (mean +/-1 standard deviation: 26 +/- 13 vs. 52 +/- 9 mg per 100 ml; P less than 0.001) whether or not triglyceride levels were raised. In seven of those with Type IV hyperlipoproteinemia, protein content of high-density lipoprotein and its subfractions 1, 2 and 3 were also reduced (P less than 0.001) in parallel with reductions in cholesterol in these fractions. Apoprotein electrophoresis showed an increase in "arginine-rich" peptide in very-low-density lipoprotein and high-density lipoprotein fraction 1, and a reduction in apoprotein Cll in very-low-density and high-density lipoprotein. In addition to their reduced high-density lipoprotein cholesterol levels, a major factor in the atherosclerosis of these patients may be their abnormal high-density lipoprotein composition. Their raised triglyceride levels could be due to defective lipoprotein lipase activation by the reduced very-low-density lipoprotein apoprotein.

Lipid and lipoprotein concentrations, including high density lipoproteins (HDL) and its subfractions, were contrasted in subjects with Type IV hyperlipoproteinemia, before and after therapy with clofibrate. Very low density lipoprotein (VLDL) levels were raised, whereas both low density lipoprotein (LDL) and HDL values were reduced in the patient group. Clofibrate reversed this trend and VLDL cholesterol and protein levels fell to approximate control values. LDL and HDL cholesterol increased but remained significantly lower than in normal controls. However, LDL and HDL protein did approach control values. Of the HDL subfractions, HDL-3 was significantly reduced in the group with Type IV hyperlipoproteinemia. Clofibrate resulted in a significant increase in the HDL-2: HDL-3 cholesterol ratio, but had only a modest effect on HDL-3 concentrations. HDL-3 may be the critical HDL subfraction responsible for the inverse correlation between levels of HDL and the development of ischemic heart disease.