Aneurysm Papers of the Month - January 1996

1. Gregory AK, Yin NX, Capella J, Xia S, Newman KM,
Tilson MD.  Features of autoimmunity in the abdominal
aortic aneurysm.  Arch Surg 1996; 131: 85-88

Abstract (adapted from authors):

Purpose: To determine whether IgG purified from AAA
specimens is immunoreactive with normal components of the
aortic wall (as determined by immunohistochemistry) and
with soluble proteins extracted from normal aortic tissue
(by Western blots).

Methods: IgG was extracted from AAA specimens with
protein A, and it was used as a probe in fixed sections
of normal aorta for immunohistochemistry.  The same IgG
preps from AAA and non-AAA patients was used to compare
reactivity with soluble proteins extracted from normal
and AAA aorta by Western blots.  

Results:  IgG from patients with AAA codistributed with
elastin-associated microfibrils in the adventitia of
normal aorta.  A unique band at ~80 kDa was visualized
when W blots were probed with IgG from 11 of 14 (79%)
patients with AAA compared with 1 of 9 (11%) of control
subjects (p=.002 Fisher's exact test).  

Conclusion:  The findings support the concept that there
are features of autoimmunity in AAA disease that may be
informative in terms of AAA etiology and also in terms of
innovations in pharmacological prevention.


Comment by mdt:  This work was presented as a poster at
the SVS meeting in 1994, and it built on the foundation
laid by Brophy et al several years ago (Ann Vasc Surg
1991; 5: 229-244).  Brophy et al observed Russell bodies
in aortic specimens with AAA; and Russell bodies are
associated with diseases of autoimmunity like Hashimoto's
thyroiditis.  A Russell body is (in essence) a B-cell
that has made so much IgG that it has choked on it! 
Taking advantage of the immunoreactivity of AAA IgG with
an aortic protein, we were able to purify enough of the
putative autoantigen to obtain a fragment of sequence
(which we reported last summer).  The initial fragment
had a resemblance to the microfibril-associated
glycoprotein of bovine aorta that was reported by
Kobayashi et al (MAGP-36).  MAGP-36 occurs in nature as
a dimer; so we have carried out additional aortic
extractions for this protein under reducing conditions. 
The result is that we have been able to sequence about
1/4 of the human homolog, to be reported in BBRC next
month.  These experiments have led us to hypothesize that
AAA is an autoimmune disease of maturity, like adult
rheumatoid arthritis.  To be continued...

BTW...  If you are interested enough in this stuff to be
reading here, come to New York in March for a symposium
on the biology of aneurysm disease to be held at
Roosevelt Hospital and sponsored by the New York Academy
of Sciences.

2. Hardman DTA, Fisher CM, Patel MI, Neale M, Chambers J,
Lane R, Appleberg M.  Ruptured abdominal aortic
aneurysms: Who should be offered surgery? J Vasc Surg
1996; 23: 123-9.  

Purpose: A retrospective review of a 9 year experience
from a single hospital in New South Wales, Australia, to
identify factors on admission associated with a 30-day
postoperative mortality.

Methods: 154 records analyzed from 1985-93.

Results: Hospital mortality was 39%.  Five independent
preoperative factors were associated with mortality:  age
>76 years; creatinine >0.19 mm/L; loss of consciousness
after arrival; Hb <9g%; and EKG ischemia.  In 52 patients
with one risk factor, mortality = 37%; in 32 with 2
factors, 72%; and with 3 or more factors, 100%.  

Conclusion:  "... in some cases health care resources are
used in a nonproductive fashion.  Restricted patient
selection and allocation of scarce resources will bring
advantages to both the patient and the community."

Comment by mdt:  The thing speaks for itself.  Much of
the rest of the world has addressed the inherent finite
economic limits related to the % of national resources
that can be devoted to health care -and most countries
have faced up to the unpleasantness of what amounts to
the rationing of health care.  When socialized medicine
has come to the countries about which I have some
personal knowledge, the process has been driven by the
legislature and has had a benevolent intention
(specifically, to control costs and preserve quality). 
Our politicians in the States have not had the guts to
face these issues and to work out the compromises that
are essential to protect all Americans from the
consequences of a serious illness.  

     So, fellow Americans, we've got the worst of all
worlds.  We've turned over health care to the
entrepreneurship of businessmen, who have imposed their
own scheme of rationing, in which money spent taking care
of sick people goes against the bottom line. 
Accordingly, they employ physicians, who (out of
desperation to provide for their families) will play
along with the game.  And doctors, who are IMHO among the
most highly motivated persons on the planet to help their
fellow man, have been cast in an adversarial relationship
with their patients.