Malondialdehyde formation by platelets of hemophiliacs]

The platelets of haemophilic patients produce after stimulation with thrombin (5 NIH-units) a significantly reduced amount of malondialdehyde in comparison to the platelets of healthy children of the same age. There is a positive correlation between the platelet count in citrated whole blood and malondialdehyde production in the group of healthy children, however the same correlation is negative in adults and strongly negative in haemophiliacs. Because of the 24 hour-intervals between the last substitution and investigation in the majority of haemophilic patients, the reduced MDA-production of their platelets seems to be the result of side effects of the administration of plasma fractions. On the other hand, the reduced capacity for the MDA-production of the platelets of haemophiliacs can be explained as the result of the release reaction of platelets after haemostasis activation following bleedings.     

Recommendations for a medical-meteorologic prognosis for hemophilia]

A one year lasting study about the relation between bleedings in haemophiliacs and weather was performed. There had been included 1802 bleeding events. The influence of meteorologic factors to bleeding was proved. The influx of warm air proved inopportune. The decrease in atmospheric pressure as well as winter cold fronts lead to increase of bleeding tendency. Haemophiliacs should avoid physical and psychical stress in such unconvenient atmospheric situations. The replacement therapy should be adapted to the weather situation.     

Importance of PPSB fraction in the treatment of hemophilia A with antibodies against factor VIII

On the basis of the indirectly established statement that activated forms of the coagulation factor are also present in PPSB fractions of own production, the activated concentrate of factor IX and of the prothrombin complex were applied in haemophilia-A patients with antibodies against factor VIII. The fraction was administered to 4 patients during 14 bleeding times, mostly during bleedings of joints an soft tissues, twice during haematuria in a dose of 40-200 E-factor IX per kg of body weight and per day. The total dose was mainly administered in a fractionized way at an interval of 8 or 12 hours. This treatment lasted for 2 to 7 days. With regard to haemostasis no fundamental improvement of global blood coagulation tests (which have pathological results in haemophilia-A patients) could be identified in the course of the treatment. However, the increase of factor II, VII, and X in the patient's plasma was striking. Contrary to exceptations, there was a less distinct increase of factor IX activity. Concluding from these findings it may be assumed that the "strengthening" of the "extrinsic system" is decisive for the haemostatic effect in the treatment mentioned.     

Hemostasis disorders after transfusions

Disturbances of haemostasis caused immunologically and non-immunologically were observed after transfusion of blood and blood derivatives. Transfusion of heparin blood increased the bleeding susceptibility only in case of pre-existing high-degree defects of haemostasis or if they were performed as massive or exchange transfusions. Massive transfusions with blood stored for a long time will induce complex defects. Under intensive substitution therapy of haemophilia A the so-called paradoxical bleeding will occur in spite of a high factor VIII level. These bleedings are supposed to be disturbances of the thrombocyte function and are caused by fibrin(ogen) derivatives. Post-transfusional thrombocytopenias may be brought to remission by repeated plasmapheresis. Factor specific inhibitory bodies will appear after substitution in a small percentage of haemophilic patients. 5 to 7 days after the onset of therapy an anamnestic reaction can be observed as a titre increase by leaps. Usually, the inhibitory titre will decrease to a mostly low basal value in the course of three to five months. The therapy with cyclophosphamide simultaneously started with the substitution will more frequently prevent the anamnestic reaction or reduce it. Titres with more than 5 units cannot be overcome at the beginning even by higher concentrations of preparations. The substitution therapy should be preceded by exchange transfusions or plasmapheresis of up to 25 units. With still higher titres only procedures of inhibitor-bypassing are possible with factor VIII preparations of animal origin or better with activated prothrombin complex preparations, such as FEIBA. Recent reports give evidence that permanent substitution with factor VIII concentrates at a highest dosage can eliminate the production of inhibitors completely.     

