Endobronchial actinomycosis mimicking pulmonary neoplasm.

A 60 year old man had recurrent pneumonia. Bronchoscopy disclosed a necrotic mass in the left lower lobe bronchus, which histological examination showed to contain sulphur granules. The endobronchial mass had disappeared by the second bronchoscopy one week later. The patient was treated with penicillin for one year and was cured. Actinomycosis must be included in the differential diagnosis of an endobronchial mass.


[Physiology of the digestive smooth muscle].

By comparison with striated muscle, the main features of digestive smooth muscle are richness, complexity and diversity specially with thanks to the enteric and prevertebral nervous neurons which add up their effects to those of the central nervous system. The morphological and molecular characteristics of the smooth muscle contractility begin to be unveiled, but a lot of basic knowledge is still needed for further pharmacological advances.


[Methods for studying the motility in the small intestine, colon and recto-anal area].

Small bowel and colonic motility can be studied either indirectly by the determination of the transit time or directly in recording bowel contractions. Small bowel transit time is usually assessed with the H2-breath test when colonic transit time is mainly determined fluoroscopically in studying the progression of radiopaque markers along the large bowel. Scintigraphic techniques are promising but not routinely used techniques. In the small bowel, gut contractions are recorded with manometric probes. To study colonic movements, electromyography is more usual than manometry. In both cases, whatever the technique employed, the large inter- and intra (topographic and nycthemeral) variability need to be considered for the interpretation of the motor patterns. Rectoanal studies led to consider two aspects: how the rectum acts as a reservoir and anal function. The ability of the rectum to be a reservoir is assessed either by the volume remaining in the rectum during the rectal perfusion with saline or by the determination of the maximal tolerable volume of distension. Manometry and/or electromyography test anal function at rest and during a rectal distension, straining or a voluntary contraction.


[Evaluation criteria for protocols submitted to the consultant committee for protection of persons in biomedical research (CCPPRB) Lyon-C].

In order to fulfill its task, the Lyon-C institutional review board (CCPPRB) developed standards for the evaluation of clinical research protocols. This check-list envisages 1- the mandatory documents in the absence of which the protocol will not be considered, 2- scientific quality standards, 3- ethical quality standards. An agreement on the use of such standards in France might improve the functioning of institutional review boards (CCPPRB) and the quality of clinical research.


[Parkinson disease in neurologic general practice in Alsace-Lorraine. Characteristics and study of the treatment].

A study was performed in 220 out-patients with Parkinson's disease followed by general neurologists. The general characteristics of the patients are similar to those observed in the large epidemiological studies. The main conclusion concerns the low use of dopamine agonists. It confirms the discrepancy between drug prescription in general practice and the data from therapeutic drug trials.


[Extended worldwide experience. HMG-CoA reductase inhibitors: lovastatin and simvastatin].

Lovastatin and simvastatin are the first licensed compounds of a potent new class of lipid lowering drugs whose mechanism of action is to inhibit HMG-CoA reductase, a rate-limiting enzyme in the cholesterol biosynthetic pathway in the liver. Inhibition of cholesterol synthesis leads to upregulation of LDL-receptors in the liver and subsequent increased LDL clearance. Both agents are pro-drugs (lactones) which undergo extensive first-pass hepatic metabolism to the beta-hydroxyl acid form. These drugs are liver specific and have low systemic exposure as open-acid forms (plasma concentration < 5% of oral dose). Thus, theoretically both drugs have low potential for systemic adverse events. They are potent and effective agents for the treatment of primary hypercholesterolemia. The adverse experiences reported for both drugs demonstrate an excellent safety profile.


[Double blind study of the efficacy of mebendazole in minor forms of human toxocariasis].

The authors discuss the results of a double-blind, placebo-controlled, randomised study on the efficacy of mebendazole versus placebo in the treatment of human toxocariasis in 45 and 43 patients respectively, who exhibited evocative clinical and biological symptoms and a seropositivity. Scores were used to quantify clinical (20 parameters) and biological (blood count, sedimentation rate, determination of total and anti-Toxocara IgE, serodiagnosis by immunoelectrophoresis) abnormalities. The reassessment were done 1 month after the end of treatment. Analyzing the results showed a similar efficacy of mebendazole and placebo on the score of clinical signs; the score of biological abnormalities was significantly reduced in mebendazole group, but the serodiagnosis by immunoelectrophoresis was the only parameter that was significantly normalized. These results corroborate previous prospective studies and allow to make a conclusion in favour of a moderate efficacy of mebendazole.


Peritoneal fluid and plasma fibrinolytic activity in women with pelvic inflammatory disease.

Previous studies have shown that the fibrinolytic activity of peritoneum is depressed in local inflammation. We measured fibrinolytic parameters in peritoneal fluid and in plasma of 10 women with pelvic inflammatory disease (PID). Nine women, in whom laparoscopy for sterilisation was performed, served as a control group. In the peritoneal fluid of women with PID, PAI-Ag, t-PA-Ag and u-PA-Ag were many times higher than in the control group. In contrast to the antigens which may be present in inert complexes, the potentially active compounds, measured as t-PA activity and plasmin-activable scu-PA, were not significantly different in the two groups, and in none of the samples was the active enzyme tcu-PA detectable. Nevertheless, the mean peritoneal fluid TDP and FbDP concentrations were about twenty times higher in the PID group than in the control group. In plasma of PID patients, none of the parameters except u-PA-Ag differed from those in the control group. The difference between control and patient plasma u-PA-Ag was statistically significant, but too small to attach any relevance to the observation. Our data suggest that, in contrast to the classical concept of decreased fibrinolytic activity as a cause of adhesion formation, intraperitoneal fibrinolysis is enhanced in peritoneal inflammation through stimulation of the local production of t-PA and u-PA. Despite concomitant production of PAI, fibrinolysis occurs at a high rate, resulting in high levels of fibrin degradation products. Since this activated fibrinolysis does not meet the demand, therapeutic enhancement should be considered to prevent adhesions.


[Physiological and clinical recall on equilibrium disorders].

Static and dynamic equilibrium (posture and gait) is indispensable for a normal behavior in human. Its mechanisms are nearly the same in superior species and in man, but humans are the only ones to have acquired exclusively biped upright position and gait. Equilibrium is a sensory function involving 3 sub systems: visual, vestibular and sensori-motor (proprioceptive), controlled by cerebellum and cerebral structures. Information coming from those 3 sub systems must be concordant. In case of discordance, the patient is in a state of sensory conflict. This conflict can induce disequilibrium or true vertigo. After a recall on equilibrium, the authors report the results of an epidemiologic study upon 5298 patients suffering of balance disorders and treated by an alpha-blocker: nicergoline (30 mg/day during 6 months).


Monocyte tissue factor expression induced by Plasmodium falciparum-infected erythrocytes.

Monocytes are active elements of the host response against Plasmodium falciparum. They are able to express tissue factor and trigger the extrinsic pathway of blood coagulation the activation of which remained unclear in malaria. Our aim was to assess the tissue factor expression of purified blood monocytes stimulated by cultured Plasmodium falciparum-infected erythrocytes. Malaria parasite induced an early generation of tissue factor with a peak between 8 and 12 h of stimulation. Maximum expression was observed for parasitemia ranging from 1 to 2%. Plasmodium falciparum culture supernatants had the same effect showing the existence of a soluble factor able to induce the tissue factor expression. These data, demonstrating an activation of the tissue factor pathway by the malaria parasite, emphasize thrombin generation. Therefore, thrombin could participate in malaria pathology either in the microcirculatory blockade via platelet and fibrinogen activation or as a mitotic.


Desmopressin has no beneficial effect on excessive postoperative bleeding or blood product requirements associated with cardiopulmonary bypass.

Cardiopulmonary bypass during open-heart surgery is sometimes associated with excessive perioperative bleeding. Following a non-randomized study suggesting that desmopressin acetate (desmopressin) reduced blood product requirements in these patients, we conducted a double-blind, placebo-controlled randomized trial of desmopressin (0.3 micrograms/kg, i. v.) in 92 patients with overt bleeding and a prolonged bleeding time. Mean blood loss during the first 24 h post-treatment was similar in the desmopressin and placebo groups (582 vs 465 ml, respectively; p = 0.15). Red-cell (p = 0.76), fresh frozen plasma (r = 0.66) and platelet unit (p = 0.74) requirements were also similar. The haemostatic effect of desmopressin has been attributed to the release of von Willebrand factor (vWF) and a reduced bleeding time. In our study, vWF and factor VIII:C levels increased while the bleeding time decreased significantly at 90 min and 24 h in both groups and, although vWF and factor VIII:C levels were slightly higher in desmopressin-treated patients at 90 min, the difference was not significant. Thrombin-antithrombin III complex, fibrinogen degradation product and tissue plasminogen activator levels, reflecting activation of the coagulation and fibrinolytic systems, respectively, decreased uniformly in both groups. We conclude that desmopressin is not useful in reducing blood loss or blood product requirements in patients with excessive immediate postoperative bleeding.


