259 grants CA-08748 and AI-12478 and contract CB-53868 from the National Cancer Institute. Requests for reprints should be addressed to G. G. REFERENCES 1. 2. 3.
Goldstein, G. Nature, 1974, 247, 11. Schlesinger, D. H., Goldstein, G. Cell, 1975, 5, 361. Basch, R. S., Goldstein, G. Proc. natn. Acad. Sci. U.S.A. 1974, 71,
1474. 4. Komuro,
K., Boyse, E. A. Lancet, 1973, i, 740. 5. Cantor, H., Boyse, E. A. J. exp. Med. 1975, 141, 1376. 6. Goldstein, G., Whittingham, S. Lancet, 1966, ii, 315. 7. Goldstein, G. ibid. p. 1164. 8. Goldstein, G. Clin. exp. Immun. 1967, 2, 103. 9. van der Geld, H. W. R., Strauss, A. J. L. Lancet, 1966, i, 57. 10. Keynes, G. ibid. 1954, i, 1197. 11. Harvey, A. M. Bull. N.Y. Acad. Med. 1948, 24, 505.
Preliminary
Woolf, A. L. Ann. N.Y. Acad. Sci. 1966, 135, 35. Stern, G. M., Hall, J. M., Robinson, D. C. Br. med. J. 1964, ii, 284. Kalden, J. R., Williamson, W. G., Johnston, R. J., Irvine, W. J. Clin. exp. Immun. 1969, 5, 319. 15. Kawanami, S., Mori, R. ibid. 1972, 12, 447. 16. Goldstein, G., Hofmann, W. W. ibid. 1969, 4, 181. 17. Goldstein, G. Lancet, 1968, ii, 119. 18. Schlesinger, D. H., Goldstein, G., Scheid, M. P., Boyse, E. A. Cell, 1975, 5, 367. 19. Simpson, J. A. Scott. med. J. 1960, 5, 419. 20. Patrick, J., Lindstrom, J. M. Science, 1973, 180, 871. 21. Patrick, J., Lindstrom, J. M., Culp, B., McMillan, J. Proc. natn. Acad. Sci. U.S.A. 1973, 70, 3334. 22. Lindstrom, J., Lennon, V., Seybold, M., Whittingham, S. Ann. N.Y. Acad. Sci. (in the press). 23. Goldstein, G., Mackay, I. R. The Human Thymus. London, 1969. 24. Aharonov, A., Tarrab-Hazdai, R., Abramsky, O., Fuchs, S. Proc. natn. Acad. Sci. U.S.A. 1975, 72, 1456.
12. 13. 14.
Communication
NEW RAPID METHOD FOR DIAGNOSIS OF DEEP VENOUS THROMBOSIS C. A. LUDLAM S. MOORE
A. E. BOLTON J. D. CASH
University Department of Therapeutics, Royal Infirmary, Edinburgh; Medical Research Council Radioimmunoassay Team, Edinburgh; and South-East Scotland Regional Blood Transfusion Service, Edinburgh The
plasma concentration of the platelet-specific protein &bgr;-thromboin fourteen patients who had was measured globulin been investigated for deep venous thrombosis by venography or 125I-fibrinogen scanning. All six patients with a proven thrombus had a raised plasma concentration of &bgr;-thromboglobulin. Eight patients Sum ary
in whom no thrombus could be demonstrated had plasma concentrations of &bgr;-thromboglobulin similar to a control group of thirty-five normal individuals. These results indicate that the measurement of plasma &bgr;-thromboglobulin concentrations may be of use in the diagnosis of deep venous thrombosis.
5-thromboglobulin concentrations in controls and patient- with and without deep venous thrombosis.