A case of Osler-Rendu disease with simultaneous thrombopenia and a factor VIII inhibitor]

Long-term determinations of haemostasis factors in a case of Osler's telangiectasia revealed the temporarily simultaneous existance of periods of thrombocytopenia, a decrease of prothrombine and a reduction of the fibrinogen and plasminogen level. These findings considered as signs of consumption coagulopathy coincided with an increased bleeding tendency of the patient. The correlation existing between the clinical symptoms and the observed disorders of coagulation may possibly be explained by the appearance of an intravascular coagulation during the late period of the haemorrhagic diathesis, which could be proved by the simultaneous increase of fibrinogen degradation products. Moreover, the patient's plasma was capable of strongly inhibiting factor VIII of a normal plasma. The possible influence of plasmatic disorders of coagulation which are caused by secondary reasons on the clinical picture of a haemorrhagic diathesis primarily based on vascular conditions is discussed.     

经股动脉导管介入支气管动脉栓塞救治难治性大咯血

目的：1996—3至2005—12期间我科与介入放射科合作,对66例内科方法未能止血的大咯血患者行支气管动脉介入栓塞术止血。观察分析止血效果及并发症。方法：患者在1250数字减影机下,经股动脉插入美国COOK公司生产的3—5FCobra导管。找到支气管动脉,造影后确定出血部位,在明确无栓塞禁忌症后,以明胶海绵粉末或PVA颗粒栓塞支气管动脉,观察止血状况及并发症。结果：总体止血率95．3％（61／64）,半年内9例复发咯血,但咯血量明显减小,复发率14．1％（9／64）。仅1例栓塞后未止血。2例动静脉瘘患者不能实行栓塞。15例出现发热,占23．4％（15／64）,所有患者均不同程度出现气短,吸氧后缓解。结论：支气管动脉栓塞救治难治性大咯血十分有效、可靠且较为安全。     

Significance of the laboratory diagnosis of hypercoagulability

Alterations characteristic of the hypercoagulation syndrome such as changes in fibrinogen content, in FDP concentration and platelet counts as well as the presence of fibrinogen complexes were demonstrated by laboratory findings in 175 patients with severe diseases and disturbances of haemostasis. Twenty per cent of the patients showed no clinical signs of disturbances of haemostasis, in 32.5 per cent pronounced venous thrombosis occurred, bleeding complications arised in 28 per cent and microthrombosis developed in 20 per cent. The different findings in the individual groups are assumed to be due not only to haemostatic factors but also to other ones.     

Causes of death in hemophilia patients in East Germany

By means of the Central Card Index of Haemophilia, a working material of the Section of Haemophilia in the Society of Haematology and Blood Transfusion of the GDR, 52 patients with heriditary haemorrhagic diatheses could be registered. These persons had died between 1962 and 1984. The average age of death amounted to 33.8 years. With 23 cases intracranial bleedings were the dominating cause of death in all haemophiliacs. From this fact the absolute necessity arises to initiate a substitutive therapy with a sufficiently high dosage, if there is an assumption of a craniocerebral trauma and, in addition, to treat hypertension in such a way that normotonic values are achieved. Even retrospectively no signs of an acquired immunodeficiency syndrome could be found in any of the patients. As haemophilic bleedings apparently represented the life limiting factors in the majority of the deceased, the importance of an early adequate substitutive therapy is stressed, the principles of which should be known to all general practioners.     

Fibrinogen beta-chain tyrosine nitration is a prothrombotic risk factor

Elevated levels of circulating fibrinogen are associated with an increased risk of atherothrombotic diseases although a causative correlation between high levels of fibrinogen and cardiovascular complications has not been established. We hypothesized that a potential mechanism for an increased prothrombotic state is the post-translational modification of fibrinogen by tyrosine nitration. Mass spectrometry identified tyrosine residues 292 and 422 at the carboxyl terminus of the beta-chain as the principal sites of fibrinogen nitration in vivo. Immunoelectron microscopy confirmed the incorporation of nitrated fibrinogen molecules in fibrin fibers. The nitration of fibrinogen in vivo resulted in four distinct functional consequences: increased initial velocity of fibrin clot formation, altered fibrin clot architecture, increased fibrin clot stiffness, and reduced rate of clot lysis. The rate of fibrin clot formation and clot architecture was restored upon depletion of the tyrosine-nitrated fibrinogen molecules. An enhanced response to the knob "B" mimetic peptides Gly-His-Arg-Pro(am) and Ala-His-Arg-Pro(am) suggests that incorporation of nitrated fibrinogen molecules accelerates fibrin lateral aggregation. The data provide a novel biochemical risk factor that could explain epidemiological associations of oxidative stress and inflammation with thrombotic complications.     