A collaborative study on the measurement of protein S antigen in plasma.

A collaborative study on the measurement of protein S (PS) antigen (total and free) in a freeze-dried ampouled test plasma by assay against local house standard plasmas was carried out in eleven laboratories. Potency estimates of total PS showed good agreement between laboratories with a geometric coefficient of variation (gcv) of 5.9% and an overall combined potency of 0.84 units per ml. Potency estimates of free PS antigen in the test sample were associated with increased variability between laboratories resulting from the polyethylene glycol (PEG) precipitation step which is used to separate free PS from PS bound to the C4b binding protein. Free PS in the test could be expressed relative to either total PS in the house standards (e.g. 0.28 units per ml) or relative to free PS in the house standards following PEG precipitation (e.g. 0.71 units free PS per ml).


[In vitro evaluation of antacid activity in gastric acid secretion in static and dynamic systems].

A valid in vitro evaluation of antacid capacity should consider: 1) the intragastric pH-range; 2) the antacid mechanism; 3) the dependence of antacid activity from intraluminal flux variations; 4) the interaction between proteins and antacids. Pharmacologically, a static method allows 1) to quantify H+ binding sites at different pH-end points of the titration: pH 3.0, 2.0 and 1.0 and 2) to characterize the antacid mechanism, neutralizing activity and/or buffering capacity. In dynamic conditions, using the "artificial stomach-duodenum" model the antacid-induced resistance to acidification was measured, the antacid mechanisms were characterized in regard to intraluminal gastroduodenal flux variations and the incidence of antacid activity on duodenal pH was evaluated. These procedures were applied to antacid evaluation of proteins, as natural antacids, and of drugs containing aluminium salts alone or combined with magnesium salts. Pharmacologically, antacid drugs exhibited a greater amount of H+ binding sites when titration end-point was pH 1.0 than pH 3.0 corresponding to the development of neutralizing activity and/or buffering capacity. In dynamic conditions, the drugs, like proteins, induced a potent resistance to acidification related to gastric emptying fluxes. Antacid effect was supported by neutralizing activity and/or by buffering capacity. It was prolonged by removal of H+ ions since lagtimes for recovering initial pH were longer than antacid total emptying, the dilution of intragastric content by H+ impoverished secretory flux contributing thus to prevent gastric acidification. At duodenal site, proteins and aluminium-containing antacids induced the same duodenal pH as controls, without antacids, while magnesium-containing antacids increased it.


High level expression of active human prothrombin in a vaccinia virus expression system.

We have worked out an efficient and time saving procedure for the expression of recombinant human prothrombin. The glycoprotein was expressed in the vaccinia virus expression system in several mammalian cell lines. The kidney cell lines Vero and BHK and the human cell line Hela were found to efficiently secrete prothrombin. Expression level of 3-4 micrograms of factor II per 10(6) cells per day corresponding to 18-23 mU per 10(6) cells per day were achieved. Since the expression levels obtained with the vaccinia virus/Vero cell system were comparable to those obtained in amplified transformed CHO cells it provides an alternative system for the efficient expression of human prothrombin and may allow to further elucidate structure-function relationships of (pro)thrombin and its various effectors.


Inhibition by D-MePhe-Pro-Arg-H (GYKI-14766) of thrombus growth in experimental models of thrombosis.

The antithrombotic action of the highly effective synthetic thrombin inhibitor D-MePhe-Pro-Arg-H (GYKI-14766) was studied in various models of experimental thrombosis. The compound administered to rats and rabbits by i.v. bolus injections, continuous i.v. infusions, subcutaneously and orally, respectively, induced significant decrease in thrombus weight (i) in a quantitative venous thrombosis model with stasis based on vascular lesion in rats, (ii) in an extracorporeal arterio-venous shunt model in rabbits, and (iii) prevented the occlusion of the vessel in arterial thrombosis induced by mechanical damage in rats. By using the arterio-venous shunt model in rabbits the inhibitory effect on thrombus growth could be demonstrated as a function of dose and time in self-controlled experiments. Blood level of the inhibitor determined by a bioassay varied between 0.09-0.67 microgram/ml whole blood when doses of 15 and 20 mg/kg were administered orally. A correlation was found between thrombin time, platelet aggregation induced by thrombin ex vivo and the weight of thrombi formed.


The consumption of antithrombin III during coagulation, its consequences for the calculation of prothrombinase activity and the standardisation of heparin activity.

The decay rate of thrombin in plasma is shown to be linearly proportional to the concentration of antithrombin III (AT III), not only in the absence but also in the presence of heparin. This is a consequence of partitioning of heparin between AT III and other plasma proteins. In previous articles were calculated the prothrombin converting activity assuming a fixed concentration of AT III. Since AT III is consumed during the clotting process, prothrombinase activity is more accurately approximated using an algorithm that counts with the decrease of the AT III concentration. It is shown this leads to higher prothrombinase activities. The (absence of) inhibition of prothrombin conversion by prothrombinase in the presence of heparins found with the previous method is also found using the new algorithm. From the results presented it is evident that characteristic parameters of heparin action have to be normalised to the AT III concentration. On this basis we define a Standard Independent Unit of the antithrombin activity of heparin.


Insights on monoclonal antibodies to kininogens' heavy chain which influence kininogens' binding to platelets.

Purified domains of low molecular weight kininogen (LK) can be used directly to determine the epitopes of monoclonal antibodies (mAbs) that have been shown to influence kininogen function. LK, purified from plasma by carboxymethyl-papain-Sepharose 4B affinity chromatography and kaolin adsorption, was digested by trypsin and chymotrypsin. The domains of LK were then separated by gel filtration followed by carboxymethyl-papain-Sepharose 4B affinity chromatography. Using the purified domains of LK's heavy chain, the regions on kininogens' heavy chain which various monoclonal antibodies are directed to were determined by enzyme-linked immunosorbent assay and immunoblotting. MAb 2B5 which neutralized kininogens' ability to inhibit calpain cross-reacted with domains 2 and 3. MAb HKH8 which reacted with kininogens' domain 1 and 2 was found to inhibit 125I-HK binding to platelets. At two-fold molar excess, mAb HKH8 was a better inhibitor of 125I-HK binding to platelets than higher concentrations, where the antibody was shown to cause increased binding to platelets. Alternatively, HKH8 F(ab')2 completely inhibited 125I-HK binding to platelets even at high concentrations of antibody. These studies indicate that purified domains of kininogens' heavy chain can be used to rapidly localize epitopes for antibodies. Further, mAb HKH8 should be a valuable probe to understand the mechanisms of kininogens' binding to platelets.


Multicenter evaluation of three commercial methods for measuring protein S antigen.

This collaborative study was designed to assess the performance of commercial methods for protein S (PS) antigen measurement. Twenty-five different samples were distributed deep-frozen (24 plasmas) or lyophilized (one plasma) to five laboratories. They were analyzed blind in each laboratory by the method used locally and by three commercial methods which included two electroimmunoassays (EIA), Asseraplate-PS (Diagnostica Stago), Rellplate-S (American Diagnostica) and an ELISA system, Asserachrom-PS (Diagnostica Stago). 1. Reproducibility. Average between-laboratory coefficients of variation were 15.4%, 17.6% and 25.3% for Asserachrom-PS, Asseraplate-PS and Rellplate-S. 2. Specificity. Results of all methods showed that PS is underestimated when C4b binding protein is high. This influence was particularly evident for the ELISA Asserachrom-PS and disappeared when the antibody-antigen incubation period was prolonged to overnight. 3. Sensitivity. In all laboratories ELISA detected even the lowest PS concentration (4 U/dl), whereas the two EIAs were less sensitive (lower detection limit 14 U/dl). All methods and laboratories correctly diagnosed a plasma sample from a PS congenitally deficient patient. Conclusions. This study shows that better standardization of PS immunoassays is necessary to improve accuracy and reduce interlaboratory variability before a candidate plasma standard can be successfully calibrated in an international collaborative study.


Standardisation of factor VIII--V. Calibration of the 2nd International Standard for Factor VIII and von Willebrand factor activities in plasma.

The proposed 2nd International Standard for Factor VIII and von Willebrand Factor activities in plasma, NIBSC code 87/718, was assayed against the 1st IRP, 80/511, and against fresh normal plasma, in 21 laboratories. There were no significant differences between the various assay methods for factor VIII antigen, von Willebrand factor antigen, and von Willebrand factor ristocetin co-factor activity. For factor VIII clotting activity there was a significant difference between the results of one-stage and two-stage assays. Plasma 87/718 has now been established by the WHO Expert Committee on Biological Standardisation as the 2nd IS for factor VIII and vWF in plasma with the following potencies: VIII:C 0.60 IU/ampoule; VIII:Ag 0.91 IU/ampoule; vWF:Ag 0.91 IU/ampoule; vWF/RCo 0.84 IU/ampoule.