Plasma
use as a tracer in the assay.7 Aliquots of plasma were and 0-2 ml. with O’OSM taken diluted to ml.) (0-01 sodium phosphate buffer, pH 7’5, containing 2% horse 1251 j8-thromboserum (Wellcome Reagents Limited). globulin was added in 0-05 ml. of diluent followed by
1251 for INTRODUCTION
DEEP venous thrombosis (D.v.T.) and subsequent embolisation present an increasing problem in hospital patients.1 Since an accurate diagnosis cannot be made on clinical criteria alone, a variety of diagnostic procedures have been developed,2 the most widely used techniques being venography and 125I-fibrinogen scanning. These methods have serious limitations when used to screen a large number of patients. Platelet aggregation occurs during thrombus formationand is followed by the release of /3-thromboglobulin, a recently isolated platelet-specific protein.4-5 This report describes a rapid radioimmunoassay for measuring the plasma concentration of /3-thromboglobulin and demonstrates its potential as a technique for the diagnosis of venous thrombosis. MATERIALS, METHODS,
AND PATIENTS
prepared as described elsewhere.5 Antiserum to 0-thromboglobulin was raised in rabbits and covalently coupled to ’Sepharose 4B ’(Pharmacia). Purified /3-thromboglobulin was labelled with Platelet-poor plasma
was
0’25 ml. sepharose-coupled antiserum at a dilution to bind about 50% of the tracer. The tubes were mixed gently for one hour, the antibody-bound protein was separated from the free /3-thromboglobulin by centrifugation, and the 1251 in the residue (antibody-bound fraction) was measured. The time taken to carry out this assay, count the samples, and calculate the results was about 24 hours. Controls were 35 apparently healthy individuals (25 males and 10 females) aged 18-67. 10 patients with symptoms and/or signs of D.v.T. were
investigated by ascending venography. 1251-fibrinogen scanning was initiated preoperatively in 4 patients particularly at risk of developing postoperative venous thrombosis. There were equal numbers of males and females, aged 31-80. RESULTS
The concentrations of /3-thromboglobulin in controls and patients are shown in the accompanying
260
figure. The mean plasma concentration of /3thromboglobulin in six patients with a positive diagnosis of D.v.T. (four by venography, two by 125Ifibrinogen scanning) was 112’8±19’0 ng. per ml. (mean± standard deviation, range 87-137 ng. per ml.). than the This was significantly greater (P01) concentrations of 0-thromboglobulin in the latter two groups. DISCUSSION
study, which describes consecutive patients adequately investigated by one of the reference procedures, there was no overlap in the /3-thromboglobulin concentrations between the two groups. Those patients without evidence of venous thrombosis had concentrations very similar to normal healthy controls. Venography and 125I-fibrinogen scanning are reliable methods for detecting venous thrombosis.2 1211-fibrinogen localises at the site of active thrombus formation and is detected by external gamma-radiation monitoring. False-positive results, however, may occur with calf haematoma or peripheral oedema, and a false-negative result may be found in the presence of old-established thrombus. The patient is exposed to the hazard of an injected radioisotope and also to the possibility of serum-hepatitis. Ascending venography is an invasive, though reliable, procedure. It does not detect small soleal thrombi.8 The X-ray contrast medium infused may predispose to thrombosisand the method is not suitable for screening a large population. Although the ultrasonic technique and impedance phlebography are non-invasive and can be used on large numbers of patients, they may fail to detect clinically significant thrombosis. The assay of plasma /3-thromboglobulin involves no risk to the patient and has the potential for assessing many patients. A variety of methods have been developed by other workers to diagnose thrombosis using a venous bloodsample. The concentration of serum fibrin-degradation products is raised in D.v.T., and this increase may be associated with pulmonary embolism; but falsenegative results are common Fletcher, using gel filtration to measure high-molecular-weight fibrinogen complexes, has been able to identify venous thrombosis and hypercoagulable states, but this technique is suitable only for a small number of samples.12 As yet, therefore, there is no simple reliable test to D.V.T.
