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Clinical approach to antiphospholipid antibodies

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    Clinical approach to antiphospholipid antibodies. Edited by stephen r levine and robin l brey (Pp 184, £55.00). Published by Butterworth Heinemann, Oxford, 2000. ISBN 0-7506-7177-7.

    This monograph devoted to antiphospholipid antibodies (APA) developed from an annual course at the American Academy of Neurology and a collaborative study group, Antiphospholipid Antibody and Stroke Study (APASS). In these formats, the two editors addressed clinical questions about the specificity, utility, and clinical consequences of APA. The book is a compilation of multiauthor chapters that provide a useful compendium of information published about APA. Although the title of the monograph Clinical approach to antiphospholipid antibodies, suggests practical information, the central question, “What are the effects of these antibodies in patients?” remains largely unanswered. This, however, is not due to a lack of attention or diligence. The first two sections review the epidemiology and immunology, detailing the evolving story of the detection and the binding patterns of the antibodies. In particular the chapter on the immunology of the APA provides some useful basic facts (cardiolipin is restricted to mitochondrial membranes) and discussions about why individual APAs differ with respect to both immunological and anticoagulant properties. Antiphospholipid antibodies are actually an array of antibodies directed against negatively charged phospholipids (essential constituents of cell membranes) and usually requiring a cofactor such as prothrombin, β2-glycoprotein 1, activated protein C, protein S, or annexin V to exert an immunological activity. Although the authors explain the basis for why these antibodies could either have a neutral, anticoagulant, or procoagulant effect, they also recognise that the antibodies could be a normal response to cryptogenic epitopes. The details of the role of (usually) cofactor β2-glycoprotein 1 are presented clearly. The section on mechanisms of thrombosis and experimental models explains that APAs are heterogeneous and not all are associated with thrombosis or other clinical manifestations. The crux of the issue! In the array of clinical features associated with the coagulopathy, CNS and placental vasculopathy, and cardiac valvulopathy, a plethora of APAs have statistical associations but are they pathogenic? Is the effect elusive because the targets involve cascades of pathways and are thus subject to numerous biological variables? Possibly. Studies in animal models indicate that in specific circumstances the APAs can induce in vivo changes. However, in the chapter reviewing treatment, the marginal effects of immune therapies (including high dosage corticosteroid} and anticoagulant/antiplatelet therapies on preventing disease recurrence in patients induces reflection about the role of the antibodies we measure clinically. The authors detailing the clinical and pathological features of primary antiphospholipid antibody syndrome (APS), secondary APS, catastrophic APS, and regular thrombotic and embolic events associated with APAs recount the many anecdotes, small series, and clinical suspicions that represent the state of the art. Again, it is very useful to have these studies presented in one place so that both novice and experienced clinicians can appreciate current information and anticipate future studies. The book is short but not quickly read. My only reservation is that more information on the APASS study would have been useful in the monograph.

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