Relationship between total prothrombin, native prothrombin and the International Normalized Ratio (INR).

Plasma levels of total prothrombin and fully-carboxylated (native) prothrombin were compared with results of prothrombin time (PT) assays for patients undergoing oral anticoagulant therapy. Mean concentrations of total and native prothrombin in non-anticoagulated patients were 119 +/- 13 micrograms/ml and 118 +/- 22 micrograms/ml, respectively. In anticoagulated patients, INR values ranged as high as 9, and levels of total prothrombin and native prothrombin decreased with increasing INR to minimum values of 40 micrograms/ml and 5 micrograms/ml, respectively. Des-carboxy-prothrombin increased with INR, to a maximum of 60 micrograms/ml. The strongest correlation was observed between native prothrombin and the reciprocal of the INR (1/INR) (r = 0.89, slope = 122 micrograms/ml, n = 200). These results indicated that native prothrombin varied over a wider range and was more closely related to INR values than either total or des-carboxy-prothrombin. Levels of native prothrombin were decreased 2-fold from normal levels at INR = 2, indicating that the native prothrombin antigen assay may be a sensitive method for monitoring low-dose oral anticoagulant therapy. The inverse relationship between concentration of native prothrombin and INR may help in identification of appropriate therapeutic ranges for oral anticoagulant therapy.


Vampire bat salivary plasminogen activator promotes robust lysis of plasma clots in a plasma milieu without causing fluid phase plasminogen activation.

Vampire bat salivary plasminogen activator (BatPA), human tissue-type plasminogen activator (tPA) or streptokinase (SK) were incubated in human citrated plasma containing a plasma clot that was radiolabelled with iodine-125 fibrin(ogen). Complete clot dissolution by BatPA (30 nM) was associated with slight activation of "fluid phase" plasminogen; the plasma levels of functional fibrinogen and alpha 2-antiplasmin decreased by only 8 and 19%, respectively. Addition of SK (3,600 IU/ml) to the clot-containing plasma caused complete clot lysis and massive activation of the "fluid phase" plasminogen, leading to greater than 60 and 96% decreases of the functional levels of fibrinogen and alpha 2-antiplasmin, respectively. Incubation of tPA (30 nM) in clot-containing plasma caused complete clot lysis as well as substantial activation of "fluid phase" plasminogen; the plasma levels of functional fibrinogen and alpha 2-antiplasmin decreased by 45 and 79%, respectively. The profound degradation of fibrinogen in the SK and tPA but not BatPA-containing samples was confirmed by immunoblot analysis. Additional experiments showed that the presence of soluble clot lysate in plasma containing tPA enhanced the extent of fibrinogen degradation from 25% to greater than 60%; the addition of soluble clot lysate to the plasma containing BatPA did not prompt further fibrinogen degradation. Finally, studies using exogenous alpha 2-antiplasmin suggested that plasmin generated via tPA-mediated activation of "fluid phase" plasminogen does not play an important role in clot dissolution.


Thrombolytic and pharmacokinetic properties of a recombinant chimeric plasminogen activator consisting of a fibrin fragment D-dimer specific humanized monoclonal antibody and a truncated single-chain urokinase.

A recombinant chimeric plasminogen activator consisting of a humanized monoclonal antibody specific for cross-linked human fibrin (MA-15C5Hu) and a 32 kDa single-chain urokinase-type plasminogen activator (scu-PA-32k) comprising amino acids Leu144-Leu411, MA-15C5Hu/scu-PA-32k, was previously found to have a 12-fold higher fibrinolytic potency than recombinant scu-PA-32k towards a human plasma clot in a human plasma milieu in vitro (Vandamme et al., Eur J Biochem 1992; 205: 139-46). Therefore, the thrombolytic and pharmacokinetic properties of MA-15C5Hu/scu-PA-32k were compared with those of recombinant single-chain urokinase-type plasminogen activator (scu-PA) in 3 different venous thrombosis models in vivo. In hamsters with a pulmonary embolus consisting of a human plasma clot, the thrombolytic potency (% lysis per dose in mg/kg administered) of MA-15C5Hu/scu-PA-32k was 23-fold higher than that of scu-PA (p less than 0.0005). In rabbits with a jugular vein clot prepared from human plasma, the thrombolytic potency of MA-15C5Hu/scu-PA-32k was 11-fold higher than that of scu-PA (p = 0.012). In baboons with an autologous whole blood clot in the femoral vein, the chimera had a 5-fold higher thrombolytic potency than scu-PA. In all three animal species, the clearance of the chimera was 10- to 27-fold reduced as compared to scu-PA. The specific thrombolytic activity (% lysis per micrograms/ml steady-state plasma u-PA antigen) was increased up to 7-fold with MA-15C5Hu/scu-PA-32k as compared with scu-PA, which is indicative of targeting of the chimera to the clot. No fibrinogen breakdown or alpha 2-antiplasmin depletion was observed during thrombolysis with the chimera. Thus, MA-15C5Hu/scu-PA-32k constitutes a recombinant chimeric plasminogen activator with a significantly enhanced thrombolytic potency in 3 different animal models of venous thrombosis.


Depression of tissue-type plasminogen activator and enhancement of urokinase-type plasminogen activator as an expression of local inflammation.

Inflammatory processes are accompanied by extravascular deposition and breakdown of fibrin. We measured fibrinolytic parameters in synovial fluid (SF) and in plasma of 36 patients with rheumatoid arthritis (RA). As a control, SF of 13 patients with blunt knee trauma, and plasma of 17 healthy volunteers were studied. In RA patients, extravascular t-PA mediated plasminogen activation was depressed: mean SF tissue-type plasminogen activator (t-PA:Ag) concentration (2.1 +/- 1.6 ng/ml) was four-fold lower, and plasminogen activator inhibitor (PAI) activity (284 +/- 212%) four-fold higher than the plasma values of the same patients or of healthy donors. In contrast, u-PA related plasminogen activation was strongly enhanced: urokinase-type plasminogen activator (u-PA) antigen (23.1 +/- 12.4 ng/ml) was more than four-fold higher, single-chain u-PA (scu-PA) (5.3 +/- 1.9 ng/ml) three-fold higher than in plasma of the same patients or of healthy donors, and active two-chain u-PA (tcu-PA) was detected in 14 of the 36 SF samples of RA patients. All of these changes in extravascular fibrinolytic parameters correspond with those induced by inflammatory mediators in cell cultures. In joint effusions of patients with a blunt knee trauma, the effects were intermediate: u-PA related parameters showed moderate changes in the same direction as in arthritis; t-PA antigen was also decreased. The only exception was that PAI was not increased. We conclude that the findings in traumatic effusions reflect transient effects as a reaction to trauma. In joint inflammation, the depressed t-PA mediated plasminogen activation, although more than compensated by the enhanced u-PA mediated plasminogen activation, results in protraction of fibrin removal. Besides, the enhanced u-PA activation might lead to proteolytic damage of the cartilage.


Lysine-binding heterogeneity of Lp(a): consequences for fibrin binding and inhibition of plasminogen activation.

Lipoprotein(a) [Lp(a)] is recognized as an independent risk factor for atherosclerosis. Lp(a) consists of a LDL-like moiety with an additional glycoprotein, apo(a), linked to apolipoprotein B-100. Apo(a) has a high homology with plasminogen (Pg). In vivo, Pg is activated on a fibrin surface by tissue Pg activator (tPA). We prepared Lp(a) from plasma by sequential ultracentrifugation followed by lysine-sepharose affinity chromatography. We found that a changing (donor dependent) fraction of the Lp(a) did not bind to lysine-sepharose. This fraction, designated Lp(a)lys-, was further purified using gel filtration. Bound Lp(a) [Lp(a)lys+] was eluted with 0.2 M EACA. Apo(a) isoforms in both fractions were identical. In contrast Lp(a)lys+ inhibited Pg activation by tPA in vitro (IC50% 20 mg/l), whereas Lp(a)lys- did not. In addition Lp(a)lys- did not bind to CNBr-digested fibrinogen whereas Lp(a)lys+ did (Kd, app = 0.2 nM). Therefore we conclude that a changing donor dependent fraction of human plasma Lp(a) does not inhibit Pg activation in vitro and does not bind to CNBr-digested fibrinogen.


Unexpected effects of aurin tricarboxylic acid on human platelets.