Any diagnostic procedure should minimise the incidence of false-positive and, more importantly, false-negative results, and in these respects venography Small and 1.211-fibrinogen scanning are reliable. thrombi in soleal veins, not recognised by either of these procedures, might be expected to give a raised plasma /3-thromboglobulin although as yet we have no
the identification of
venous
thrombosis.
Dr T. A. S. Buist has given invaluable support. C. A. L. is in receipt of a Medical Research Council junior research
In this
detect
patients with rheumatic heart-disease, prosthetic car diac valves, and arterial thrombosis.5 Moreover, during blood clotting /3-thromboglobulin is released from platelets and a carelessly collected blood-sample can contain a high concentration of /3-thromboglobulin. Therefore, great care is required during venepuncture and the preparation of the plasma. If our observations are confirmed, when a larger population is studied, the measurement of plasma a-thromboglobulin concentration by a rapid radioimmunoassay may become a useful screening-test for
evidence for, this.
Other
causes
of intravascular
platelet aggregation can result in a raised plasma 13thromboglobulin level, and this has been observed in
fellowship. Requests for reprints should be addressed to C. A. L., University Department of Therapeutics, Royal Infirmary, Edinburgh EH3 9YW. REFERENCES 1. 2. 3.
4. 5. 6. 7.
8. 9. 10.
11.
12.
Registrar General’s Statistical Review of England and Wales, 1972. Kakkar, V. V., Corrigan, T. P. Prog. cardiovasc. Dis. 1974, 17, 207. French, J. E. in Thrombosis (edited by S. Sherry, K. M. Brinkhouse, E. Genton, and J. M. Stengle); p. 300. Washington, D.C., 1969. Moore, S., Pepper, D. S., Cash, J. D. Biochim. biophys. Acta, 1975, 379, 360. Ludlam, C. A., Moore, S., Bolton, A. E., Pepper, D. S., Cash, J. D. Thrombosis Res. 1975, 6, 543. Cuatrecasas, P. J. biol. Chem. 1970, 245, 3049. Greenwood, F. C., Hunter, W. M., Glover, J. S. Biochem. J. 1963, 89, 114. Hirsh, J., Gallus, A. S., Cade, J. F. Thromb. Diath. hœmorrh. 1974, 32, 11. Ritchie, W. G. M., Lynch, P. R., Stewart, G. J. Invest. Radiol. 1974, 9, 444. Ruckley, C. V., Das, P. C., Leitch, A. G., Donaldson, A. A., Copland, W. A., Redpath, A. J., Scott, P., Cash, J. D. Br. med. J. 1970, iv, 395. Tibbutt, D. A., Chesterman, C. N., Allington, M. J., Williams, E. W., Faulkner, T. ibid. 1975, i, 369. Fletcher, A. P., Alkjaersig, N. in Recent Advances in Thrombosis (edited by L. Poller); p. 87. Edinburgh, 1973.
Reviews of Books The Role of Diagnosis in
Psychiatry
R. E. KENDELL, F.R.C.P., professor of psychiatry, University of Edinburgh. Oxford: Blackwell Scientific Publications. 1975. Pp. 176. E3.50.