Kinetic study of von Willebrand factor self-aggregation induced by ristocetin

Von Willebrand factor (VWF) is a multimeric glycoprotein present in circulating blood and in secretory granules of endothelial cells and platelets. VWF is sensitive to hydrodynamic shear stress that promotes conformational changes, rendering it able to interact with subendothelial proteins and platelets, thus promoting primary haemostasis. Likewise, the binding of the glycopeptide antibiotic ristocetin to VWF triggers hemostatically relevant conformational transitions. These changes reveal both the interaction site for platelet receptor GpIbα and the Tyr1605-Met1606 peptide bond, which is cleaved by the regulatory metalloprotease ADAMTS-13. In this study we investigated by a combined approach of light scattering spectroscopy and turbidimetry the ability of VWF to self-associate in solution in the presence of ristocetin and in the absence of any protein adsorbing surface. Micro- and macro-aggregates induced by ristocetin, have been characterized under static conditions in the early stage of formation and on a longer time scale (up to 10 h). These findings show that VWF multimers form supramolecular structures favoring platelet trapping not only under high shear stress or interaction with external surfaces, but also in solution under static conditions when the conformational state of the protein is changed only by chemical potential of allosteric effectors.     

Separation of human antihemophilic factor (AHF, factor VIII) from fibrinogen by means of defibrase.

Various attempts have been made in the past to remove fibrinogen from plasma fractions rich in factor VIII. Present studies indicated the Defibrase, a preparation of a thrombin-like enzyme from the venom of Bothrops atrox, might be successfully employed for this purpose. Addition of Defibrase to plasma or low-purity factor VIII concentrates allows for the complete removal of fibrinogen without any apparent reduction in the activity. It was also shown that treatment with Defibrase neither decreases the stability of factor VIII nor apparently affects its antigens properties.     

Oxidation of Met1606 in von Willebrand factor is a risk factor for thrombotic and septic complications in chronic renal failure

CKD (chronic kidney disease) is a life-threatening pathology, often requiring HD (haemodialysis) and characterized by high OS (oxidative stress), inflammation and perturbation of vascular endothelium. HD patients have increased levels of vWF (von Willebrand factor), a large protein (~240?kDa) released as UL-vWF (ultra large-vWF polymers, molecular mass ~20000-50000?kDa) from vascular endothelial cells and megakaryocytes, and responsible for the initiation of primary haemostasis. The pro-haemostatic potential of vWF increases with its length, which is proteolytically regulated by ADAMTS-13 (a disintegrin and metalloproteinase with thrombospondin motifs 13), a zinc-protease cleaving vWF at the single Tyr1605-Met1606 bond, and by LSPs (leucocyte serine proteases), released by activated PMNs (polymorphonuclear cells) during bacterial infections. Previous studies have shown that in vitro oxidation of Met1606 hinders vWF cleavage by ADAMTS-13, resulting in the accumulation of UL-vWF that are not only more pro-thrombotic than shorter vWF oligomers, but also more efficient in binding to bacterial adhesins during sepsis. Notably, HD patients have increased risk of developing dramatic cardiovascular and septic complications, whose underlying mechanisms are largely unknown. In the present study, we first purified vWF from HD patients and then chemically characterized its oxidative state. Interestingly, HD-vWF contains high carbonyl levels and increased proportion of UL-vWF polymers that are also more resistant to ADAMTS-13. Using TMS (targeted MS) techniques, we estimated that HD-vWF contains >10% of Met1606 in the sulfoxide form. We conclude that oxidation of Met1606, impairing ADAMTS-13 cleavage, results in the accumulation of UL-vWF polymers, which recruit and activate platelets more efficiently and bind more tightly to bacterial adhesins, thus contributing to the development of thrombotic and septic complications in CKD.     