Aurin tricarboxylic acid (ATA) is a potent inhibitor of ristocetin-mediated platelet agglutination and of shear-induced, von Willebrand factor (vWf)-mediated platelet aggregation, probably via inhibition of vWf interaction with glycoprotein Ib (GPIb). We examined the effects of ATA (both the sodium salt and a solution of ATA in ethanol) on platelet functions in citrated plasma (PRP) and in suspensions of washed platelets in Tyrode-albumin solution (contains 2 mM Ca2+). ATA (42-211 micrograms/ml) blocked aggregation and release of granule contents induced by thrombin (0.15 U/ml in PRP; 0.03 U/ml in platelet suspension). Responses to higher concentrations of thrombin were not inhibited. ATA also prolonged thrombin-induced clotting of fibrinogen. Since ATA had no effect on fibrinogen-induced responses of chymotrypsin-treated platelets, ATA probably acts on thrombin rather than on fibrinogen. In PRP and platelet suspensions, ATA (acid form 106 micrograms/ml; sodium salt 122 micrograms/ml) had little effect on ADP-induced platelet aggregation. The sodium salt of ATA (61-122 micrograms/ml) enhanced collagen-induced aggregation and release by platelets in citrated plasma and by washed platelets; the enhancement was extensively inhibited by aspirin. With platelet suspensions, ATA significantly enhanced aggregation and release caused by low concentrations of sodium arachidonate (15-50 microM); aggregation and release caused by higher concentrations of arachidonate were somewhat inhibited by ATA. Arachidonate-induced aggregation and release were also enhanced by ATA in PRP. ATA enhanced aggregation and release induced by the calcium ionophore A23187; aspirin had little effect on the enhancement.(ABSTRACT TRUNCATED AT 250 WORDS)


Transient expression of recombinant glycoprotein Ib alpha polypeptides in COS cells that inhibit von Willebrand factor binding to the platelet glycoprotein Ib/IX complex.

The cDNA encoding the glycoprotein Ib alpha polypeptide has been expressed in COS cells. Transfection with full-length cDNA and a cDNA truncated at an internal XbaI site produced a recombinant polypeptide doublet with estimated molecular weights of 48 and 46 kDa (rGpIb alpha L318) which could be resolved into a single band of molecular weight 36 kDa following digestion with endoglycosidase F. A portion of the truncated polypeptide was retained in the endoplasmic reticulum of COS cells and slowly released. A second fraction was rapidly secreted into COS cell-conditioned medium and could be used for functional studies. Soluble rGpIb alpha L318 harvested from COS cell-conditioned medium inhibited ristocetin-dependent binding of [125I]-vWF to fixed washed human platelets (IC50 20 nM). Binding was inhibited by reduction and alkylation of "rGp1b alpha L318" suggesting the need for a critical disulfide bond to maintain biological activity of the recombinant polypeptide. We conclude that the recombinant polypeptides produced by transfection of GpIb alpha cDNA into heterologous cells are secreted, soluble, and can inhibit vWF binding to platelet GpIb/IX.


Defect of platelet aggregation and adhesion induced by autoantibodies against platelet glycoprotein IIIa.

A young patient developed chronic idiopathic thrombocytopenic purpura. Prednisone therapy normalized platelet number, but bleeding symptoms did not disappear. Platelet function was severely impaired, since platelet aggregation, ATP release and adhesion to collagen and subendothelial matrix were significantly reduced. Plasma and purified immunoglobulins of the patient reproduced the functional defects in normal platelets. Immunoblotting revealed that patient's plasma contained an antibody reacting with a component of platelets with the same electrophoretic mobility of glycoproteins IIIa of normal platelets. Moreover, patient's plasma inhibited the binding of an anti-GPIIb/IIIa monoclonal antibody to platelet surface. Additional immunosuppressive therapy with prednisone and azathioprine normalized platelet function and induced the disappearance of bleeding symptoms.


Ridogrel inhibits systemic and renal formation of thromboxane A2 and antagonizes platelet thromboxane A2/prostaglandin endoperoxide receptors upon chronic administration to man.

The effects of ridogrel, a dual thromboxane A2 (TXA2) synthase inhibitor and TXA2/prostaglandin (PG) endoperoxide receptor antagonist, on systemic and renal production of prostaglandins and on platelet TXA2/PG endoperoxide receptors was evaluated upon chronic administration (300 mg b.i.d. orally, for 8 and 29 days) to man. Such a medication with ridogrel inhibits the systemic as well as the renal production of TXA2 as measured by the urinary excretion of 2,3-dinor-TXB2 and TXB2 respectively without inducing significant changes in systemic or renal PGI2 production. Simultaneously with the latter effects, the production of TXB2 by spontaneously coagulated whole blood ex vivo is inhibited (greater than 99%) while that of PGE2 and PGF2 alpha is largely increased. Administration of ridogrel causes a three- to five-fold shift to the right of concentration-response curves for U46619 in eliciting platelet aggregation; no tachyphylaxis is observed after 29 days of treatment in this respect. Apart from a reduction of serum uric acid levels with a concomitant increase in urinary uric acid excretion during the first days of treatment, no clinically significant changes in hematological, biochemical, hemodynamic and coagulation parameters occur during the 8 days or 29 days study. The study demonstrates that ridogrel is a potent inhibitor of the systemic as well as renal TXA2 synthase and an antagonist of platelet TXA2/PG endoperoxide receptor in man, covering full activity during 24 h at steady-state plasma level conditions without tachyphylaxis during 29 days of medication. The compound is well tolerated, at least during 1 month of administration.


Studies of fibrinogen binding to platelets by flow cytometry: an improved method for studies of platelet activation.

Platelet function is dependent upon membrane receptors and their interaction with other proteins. Platelet activation appears to cause a structural change of the glycoprotein IIb/IIIa complex that exposes the fibrinogen binding site, which subsequently binds fibrinogen. Fluorescence-activated flow cytometry (FACS) is an efficient method for studying membrane proteins. Flow cytometry gives single-cell data, allowing the detection of only a small proportion of labelled platelets in whole blood without any washing steps. One problem with this method is that the labelled antibodies and the antigen, if present in plasma, form an immune complex, which may cause false positive reactions due to interaction between mammalian IgG and Fc gamma receptors on the platelets. We show that immune complexes with chicken IgG do not activate human platelets. We have developed a method for measuring platelet-bound fibrinogen in whole blood and platelet-rich plasma utilising fluorescein isothiocyanate (FITC)-conjugated chicken antibodies directed towards human fibrinogen. As low as 1% activated platelets could be detected without interference from Fc-interactions.


Intravenous acetylsalicylic acid--dose-related effects on platelet function and fibrinolysis in healthy males.

Low-dose acetylsalicylic acid (ASA) has been shown to be beneficial in patients with acute myocardial infarction and unstable angina pectoris. Oral administration of ASA is difficult in the acute phase of these syndromes. In this study we evaluated the effect of 25 mg, 50 mg or 100 mg of ASA given as an intravenous bolus injection on platelet function and fibrinolysis in healthy males and related this to plasma concentrations of ASA. No adverse effects were found. A complete inhibition of serum thromboxane B2 synthesis was demonstrated 5 min after injection of 100 mg ASA intravenously. ASA disappeared from the circulation within 60 min after bolus injection and at this time thromboxane B2 synthesis was inhibited dose-dependently by 71%, 90% and 100% for doses of 25 mg, 50 mg and 100 mg, respectively. Inhibition of thromboxane B2 synthesis after 100 mg of intravenous ASA was still 96.5% at 24 h and 93.4% at 48 h after the injection. The bleeding time measured at 30 min after ASA administration was significantly prolonged on the average by 70 s, 144 s and 211 s after 25 mg, 50 mg and 100 mg of ASA, respectively. Minor, but significant changes were found in tissue plasminogen activator antigen and in plasminogen activator inhibitor within the first hour after injection of low dose ASA, but similar changes were found after injection of saline. No change in tissue plasminogen activator activity was found.(ABSTRACT TRUNCATED AT 250 WORDS)


The bioluminescent detection of platelet released ATP: collagen-induced release and potential errors.

The bioluminescent detection of ATP released from activated platelets is an important diagnostic and experimental assay. Potential errors in the interpretation of the data may be introduced due to the lability of luciferin-luciferase and the amount of platelet agonist employed. Loss of luciferin-luciferase activity is temperature dependent with a 50% decrease in activity in 1-4 min at 37 degrees C. Plasma components do not appear to contribute to the inactivation of the detection system. Due to the significant loss of enzyme activity at variable times, the method of standardizing ATP concentrations is crucial for the accurate determination of ATP released from activated platelets. A nearly 5-fold error is introduced into the routinely employed assay procedure where the standard ATP concentration is determined 5 min after the addition of agonist. This report demonstrates that the standard ATP concentration must be determined with a separate platelet sample at the same time as the ATP was released from the agonist-induced experimental platelet sample. A second significant error in the assay system may be introduced by the agonist concentration employed even when the final level of aggregation is the same. When collagen is employed as the agonist the amount of ATP released appears to depend, in part, on the initial intensity of the aggregation response and not on collagen type (Type I versus IV). The corrective procedures described here for the detection of ATP are not likely to change the qualitative results of most studies but would significantly alter the quantitative results.