" To our generation," writes Professor Kendell, " it is self-evident that diseases, tuberculosis as well as schizophrenia, are nothing but man made abstractions, inventions justified only by their convenience and liable at any time to be adjusted or discarded. Our present outlook is so wholeheartedly empirical that we find it difficult to credit how an earlier generation could have talked of diseases being ’discovered’ like so many gold sovereigns on a beach, or have imagined that there were a finite number of them waiting to be identified." This is a most polished and readable monograph, taking the reader on from an erudite chapter on the nature of disease to a consideration of the syndromal nature of psychiatric disorders and the problems posed by their classification. The various forms of multivariate analysis which must be used to illuminate such problems are described with effortless clarity, and Kendell proceeds to a discussion on the choice between categories and dimensions. There is a patient rebuttal of Eysenck’s polemical espousal of a dimensional model for psychoses, and the author comes down in favour of a categorical model for psychoses and a dimensional model for neuroses and personality disorders. This book comes at a time when psychiatric diagnosis has been attacked as harmful, or at
Goldstein, G. Nature, 1974, 247, 11. Schlesinger, D. H., Goldstein, G. Cell, 1975, 5, 361. Basch, R. S., Goldstein, G. Proc. natn. Acad. Sci. U.S.A. 1974, 71,
1474. 4. Komuro,
K., Boyse, E. A. Lancet, 1973, i, 740. 5. Cantor, H., Boyse, E. A. J. exp. Med. 1975, 141, 1376. 6. Goldstein, G., Whittingham, S. Lancet, 1966, ii, 315. 7. Goldstein, G. ibid. p. 1164. 8. Goldstein, G. Clin. exp. Immun. 1967, 2, 103. 9. van der Geld, H. W. R., Strauss, A. J. L. Lancet, 1966, i, 57. 10. Keynes, G. ibid. 1954, i, 1197. 11. Harvey, A. M. Bull. N.Y. Acad. Med. 1948, 24, 505.
Preliminary
Woolf, A. L. Ann. N.Y. Acad. Sci. 1966, 135, 35. Stern, G. M., Hall, J. M., Robinson, D. C. Br. med. J. 1964, ii, 284. Kalden, J. R., Williamson, W. G., Johnston, R. J., Irvine, W. J. Clin. exp. Immun. 1969, 5, 319. 15. Kawanami, S., Mori, R. ibid. 1972, 12, 447. 16. Goldstein, G., Hofmann, W. W. ibid. 1969, 4, 181. 17. Goldstein, G. Lancet, 1968, ii, 119. 18. Schlesinger, D. H., Goldstein, G., Scheid, M. P., Boyse, E. A. Cell, 1975, 5, 367. 19. Simpson, J. A. Scott. med. J. 1960, 5, 419. 20. Patrick, J., Lindstrom, J. M. Science, 1973, 180, 871. 21. Patrick, J., Lindstrom, J. M., Culp, B., McMillan, J. Proc. natn. Acad. Sci. U.S.A. 1973, 70, 3334. 22. Lindstrom, J., Lennon, V., Seybold, M., Whittingham, S. Ann. N.Y. Acad. Sci. (in the press). 23. Goldstein, G., Mackay, I. R. The Human Thymus. London, 1969. 24. Aharonov, A., Tarrab-Hazdai, R., Abramsky, O., Fuchs, S. Proc. natn. Acad. Sci. U.S.A. 1975, 72, 1456.
12. 13. 14.
Communication
NEW RAPID METHOD FOR DIAGNOSIS OF DEEP VENOUS THROMBOSIS C. A. LUDLAM S. MOORE
A. E. BOLTON J. D. CASH
University Department of Therapeutics, Royal Infirmary, Edinburgh; Medical Research Council Radioimmunoassay Team, Edinburgh; and South-East Scotland Regional Blood Transfusion Service, Edinburgh The
plasma concentration of the platelet-specific protein &bgr;-thromboin fourteen patients who had was measured globulin been investigated for deep venous thrombosis by venography or 125I-fibrinogen scanning. All six patients with a proven thrombus had a raised plasma concentration of &bgr;-thromboglobulin. Eight patients Sum ary
in whom no thrombus could be demonstrated had plasma concentrations of &bgr;-thromboglobulin similar to a control group of thirty-five normal individuals. These results indicate that the measurement of plasma &bgr;-thromboglobulin concentrations may be of use in the diagnosis of deep venous thrombosis.
5-thromboglobulin concentrations in controls and patient- with and without deep venous thrombosis.