Haemophilia A home therapy in the United Kingdom 1975-6.

Data on home treatment for patients with haemophilia A (factor VIII deficient haemophilia) were compiled for 1975 and 1976 from questionnaires answered by directors of haemophilia centres throughout the United Kingdom. There were 48 haemophilia centres in 1975 and 71 in 1976. The number of patients on or in training for home treatment increased from 267 to 488 in the two years, and a further 241 haemophiliacs were considered suitable for home therapy by the end of 1976. Apart from a small (but increasing) number of haemophiliacs on prophylactic treatment, most patients were on low-dose (250-500 units) on-demand regimens, using a mean of 20 000 factor VIII units per patient per year in 1976. An estimated 55% of the blood product used for home therapy in the UK in 1976 was imported from commercial sources. Despite the fact that the numbers of patients on home treatment have increased, so that about 60% of the potential population were receiving or being considered for home treatment in 1976, inadequacies in the service still remain. In some centres follow-up is clearly inadequate; about 15% of patients still rely on cryoprecipitate; and too little money has been invested in making the NHS self-sufficient in factor VIII production.     

Plasma exchange and human factor VIII concentrate in managing haemophilia A with factor VIII inhibitors.

Plasma exchanges were combined with human factor VIII concentrate therapy in the treatment of major bleeding episodes in five patients with haemophilia A and factor VIII inhibitors. All patients had a good clinical response to combined treatment. Inhibitor levels showed satisfactory falls before rapid secondary increases of inhibitor levels took place. A sixth patient with von Willebrand''s disease and a factor VIII clotting activity inhibitor was successfully prepared for operation using plasma exchange. Postoperative haemostasis and healing were normal. In two patients the plasma exchanges were relatively more effective than the administered human factor VIII in reducing the levels of factor VIII inhibitor. Combined plasma exchange and human factor VIII treatment may offer a rapidly effective means of reducing factor VIII inhibitor levels in this group of patients, together with significant saving of costs.     

Effect of bencyclan and theophylline on changes of platelet aggregation and factor 3 activity]

The ADP- and adrenaline-induced platelet aggregation and platelet factor 3 availability were studied in patients before and eight hours after intravenous administration of bencyclan (100 mg) and/or theophylline (240 mg). Aggregation was primarily inhibited by bencyclan, the availability of factor 3 was inhibited by theophylline. Combination of both drugs exerted additive effects on both parameters. The combined use of drugs as inhibitors of aggregation is recommended, since they inhibit primary haemostasis simultaneously at two points of attack.     

The action of MBL-associated serine protease 1 (MASP1) on factor XIII and fibrinogen

The complement system is an important recognition and effector mechanism of the innate immune system that upon activation leads to the elimination of foreign bodies. It can be activated through three pathways of which the lectin pathway is one. The lectin pathway relies on the binding of mannan-binding lectin (MBL) or the ficolins and the subsequent activation of the MBL-associated serine proteases (MASPs), namely, MASP1, 2 and 3 which all form complexes with both MBL and the ficolins. Major substrates have only been identified for MASP2 i.e. C4 and C2. For MASP1 only a few protein substrates which are cleaved at a low rate have been identified while none are known for MASP3. Since chromogenic substrate screenings have shown that MASP1 has thrombin-like activity, we wanted to investigate the catalytic potential of MASP1 towards two major proteins involved in the clotting process, fibrinogen and factor XIII, and compare the activity directly with that of thrombin. We found that rMASP1 and thrombin cleave factor XIII A-chain and the fibrinogen beta-chain at identical sites, but differ in cleavage of the fibrinogen alpha-chain. The thrombin turnover rate of factor XIII is approximately 650 times faster than that of rMASP1 at 37 degrees C, pH 7.4. rMASP1 cleavage of fibrinogen leads to the release of the proinflammatory peptide fibrinopeptide B. Thus rMASP1 has similar, but not identical specificity to thrombin and its catalytic activity for factor XIII and fibrinogen cleavage is much lower than that of thrombin. Nevertheless, rMASP1 can drive the formation of cross-linked fibrinogen. Since MASP1 is activated on contact of MBL or the ficolins with microorganisms, fibrinogen and factor XIII may be involved in the elimination of invading pathogens.     

