Coagulopathies and arterial stroke

Although hypercoagulable states are most often associated with venous thrombosis, arterial thromboses are reported in protein S, protein C, and antithrombin III deficiencies, factor V Leiden and prothrombin gene mutations, hyperhomocysteinemia, dysfibrinogenemia, plasminogen deficiency, sickle cell disease, and antiphospholipid antibody syndrome.

Idiopathic (asymptomatic) monoclonal gammopathies

Asymptomatic forms of monoclonal gammopathies (MG) are recognized with increasing frequency; their recognition and differentiation from the symptomatic forms of MG appear imperative, since the therapeutic approaches are different. Available clinical and laboratory indexes lack specificity required for useful and practical discrimination; presently, we must still rely on the timecourse monitoring of such laboratory values as hemoglobin levels, M-protein concentrations, and presence of Bence Jones proteins. Elucidation of histocompatibility A and W antigenic profiles, as well as the functions and kinetics of B-lymphocytes from such patients, appear most promising. Evidence of the causative role of extrinsic and intrinsic antigenic stimulation in MG production is increasing; segregation into two distinct concentration ranges of M-proteins in the asymptomatic and symptomatic groups suggests two control levels of the expression of immune response (Ir) genes, due to partial or complete derepression of the latent Ir gene function, reflecting "partial" (asymptomatic, benign MG) and "complete" (symptomatic, malignant MG) monoclonal immune responders.

Dietary and drug treatment of hyperlipidemia in diabetes

Diabetics have increased risk of ASCVD and patients with ASCVD have increased incidence of diabetes. Patients with diabetes are susceptible to hypertriglyceridemia, particularly if they are obese maturity-onset diabetics. Elevated plasma triglycerides may constitute a greater risk factor for ASCVD than elevated plasma cholesterol in diabetics.

The classification of hyperlipidemia can be made on the basis of plasma cholesterol and triglyceride concentration measured in the fasting state. Hypercholesterolemia (type II) or hypertriglyceridemia with or without hypercholesterolemia (type IV) will comprise the great majority of hyperlipidemias.

The treatment of hyperlipidemia in diabetics is uncertain because most dietary and drug studies have centered about cholesterol rather than Trigrycerides, and most such studies have excluded diabetics. It is necessary, then, to assume that treatment ppropriate for nondiabetics is also appropriate for diabetics.

The first order of treatment is restoration of body weight to ideal, as Is usually the case, it exceeds ideal weight.

If weight reduction fails to bring about normal lipids, modest reduction of total dietary fat, of saturated fat, and slight increase in nsaturated fat and decrease in dletary cholesterol is worth a trial regardless of type of lipidemia. Although this diet is aimed chiefly at reduction of cholesterol it either does not change or may even decrease the plasma triglyceride concentration. Carbohydrates should be in the complex form with high fiber content.

If hypertriglyceridemia persists despite the above measures, limited evidence suggests that restriction of dietary carbohydrate to 40 or 30 per cent of calories with a corresponding increase in fat may be effective. If the added fat is polyunsaturated the cholesterol will nort increase. If chylomicronemia is present a very low fat diet may be necessary.

Only when diet fails are drugs justified. Only two drugs are of practical usefulness: cholestyramine for the treatment of pure hypercholesterolemia (type II) and clofibfate for the treatment of hypertriglyceridemia (types III, IV and V). Clofibrate is probably worth trying also in hypercholesterolemia.

There is as yet no firm evidence that lowering lipids by whatever means reduces the risk of ASCVD, though several studies give cause for optimism. Diabetics have been excluded from most such studies. There is need for long-range diet and drug studies of diabetics.

[Immunoglobulins and dysglobulinemias. Introduction and general data]

The author reviews the present state of knowledge of value in rheumatology concerning serum immunoglobulins, their structure, their cellular biosynthesis, and their relation to membrane immunoglobulins of the B lymphocytes. He then examines the concept of dysglobulinaemia and explains why the terms monoclonal immunoglobulin and monoclonal immunoglobulinopathy are preferable to dysglobulinaemia and paraprotein. The clinical and immunochemical classification of monoclonal immunoglobulins, the problem of amylosis, and the relationship with plasmocytic dyscrasias and with the cryoglobulins are then discussed. Afterwards the pathogeny of these affections is briefly considered.

Classification of lipoproteins and lipoprotein disorders

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