Plasma
use as a tracer in the assay.7 Aliquots of plasma were and 0-2 ml. with O’OSM taken diluted to ml.) (0-01 sodium phosphate buffer, pH 7’5, containing 2% horse 1251 j8-thromboserum (Wellcome Reagents Limited). globulin was added in 0-05 ml. of diluent followed by
1251 for INTRODUCTION
DEEP venous thrombosis (D.v.T.) and subsequent embolisation present an increasing problem in hospital patients.1 Since an accurate diagnosis cannot be made on clinical criteria alone, a variety of diagnostic procedures have been developed,2 the most widely used techniques being venography and 125I-fibrinogen scanning. These methods have serious limitations when used to screen a large number of patients. Platelet aggregation occurs during thrombus formationand is followed by the release of /3-thromboglobulin, a recently isolated platelet-specific protein.4-5 This report describes a rapid radioimmunoassay for measuring the plasma concentration of /3-thromboglobulin and demonstrates its potential as a technique for the diagnosis of venous thrombosis. MATERIALS, METHODS,
AND PATIENTS
prepared as described elsewhere.5 Antiserum to 0-thromboglobulin was raised in rabbits and covalently coupled to ’Sepharose 4B ’(Pharmacia). Purified /3-thromboglobulin was labelled with Platelet-poor plasma
was
0’25 ml. sepharose-coupled antiserum at a dilution to bind about 50% of the tracer. The tubes were mixed gently for one hour, the antibody-bound protein was separated from the free /3-thromboglobulin by centrifugation, and the 1251 in the residue (antibody-bound fraction) was measured. The time taken to carry out this assay, count the samples, and calculate the results was about 24 hours. Controls were 35 apparently healthy individuals (25 males and 10 females) aged 18-67. 10 patients with symptoms and/or signs of D.v.T. were
investigated by ascending venography. 1251-fibrinogen scanning was initiated preoperatively in 4 patients particularly at risk of developing postoperative venous thrombosis. There were equal numbers of males and females, aged 31-80. RESULTS
The concentrations of /3-thromboglobulin in controls and patients are shown in the accompanying
260
figure. The mean plasma concentration of /3thromboglobulin in six patients with a positive diagnosis of D.v.T. (four by venography, two by 125Ifibrinogen scanning) was 112’8±19’0 ng. per ml. (mean± standard deviation, range 87-137 ng. per ml.). than the This was significantly greater (P01) concentrations of 0-thromboglobulin in the latter two groups. DISCUSSION
study, which describes consecutive patients adequately investigated by one of the reference procedures, there was no overlap in the /3-thromboglobulin concentrations between the two groups. Those patients without evidence of venous thrombosis had concentrations very similar to normal healthy controls. Venography and 125I-fibrinogen scanning are reliable methods for detecting venous thrombosis.2 1211-fibrinogen localises at the site of active thrombus formation and is detected by external gamma-radiation monitoring. False-positive results, however, may occur with calf haematoma or peripheral oedema, and a false-negative result may be found in the presence of old-established thrombus. The patient is exposed to the hazard of an injected radioisotope and also to the possibility of serum-hepatitis. Ascending venography is an invasive, though reliable, procedure. It does not detect small soleal thrombi.8 The X-ray contrast medium infused may predispose to thrombosisand the method is not suitable for screening a large population. Although the ultrasonic technique and impedance phlebography are non-invasive and can be used on large numbers of patients, they may fail to detect clinically significant thrombosis. The assay of plasma /3-thromboglobulin involves no risk to the patient and has the potential for assessing many patients. A variety of methods have been developed by other workers to diagnose thrombosis using a venous bloodsample. The concentration of serum fibrin-degradation products is raised in D.v.T., and this increase may be associated with pulmonary embolism; but falsenegative results are common Fletcher, using gel filtration to measure high-molecular-weight fibrinogen complexes, has been able to identify venous thrombosis and hypercoagulable states, but this technique is suitable only for a small number of samples.12 As yet, therefore, there is no simple reliable test to D.V.T.
Any diagnostic procedure should minimise the incidence of false-positive and, more importantly, false-negative results, and in these respects venography Small and 1.211-fibrinogen scanning are reliable. thrombi in soleal veins, not recognised by either of these procedures, might be expected to give a raised plasma /3-thromboglobulin although as yet we have no
the identification of
venous
thrombosis.