Role of platelet-activating factor in the development of endothelial dysfunction in hemorrhagic hypotension and retransfusion.

Platelet-activating factor (PAF), an important mediator of ischemic and shock states, has been shown to prime direct and neutrophil-mediated endothelial cell injury. In the present study we investigated therefore whether PAF is involved in the development of dysfunction of the cerebrovascular endothelium in hemorrhagic hypotension and retransfusion in cats. In vitro responses of middle cerebral arteries prepared from control animals and from animals subjected to hemorrhagic hypotension with or without specific PAF antagonist WEB 2086 treatment (1 mg/kg initial bolus followed by a 0.05 mg/kg/min infusion) were studied by measuring isometric force in organ chambers containing Krebs-Henseleit solution (37 degrees C, gassed with 95% O2-5% CO2). Bleeding was performed in a stepwise fashion by bringing the mean arterial blood pressure to 90, 70 and 50 mmHg and maintained for 20 min at each level followed by a 20-min retransfusion. Hemorrhagic hypotension and retransfusion caused a marked attenuation of the acetylcholine- and ATP-induced endothelium-dependent relaxations of the middle cerebral artery whereas the dilations induced by the nitric oxide donor and direct vasorelaxant SIN-1, remained unaltered. In the vessels, prepared from animals which received WEB 2086 treatment during hemorrhage and retransfusion there were more pronounced cholinergic (but not purinergic) relaxations than in the untreated animals subjected to hemorrhage. SIN-1 induced relaxations remained unaltered after WEB 2086 treatment. Our results suggest that platelet-activating factor is in part involved in the pathophysiological processes leading to the development of the endothelial dysfunction in the present model of hemorrhagic hypotension and retransfusion.


Determination of r DNA hirudin and A-human thrombin- hirudin complex in plasma samples: enzyme linked immunosorbent assays for hirudin and complex vs. chromogenic thrombin substrate assay.

rDNA hirudin plasma concentrations in man and rhesus monkeys were determined over a period of 15 and 24 h. The plasma concentration of alpha-human thrombin-hirudin complex was measured after administration of the complex to rhesus monkeys. The complex was also determined after administration of hirudin to man and rhesus monkeys to study a possible formation of a complex with alpha-human thrombin in blood. The determination of hirudin was performed by a sandwich ELISA, using polyclonal and monoclonal antibodies and the chromogenic thrombin substrate assay. The alpha-human thrombin-hirudin complex concentration in the plasma of rhesus monkeys was measured over a period of 48 hours. The results of a sandwich ELISA were compared with those of the chromogenic thrombin substrate assay. A good agreement between the total hirudin concentrations analyzed by the hirudin ELISA and the alpha-human thrombin-hirudin complex ELISA and those of the chromogenic thrombin substrate assay, measuring total hirudin, too, was observed.


Preparation of plasma for the detection of lupus anticoagulants and antiphospholipid antibodies.

The effect of different methods of plasma preparation on the results of 1) a clotting assay for lupus anticoagulant (LA) detection (the dilute activated partial thromboplastin time, dAPTT), and of 2) an ELISA test for anticephalin antibody (aCEPHA) detection, was evaluated. It is well known that platelet disintegration resulting from freeze-thawing of plasma samples may release procoagulant phospholipid--"LA-bypassing" activity. Even with fresh plasma, the dAPTT of LA positive samples was sensitive to the presence of residual blood platelets. This effect was accentuated by freezing and thawing: with test plasma that had been prepared by a centrifugation force of 3,000 g or less for 15 min at 4 degrees C, freeze-thawing caused a significant shortening of the dAPTT. This phenomenon could not be demonstrated with filtered test plasma, which was platelet free. Surprisingly, ultracentrifugation also led to a substantial shortening of the dAPTT compared to filtered plasma, and should not be recommended as a method of plasma preparation for LA detection. The ELISA test was less sensitive to residual platelets than the dAPTT. Thus, plasma prepared by a centrifugation force of at least 1,500 g may be stored at -20 degrees C before performance of the ELISA test. For the dAPTT, filtering of test plasma and control plasma after centrifugation is recommended for maximum sensitivity, regardless of whether they are to be examined in the fresh state or after freezing and thawing.


Effects of long-term treatment with warfarin on fibrinogen, FPA, TAT, and D-dimer in patients with coronary artery disease.

Sixty-four patients undergoing aorto-coronary bypass surgery were randomized to receive antithrombotic treatment with acetylsalicylic acid (ASA), 300 mg/d (n = 30) or warfarin, INR = 2.5 - 4.2 (n = 34). The levels of fibrinogen, thrombin-antithrombin III complexes (TAT), fibrinopeptide A (FPA) and D-dimer were assessed before surgery and 9 months postoperatively. In the warfarin treated group the fibrinogen levels were increased after 9 months, while the levels of TAT, FPA and D-dimer were decreased. In the ASA group TAT levels were increased at 9 months, whereas no significant changes in fibrinogen, FPA or D-dimer from baseline were noted. Thus, a reduced activation of the coagulation system has been demonstrated during long-term treatment with warfarin in patients with coronary artery disease.


HA-29: an inhibitor of thromboxane A2 formation with antagonism of thromboxane A2/prostaglandin endoperoxide receptor in rabbit platelets.

HA-29, 2-[(3-methoxyphenyl)methyl]-pyrano[2,3-c]pyrazol-6(1H)-one, was investigated for its inhibitory mechanism of action in washed rabbit platelets. This compound inhibited the aggregation and ATP release of rabbit platelets induced by arachidonic acid and collagen in a concentration-dependent manner, without affecting those induced by ADP, PAF and thrombin. Prolongation of the incubation time of HA-29 with platelets did not cause further inhibition and the aggregability of the agent-treated platelets could be restored after washing of platelets. The concentration-response curve of U-46619-induced platelet aggregation was shifted to the right by HA-29 in a concentration-dependent manner, but the maximal aggregation was suppressed by HA-29. The pA2 and pA10 values of HA-29 on U-46619-induced platelet aggregation were 4.26 and 3.58, respectively, with a slope value of -1.4. The U-46619-induced aggregation was markedly disaggregated by HA-29 even it was added 5 min after U-46619. HA-29 inhibited the secondary aggregation and ATP release, but not the primary aggregation of human platelet-rich plasma induced by ADP and epinephrine. Thromboxane B2 formation caused by arachidonic acid, collagen and thrombin was markedly suppressed by HA-29. HA-29 also inhibited the formation of prostaglandin D2 caused by arachidonic acid. HA-29 inhibited almost completely the formation of inositol monophosphate caused by U-46619, but not that by collagen or thrombin. HA-29 did not affect U-46619-induced contraction of rat aorta. It is concluded that the antiplatelet effect of HA-29 is due to the inhibition of thromboxane A2 formation and blockade of thromboxane A2/prostaglandin endoperoxide receptor.


Low concentrations of sodium azide specifically inhibit a thromboxane A2 pathway in human platelets.

Sodium azide completely inhibits the serotonin release induced by ADP, arachidonic acid and the thromboxane A2 mimetic U46619, but does not have any effect on the activation by PMA. Collagen and thrombin are inhibited when used at low concentrations, but not at high concentration. This pattern of activation suggests that the inhibition by azide is not a metabolic inhibition. The antagonism of U46619-induced secretion was further studied and was shown to be non-competitive. It is selective for certain components of the U46619 stimulus-response coupling: aggregation, serotonin secretion and the activation of protein kinase C are completely or almost completely inhibited by 300 microM sodium azide. Shape change, calcium elevation, cytoplasmic alkalinization and phosphorylation of myosin light chain are only partially modified. This suggests that azide may specifically inhibit one of the different forms of thromboxane A2 receptors present in platelets.


Influence of heparin treatment on biochemical markers of an activation of the coagulation system.