One-year analysis of bleeding events in 223 hemophiliacs in the DDR]

The reports of 223 haemophiliacs living in the districts Halle, Leipzig, Karl-Marx-Stadt, and Gera had been analyzed for bleeding events in 1986. There were suffering from haemophilia A 185, from haemophilia B 36 and 2 persons from a complex disorder. In each case 73 patients suffer from a severe and a moderate type of haemophilia. In 55 patients the diagnosis was mild form of haemophilia and in 22 subhaemophilia. Altogether 1802 bleeding episodes had been registered with the following locations: elbow joint 21.0%, knee joint 17.9%, ankle 14.2%, shoulder 4.3%. In 5% of all cases multiple joints had been affected at the same time. Soft tissue bleedings occurred in 16.7% of all cases. For substitution treatment of these 1802 bleeding events altogether 9020 transfusion units were needed, appropriate to 40.4 per year and 52.4 per year and bleeding patient respectively. Expense and duration of treatment depend on the bleeding location. Conclusions for the clinics and the transfusion service are possible.     

Treatment of refractory chronic idiopathic thrombocytopenic purpura with high dose intravenous immunoglobulin

Three patients with a history of chronic idiopathic thrombocytopenic purpura stretching back over 20 years are reported. Despite splenectomy and immunosuppressive therapy satisfactory control of their disease has not been achieved. They had remained refractory to all therapeutic manoeuvres with corticosteroids and immunosuppressives for years with thrombocyte counts between 5,000 and 25,000/microliters and the concommitant risk of bleeding. This report describes the treatment of bleeding complications in these patients with high dose intravenous immunoglobulin; the peripheral blood thrombocyte count increased in all three patients from subnormal towards normal, but 2 to 4 weeks later returned to its initial low value. During the therapeutically induced raised thrombocyte count a normal bleeding time and only a moderate inhibition of thrombocyte adhesion and aggregation was observed resulting in reasonable haemostasis. High dose intravenous immunoglobulin is therefore a practical method for the control of bleeding complications in patients with refractory chronic idiopathic thrombocytopenic purpura. A clear explanation for its mode of action has not been found - the lymphocyte subpopulations remained unchanged and immunoglobulin production in vitro during the course of treatment was only minimally decreased.     

Coagulation factor levels in non-metastatic colorectal cancer patients

There is evidence that high plasma levels of factor (F) VIII, FIX, FXI and fibrinogen are independent risk factors for venous thromboembolism. AIM: To determine the plasma concentrations of several coagulation factors and C4b-binding protein (C4BP) in a group of patients with non-metastatic colorectal cancer in order to investigate some aspects of cancer-acquired thrombophilia. METHODS: Plasma fibrinogen, FII, FV, FVII, FVIII, FIX, FX, FXI and FXII activity levels and C4BP concentrations were determined in 73 patients with non-metastatic colorectal cancer (48 colon and 25 rectum) and in 67 matched control subjects. No one in either group had had previous thrombotic events. RESULTS: Mean plasma concentrations of fibrinogen (functional and antigen), FVIII, FIX, FV and C4BP were significantly higher in colorectal cancer patients than in control subjects, while FVII and FXII levels were significantly decreased. Several correlations were found between the increased coagulation factors and C4BP concentrations, while FVII was highly correlated with FXII. CONCLUSIONS: In colorectal cancer patients high plasma fibrinogen, FVIII and FIX levels might represent further risk factors for venous thrombotic complications in the immediate post-surgery period, while decreased FVII and FXII concentrations may be an index of intravascular coagulation activation, still in a subclinical phase.