Dr T. A. S. Buist has given invaluable support. C. A. L. is in receipt of a Medical Research Council junior research
In this
detect
patients with rheumatic heart-disease, prosthetic car diac valves, and arterial thrombosis.5 Moreover, during blood clotting /3-thromboglobulin is released from platelets and a carelessly collected blood-sample can contain a high concentration of /3-thromboglobulin. Therefore, great care is required during venepuncture and the preparation of the plasma. If our observations are confirmed, when a larger population is studied, the measurement of plasma a-thromboglobulin concentration by a rapid radioimmunoassay may become a useful screening-test for
evidence for, this.
Other
causes
of intravascular
platelet aggregation can result in a raised plasma 13thromboglobulin level, and this has been observed in
fellowship. Requests for reprints should be addressed to C. A. L., University Department of Therapeutics, Royal Infirmary, Edinburgh EH3 9YW. REFERENCES 1. 2. 3.
4. 5. 6. 7.
8. 9. 10.
11.
12.
Registrar General’s Statistical Review of England and Wales, 1972. Kakkar, V. V., Corrigan, T. P. Prog. cardiovasc. Dis. 1974, 17, 207. French, J. E. in Thrombosis (edited by S. Sherry, K. M. Brinkhouse, E. Genton, and J. M. Stengle); p. 300. Washington, D.C., 1969. Moore, S., Pepper, D. S., Cash, J. D. Biochim. biophys. Acta, 1975, 379, 360. Ludlam, C. A., Moore, S., Bolton, A. E., Pepper, D. S., Cash, J. D. Thrombosis Res. 1975, 6, 543. Cuatrecasas, P. J. biol. Chem. 1970, 245, 3049. Greenwood, F. C., Hunter, W. M., Glover, J. S. Biochem. J. 1963, 89, 114. Hirsh, J., Gallus, A. S., Cade, J. F. Thromb. Diath. hœmorrh. 1974, 32, 11. Ritchie, W. G. M., Lynch, P. R., Stewart, G. J. Invest. Radiol. 1974, 9, 444. Ruckley, C. V., Das, P. C., Leitch, A. G., Donaldson, A. A., Copland, W. A., Redpath, A. J., Scott, P., Cash, J. D. Br. med. J. 1970, iv, 395. Tibbutt, D. A., Chesterman, C. N., Allington, M. J., Williams, E. W., Faulkner, T. ibid. 1975, i, 369. Fletcher, A. P., Alkjaersig, N. in Recent Advances in Thrombosis (edited by L. Poller); p. 87. Edinburgh, 1973.
Reviews of Books The Role of Diagnosis in
Psychiatry
R. E. KENDELL, F.R.C.P., professor of psychiatry, University of Edinburgh. Oxford: Blackwell Scientific Publications. 1975. Pp. 176. E3.50.
" To our generation," writes Professor Kendell, " it is self-evident that diseases, tuberculosis as well as schizophrenia, are nothing but man made abstractions, inventions justified only by their convenience and liable at any time to be adjusted or discarded. Our present outlook is so wholeheartedly empirical that we find it difficult to credit how an earlier generation could have talked of diseases being ’discovered’ like so many gold sovereigns on a beach, or have imagined that there were a finite number of them waiting to be identified." This is a most polished and readable monograph, taking the reader on from an erudite chapter on the nature of disease to a consideration of the syndromal nature of psychiatric disorders and the problems posed by their classification. The various forms of multivariate analysis which must be used to illuminate such problems are described with effortless clarity, and Kendell proceeds to a discussion on the choice between categories and dimensions. There is a patient rebuttal of Eysenck’s polemical espousal of a dimensional model for psychoses, and the author comes down in favour of a categorical model for psychoses and a dimensional model for neuroses and personality disorders. This book comes at a time when psychiatric diagnosis has been attacked as harmful, or at