Monitoring of anticoagulant treatment is not yet satisfactory. Otherwise optimal treatment control in special situations as low dose heparin prophylaxis in hip surgery or high dose anticoagulant treatment in patients after coronary stent implantation may be desirable. Recently available thrombin markers were analyzed in 51 patients under low dose (group 1) and 30 patients under high dose therapy with unfractionated heparin (group 2a and b) as well as in controls (n = 26). Before therapy these parameters were significantly elevated in both patient groups. Elevated thrombin-antithrombin III-complexes (TAT) despite adequate prolongation of aPTT under high dose heparin in 38.2% of patients indicate that therapeutic concentrations of heparin in these cases are insufficient for depressing this parameter completely. During low dose therapy only prothrombin fragment (F1 + 2) significantly decreased. This may be explained by catalytic induction of TAT-complex formation by heparin. Decrease of D-Dimer under heparin therapy in both groups does not parallel with TAT and F1 + 2 but was more prolonged. This can be explained by dependence of the D-Dimer level on spontaneous fibrinolytic activity and by a longer plasma half-life as well as a chronic and continuous fibrinolytic process in an older thrombus. In conclusion, thrombin markers seem to be helpful in estimating anticoagulant treatment efficacy. As a consequence, anticoagulant treatment has to be intensified in high-risk patients for complete depression of these markers. Whether the benefit of higher heparin doses is worth the risk of drug-induced hemorrhage, however, remains to be clarified in clinical studies.


Effect of physical stress on 5-hydroxytryptamine uptake kinetics (Km and Vmax) in human platelets.

Platelet 5-HT uptake is possibly one mechanism by which plasma level of 5-HT is physiologically controlled. This mechanism may be of importance in the vascular 5-HT mediated tone and protect against thrombolysis and cardiovascular events. Physical stress is known to affect various platelet functions. The aim of this study was to investigate whether or not physical stress has any influence on platelet 5-HT uptake kinetics. In healthy adult persons (n = 13) the maximal rate (Vmax) and Michaelis-Menten constant (Km) of platelet 5-HT uptake (in vitro) were determined before (a), immediately after (b) and 1 hour after 50 min of squash playing (c). Immediately after squash Vmax and Km were elevates significantly as compared to the values before squash [Vmax(a): 77.0 +/- 31.0 (SD) pmol 5-HT/10(8) pl./min, Vmax(b): 109.9 +/- 48.4 (SD) pmol 5-HT/10(8) pl./min, p less than 0.01; Km(a): 5.16 +/- 1.73 (SD) x 10(-7) mol/1, Km(b): 7.59 +/- 2.37 (SD) x 10(-7) mol/1, p less than 0.05]. The percent elevations of Vmax (47%) and Km (42%) were of the same range. One hour after squash the values of Vmax(c) and Km(c) were found to be normalized. It is concluded that physical stress, like squash playing, does not affect net platelet 5-HT uptake in healthy persons at physiological plasma 5-HT concentrations. The significant increases of Vmax and Km of platelet 5-HT uptake are suggested to be adaptation reactions to keep the platelet net 5-HT uptake constant.


Activation of human prothrombin by the venom of Lonomia achelous (Cramer) caterpillars.

In this paper, we demonstrated that the procoagulant action of Lonomia achelous (Cramer) is due in part to a component that activates prothrombin. The activation by crude venom and Fractions obtained by gel filtration on Sephadex G-75 is not dependent of phospholipid, Ca++ or Factor V. The activation of prothrombin by Fraction I is greatly stimulated by Factor V in the presence of phospholipid and Ca++; in presence of SBTI, we found that the Fraction I and Factor Xa act in a similar manner. These results suggest that the Fraction I is a Factor Xa - like prothrombin activator.


Rapid quantitative evaluation of plasma D-dimer levels in thrombotic states using an automated latex photometric immunoassay.

To evaluate a recently developed latex photometric immunoassay (LPIA) that which can measure 40 samples quantitatively within 30 minutes, we measured D-dimer levels in blood samples obtained from patients with disseminated intravascular coagulation (DIC). Linearity of D-dimer determination was shown over the range from 0.5 to 36 micrograms/ml, and recovery studies demonstrated 94 to 108% recovery. The intra-assay and inter-assay coefficients of variation ranged from 0.6 to 11.3% at plasma D-dimer levels of 0.54 to 30.1 micrograms/ml. No interference by lipids, bilirubin, haemoglobin, rheumatoid factor, or gamma-globulin was noted. The normal D-dimer range was less than 0.5 microgram/ml in healthy ambulatory subjects, while the level in elderly subjects with atherosclerosis (14%) or in immobilized subjects (38%) was well above this limit. There was a strong correlation between plasma and serum D-dimer levels (r = 0.993). D-dimer levels measured by this LPIA showed a good correlation with those determined using two kinds of ELISA. The LPIA D-dimer levels were elevated in some subjects with diseases predisposing to DIC, but remained below 10.0 micrograms/ml. On the other hand, the LPIA D-dimer levels in DIC subjects were almost always above 10.0 microgramS/ml. Our study showed that a hypercoagulable state should be suspected when the LPIA D-dimer level is greater than 0.5 microgram/ml and that DIC should be diagnosed when the level is greater than 10.0 micrograms/ml in the presence of an appropriate underlying disease. This LPIA system can rapidly evaluate the presence of a hypercoagulable state as accurately as any ELISA, and thus seems potentially valuable for both emergency and routine laboratory use.


A computerised system of screening for deep venous thrombosis.

We have developed a computer controlled system of strain gauge plethysmography for use as a screening tool for proximal segment venous thrombi which is simple to use, well tolerated by patients and extremely accurate. The computerised test was evaluated in 171 limbs of 163 symptomatic patients by comparison with subsequent ascending venography. Each of twenty occlusive proximal segment thrombi were identified, one non occlusive thrombus screened normal giving an overall sensitivity of 95.2%. The specificity of the test was 80% with a negative predictive value of 99.0%. The computerised system allows accurate screening for proximal segment venous thrombosis, and may permit more selective use of venography in the symptomatic post-operative limb.


Hemorheological alterations in mild essential hypertension.

Blood rheological properties were studied in 21 patients suffering from essential hypertension (EHT), degree I-II according to WHO criteria. These patients were diagnosed "de novo". The whole blood filterability (WBF), blood viscosity (BV) at 230 s-1 and 23 s-1, red cell deformability (FI), erythrocyte aggregation in autologous (MEA) and normal plasma (MEAc), fibrinogen (Fbg) and hematocrit (Ht) have been evaluated. In the hypertensive patients we have found decreased WBF, greater BV and FI in comparison with the control group (p less than 0.001). Likewise, MEA and Fbg were increased, though the differences were less significant (p less than 0.01). The evaluation of Ht did not show any differences between the two groups. The results suggest that in the newly diagnosed EHT, clear hemorheological alterations occur, both in plasma and in the erythrocytes, which could play a role in the pathogenesis of the aforementioned disease.


Soluble, cross-linked fibrin(ogen) hybrid oligomers do not stimulate t-PA conversion of plasminogen.

Cross-linked hybrid oligomers of fibrinogen and fibrin are found in plasma from fibrinaemic patients and normal individuals as well as in preparations of purified human fibrinogen. The present study was undertaken to see if such hybrid oligomers have the same stimulatory effect on tissue plasminogen activator (t-PA) conversion of plasminogen as do polymeric and monomeric fibrin. Hybrid oligomeric fibrin(ogen) material was provided by subjecting purified human fibrinogen to gel filtration in urea-containing buffer at pH 5.6. Well separated fractions of hybrid oligomeric material and monomeric fibrinogen were thus obtained. Some of this material was converted to soluble polymeric or monomeric fibrin using insolubilized thrombin. Hybrid polymeric fibrin, polymeric fibrin or monomeric fibrin were then added to citrated, normal plasma to 2.5 or 5 per cent of the plasma fibrinogen concentration. The added material was kept in solution by plasma fibrinogen. The "COA-SET Fibrin Monomer Test" (Kabi,Stocholm,Sweden), based on the ability of fibrin monomers to enhance t-PA mediated plasminogen-plasmin conversion, was used to compare the potential stimulatory effect of the preparations above. The results led to the following conclusions: 1) Cross-linked, soluble fibrin(ogen) hybrid polymers in a concentration of 5 per cent of plasma fibrinogen concentration (w/w) do not stimulate t-PA. 2) Thrombin conversion of the fibrin-fibrinogen hybrid material resulted in an increase in the rate of t-PA mediated plasminogen conversion, corresponding to the one observed with equivalent (w/w) amounts of fibrin monomers. Compared on a mole to mole basis, fibrin oligomers are more powerful than fibrin monomers as stimulators of t-PA activity.


Platelet microvesicles adhere to subendothelium and promote adhesion of platelets.

A role in hemostasis has been suggested for platelet membrane microvesicles (mv). The objectives of the studies reported here include functional analysis of platelet mv in models developed for study of platelet adhesion, as well as investigation of possible interactions between mv and intact platelets in these same adhesion models. Microvesicles were prepared from washed platelet concentrates by repeated freezing and thawing. Adhesion to subendothelium was measured quantitatively by radiolabelling mv with 111-In, and morphologically by scanning electron microscopy. Platelet mv adhered to subendothelium quantitatively over time. Using a modified Baumgartner chamber, we found adhesion of mv to subendothelium significantly increased with increasing shear rates. With this same model we found that prior exposure of subendothelium to mv greatly increased subsequent adhesion of platelets to the same everted vessel, compared to platelet adhesion in the absence of mv. All of these experiments were conducted with mv suspended in ACD/saline, indicating that plasma components are not essential for adhesion of mv. Our studies show that platelet mv adhere to subendothelium in much the same way as do platelets, and support the concept of a hemostatic role for mv in that they appear to increase platelet adhesion.


Plasminogen activators and plasminogen activator inhibitor 1 before and after venous occlusion of the upper limb in thromboangiitis obliterans (Buerger's disease).

Plasma levels of plasminogen activators (t-PA, u-PA) and their inhibitor (PAI-1) were studied in patients suffering from Buerger's disease and healthy volunteers before and after 15 minutes of venous occlusion test. The baseline levels of t-PA in group of patients did not differ from those of controls. On the contrary patients with Burger's disease showed a marked increase in u-PA antigen concentrations with concomitant decrease in PAI-1 antigen levels. During venous stasis t-PA antigen concentrations increased in all subjects, however it was much pronounced in controls. Venous occlusion resulted in significant decrease in free PAI-1 levels in the group of patients only. In conclusion, Buerger's disease is associated with the endothelial derangement with increased u-PA release and decreased PAI-1 release, which does not influence the function of fibrinolytic system. The fact that the reduced response of the endothelium to release t-PA after venous stasis goes in parallel with marked decrease in PAI-1 antigen levels seems to suggest that patients suffering from Buerger's disease are not at high risk of intravascular fibrin deposition.


Pharmacological profile of G619, a new platelet aggregation inhibitor.

G619, a 4-OH-isophthalic acid derivative, was studied for its capacity to inhibit platelet aggregation. G619 dose-dependently inhibited U46619, collagen, ADP, PAF, thrombin and epinephrine-induced platelet aggregation in vitro. The IC50 values for inhibition of U46619-induced human and rabbit platelet aggregation were 39 and 43 microM, respectively. G619, at 100 microM, inhibited high concentration collagen (10 micrograms/ml)-induced aggregation of rabbit platelets pretreated with indomethacin and increased the level of cAMP in washed rabbit platelets by 30% (p less than 0.01 vs basal). However, G619, did not inhibit fibrinogen binding to GPIIb/IIIa receptor, phosphodiesterase, U46619-induced contractile responses on canine saphenous vein or rabbit aorta, calcium-induced vasoconstriction and thrombin or PAF-induced elevation of [Ca++]i in platelets in vitro. In vivo, the U46619-induced maximal thrombocytopenia in rats was reduced from 40% (vehicle) to 22% and 18% by 10 and 30 mg/kg of G619 i.v., respectively. G619 (30 mg/kg) had no effect on the U46619-induced vasopressor response or sudden death in rats, and had no effect on TxB2 formation. Our results indicate that G619 is a broad-spectrum platelet aggregation inhibitor and may have its effect on a common mechanism for platelet aggregation besides an effect on the thromboxane A2 receptor.


Laboratory heterogeneity of the lupus anticoagulant: a multicentre study using different clotting assays on a panel of 78 samples. Hemostasis Committee of the "Société Française de Biologie Clinique".

The laboratory heterogeneity of the lupus anticoagulant (LA) was investigated in a multicentre study using a panel of 78 plasma samples diagnosed as containing a LA. Consecutive samples were collected by 12 participants using various screening tests, and sent to 7 laboratories which performed one or more clotting assays among the following: activated partial thromboplastin time (APTT), dilute Russell viper venom time, kaolin clotting time (KCT), dilute tissue thromboplastin time (dTTI) and a platelet neutralization test. For APTT and dTTI, 10 versions of these tests including standard and mixing procedures were carried out. They varied by reagents, phospholipid concentration or methodology. Cut-off times were determined for each test by comparing the results of the panel to those of a control population. When the data of all clotting assays were pooled, 70 of the 78 selected plasmas were considered to contain LA, 15 of them having a low-titer inhibitor. Sensitivity, defined as the proportion of positive results among LA-containing plasmas, varied from 62 to 100% and was positively related to responsiveness (defined as the mean ratio of clotting time to cut-off time). Laboratory heterogeneity of LA-containing plasma was illustrated by a star symbol plot analysis. Different populations of samples, with LA preferentially recognized by one assay (or group of assays) irrespective of the overall sensitivity of this assay, were identified. Multiple component analysis demonstrated the heterogeneity of low-titer inhibitors, which complicates their recognition in routine laboratory investigation.


Blood compatibility of venous prosthesis made of textile or non-textile material.

To study blood compatibility of venous prosthesis made of textile or non-textile material, the inferior vena cava of 37 rabbits was partly replaced by 3 mm internal diameter synthetic tube graft made of textile material (T: woven tetron) or non-textile material (P: polytetrafluoroethylene). At designated time intervals after the replacement (5 hours to 4 weeks), graft patency was examined and the dry weight of intraluminal deposits was measured. The harvested grafts were then subjected to light and scanning electron microscopy. All the T-grafts were occluded as early as 5 hours after grafting but when ticlopidine was administered prior to the grafting, all the grafts were patent. All the P-grafts were patent up to 4 weeks after grafting, though the amount of intraluminal deposits was increased in a time related manner, narrowing the lumen of the grafts. The luminal surface of the P-grafts harvested at 5 hours after grafting was covered by piles of fibrin networks entrapping erythrocytes without an association of platelet aggregates, which resembles the finding in the T-grafts harvested from the ticlopidine treated rabbits. In the P-grafts, both the proximal and distal luminal surfaces near the anastomosis were fully covered with endothelial cells by 2 weeks and the entire luminal surface was covered with these cells by 4 weeks. From these results, the following conclusions were obtained; (1) P-graft was superior to T-graft for venous prosthesis, which is mainly due to the inertness of P against platelet activation. (2) Though the luminal surface of the P-grafts was completely covered with endothelial cells by 4 weeks after grafting, the lumen was markedly narrowed by intimal hyperplasia.


Increased levels of tissue plasminogen activator (t-PA) and tissue plasminogen activator inhibitor (PAI) correlate with tumor necrosis factor alpha (TNF alpha)-release in patients suffering from microangiopathy following allogeneic bone marrow transplantation (BMT).

Severe microangiopathy resembling thrombotic thrombocytopenic purpura (TTP) has been reported as a complication of acute graft-versus-host disease (aGvHD) in patients receiving cyclosporin (CsA) prophylaxis following allogeneic BMT. In order to analyze the pathophysiological events involved in microangiopathy, a prospective study comparing release of von Willebrand Factor (vWF), t-PA and PAI, as well as TNF alpha and further coagulation parameters was performed in 32 patients. Endothelial damage as the central lesion was confirmed by the close association of vWF and t-PA:Antigen with severity of microangiopathy. t-PA activity, however, was neutralized by a simultaneous rise in PAI. Activation of coagulation in the course of microangiopathy was further confirmed by increased levels of DDimer (DDi), fibrinopeptide A (FPA), beta-thromboglobulin (beta TG) and platelet factor 4 (PF4). As clinical grades of microangiopathy, as well as the release of t-PA:Ag and PAI were correlated with systemic release of TNF alpha our data further support our hypothesis of cytokine induced endothelial damage in clinical complications following allogeneic BMT.


Subcellular localization of radioactively labelled defibrotide in cultured endothelial cells.

Defibrotide is a new antithrombotic and fibrinolytic drug which is obtained by controlled depolymerization of mammalian DNA. In various models of arterial and venous thrombosis, it has been shown that it induces tissue plasminogen activator [tPA] and prostacyclin [PGI2] release from the vessel wall. We have previously shown the presence of specific binding sites with a Kd of 4.2 micrograms/ml for radioactively labelled defibrotide. The present study was undertaken to identify the location of the binding site. Confluent cultures of endothelial cells from human umbilical vein were incubated with media containing 3H-acetyl-defibrotide for various intervals of time. Cells were then washed and harvested nonenzymatically. Subcellular location of 3H-defibrotide was investigated by fractionating cells on discontinuous sucrose gradient and measuring the distribution of radioactivity. 5'-nucleotidase enzyme activity was also measured to ensure the location of membrane fraction. Our results suggest that the major location of 3H-defibrotide in endothelial cells is the plasma membrane. On the other hand, nuclei also contain a considerable amount of the drug which suggests a mechanism where binding to a membrane protein is followed by internalization.


Purification of factor XIa inhibitor from human platelets.

An inhibitor of activated factor XI (FXIa) in human platelets was recently identified as an amyloid beta-protein precursor (APP). We purified an FXIa inhibitor (XIaI) from the supernatant of activated human platelets, and assessed its inhibitor activity toward FXIa amidolytic activity. Approximately 90 micrograms of XIaI that cross-reacted with anti-APP antibody was obtained from two hundred units of platelet suspension by employing a six-step column chromatography procedure. The molecular weight of the purified XIaI was 94,000. The Ki value of XIaI to factor XIa was 526 +/- 120 pM, and the inhibition was enhanced by the addition of ZnCl2. The amino-terminal sequence of XIaI was L-E-V-P-T-D-G-N-A-, which is identical to that for the leucine (N18) to alanine (N26) sequence of APP751 and the amino-terminal sequence of protease nexin-2.


Formation of an association between factor XII and kallikrein in human plasma--significance of storage of plasma and the functional state of plasma kallikrein.

In a previous study evidence was provided that zymogen FXII might associate with part of the kallikrein generated by acetone treatment of human plasma in the presence of benzamidine (Thromb. Res. 61, 123-133, 1991). Some results also suggested an increase in such a complex formation upon storage of plasma, and two questions were raised in the present study: Does kallikrein activated by acetone-treatment of plasma exist in modifications with different abilities to associate with FXII? And will -70 degrees storage of plasma increase the liability to complex formation? S-2302 amidase assays carried out in mixtures of normal plasma and plasma genetically deficient in prekallikrein (PK) suggested an inhomogeneity of the kallikrein generated. A minor and unstable part of it could be blocked by corn trypsin inhibitor, thus indicating the presence of an association with FXII. In fractions from gel filtration of acetone-activated plasma, kallikrein was assayed as S-2302 amidase, high molecular weight kininogen (HK) was measured in rocket immunoassay, and FXII, PK and HK were studied in PAGE immunoblot experiments. When freshly collected plasma was used, an amidase double peak (mol. wts. 400 and 300 kD) indicated an inhomogeneity of the kallikrein present, HK being observed in both peaks. FXII eluted separately over a gel. mol. wt. range of 90-55 kD. When plasma was stored at -70 degrees for 10 months before use, the more low-molecular part of the kallikrein double-peak had disappeared and was recovered, in a highly unstable state, adsorbed to the column material together with HK and FXII. Accordingly both functional assays and the results of immunoblot experiments indicated an inhomogeneity of the kallikrein present, and also a tendency of the minor part of it to associate with FXII, a tendency increased upon storage of plasma at -70 degrees.


Preferential consumption of heparin cofactor II in disseminated intravascular coagulation associated with acute promyelocytic leukemia.

We measured plasma heparin cofactor II (HC II) activity in patients with disseminated intravascular coagulation (DIC) due to various underlying diseases together with the levels of antithrombin III (AT III), pseudocholinesterase (a marker of hepatic synthesis), and various haemostatic molecular markers. Both HC II and AT III were decreased in DIC secondary to all the underlying diseases studied, except acute promyelocytic leukemia (APL), when compared with healthy subjects. The lowest HC II and AT III levels was observed in coagulopathy secondary to liver disease, the HC II level in sepsis was the second lowest. In DIC due to APL, the decrease in HC II was not accompanied by a decrease in AT III. Thus, we divided all 124 samples tested into APL and non-APL groups. The HC II level correlated positively with fibrinogen and plasminogen in both the APL and non-APL groups. In the APL group, the HC II level had a significant negative correlation with the thrombin-AT III complex (TAT), fibrinogen/fibrin degradation products, and D-dimer levels as well as the prothrombin time, while AT III showed no correlations with any of the haemostatic parameters. These results suggest that HC II may be consumed preferentially by thrombin in APL patients with DIC, and thus may spare the consumption of AT III. Accordingly, HC II seems to be a superior indicator of DIC than AT III in APL patients. Moreover, replacement therapy with HC II instead of AT III may be useful to treat DIC associated with APL. In the non-APL group, the HC II levels were positively correlated with the levels of AT III and pseudocholinesterase activity. This indicates that plasma HC II levels are closely related not only to consumption coagulopathy but also to hepatic synthetic activity, as is the case for plasma AT III.


Purification of tissue factor pathway inhibitor (TFPI) from rabbit plasma and characterization of its differences from TFPI isolated from human plasma.

Tissue factor pathway inhibitor (TFPI) is a Kunitz-type protease inhibitor that is thought to function as a natural anticoagulant to regulate tissue factor-induced coagulation (Proc. Natl. Acad. Sci. U.S.A. 88, 708, 1991). TFPI's mechanism of action has been well characterized as a two step reaction in which TFPI combines with factor Xa and subsequently TFPI/factor Xa combines with and effectively neutralizes factor VIIa/tissue factor. In human plasma, TFPI occurs in two major molecular weight forms of 34 and approximately 40 kDa. The 40 kDa form is a heterodimer of TFPI in covalent disulfide linkage to human apolipoprotein AII. TFPI circulates in human plasma primarily in association with the plasma lipoproteins. We have now isolated and partially characterized TFPI from rabbit plasma and find that, although functionally and immunologically related to TFPI isolated from human plasma, it differs from human TFPI in some of its physical properties. Rabbit TFPI is larger (approximately 45 kDa) and more extensively glycosylated than human TFPI, does not form mixed disulfides with other proteins in plasma, and unlike its human counterpart, does not circulate in plasma associated with lipoproteins.


Changes in plasma tetranectin following hip surgery with or without thrombotic complications.

The fibrinolytic system seems to play a role in the development of postoperative thromboembolic complications (DVT). The newly described tetrameric protein tetranectin (TN), which has been found to enhance the activation of plasminogen to plasmin, therefore was studied in 55 patients who had total hip replacement and solely elastic stockings as physical thromboprophylaxis. No significant difference in plasma TN was found between the 5 patients with DVT and those without DVT, neither preoperatively or postoperatively at day 0, 1, 3, 7 or 10. A significant decrease in plasma TN was found from preoperative to postoperative values, indicating that TN may be a possible marker for other postoperative events. Because of the observed postoperative decrease it is important to consider the sampling time in the future research with TN.


A method for quantitative determination of flow induced human platelet adhesion and aggregation.

Adhesivity and aggregability of blood platelets may reflect normal and diseased states. A quantitative assessment of such reactivity should thus provide further insight into disease mechanism. The well defined conditions of stagnation point flow using platelet-rich-plasma (PRP) as fluid permit quantitative treatment of the formation of platelet microthrombi on the stagnation plate. By measuring the growth kinetics (photometry) and corresponding morphology (light- and electron microscopy) of the microthrombus, platelet adhesion as well as aggregation could be analyzed separately by means of a quantitative procedure. Parameters are evaluated for PRP samples obtained from patients exhibiting deep venous thrombosis, arterial angiopathy or myocardial infarction, respectively. The results obtained demonstrate the usefulness of the proposed method for quantifying platelet reactivity as reflected by type and degree of flow induced platelet deposition. This, in turn, provides a basis for correlating the in vitro findings with the disease state.


Affinity chromatography of platelets on immobilized thrombin: retention of catalytic activity by platelet-bound thrombin.

Radioactivity from I125-labeled human platelets was measured to estimate the extent of binding of platelet surface proteins to immobilized thrombin. 1-3% of the radioactivity was bound with 10-20% of this amount apparently irreversibly bound to the thrombin matrix. Site-specific chemical modification of thrombin with pyridoxal-5'-phosphate, N-bromosuccinimide or tetranitromethane resulted in a variable reduction of the amount of radiolabel bound. When thrombin modified with H-D-PheProArg-chloromethyl ketone (PPACK) was coupled to the matrix, there was no difference in the binding of platelet membrane proteins when compared to a control thrombin preparation while thrombin modified with tosyl-Lys-chloromethyl ketone (TLCK) coupled to the matrix did not bind radiolabel any more effectively than albumin which served as the control. However, when thrombin was modified with PPACK after coupling to the agarose matrix, ability to bind radiolabel was lost. Thrombin bound to platelets remained catalytically active when assayed with a peptide nitroanilide substrate. These results suggest tight binding between thrombin and platelets that is not only not dependent on active site integrity but leaves the bound thrombin catalytically competent.


Arterial thrombosis model with photochemical reaction in guinea-pig and its property.

We have already developed an arterial thrombosis model in the rat femoral artery which utilized photochemical reaction between systemically injected rose bengal and transillumination of a green light with 540 nm wave length from the outside of the vessel. In the present study, we applied this model to guinea-pigs in order to produce a more suitable thrombus model for evaluation of antithrombotic drugs which act on the prostaglandin cascade. In the guinea-pigs, the irradiated femoral artery was completely occluded in 7 min after the injection of rose bengal (10 mg/kg) in a similar manner to the rats. The processes of primary endothelial injury and the subsequent formation of thrombus during this manipulation were observed by the electron microscopy. Pretreatment with aspirin and Y-20811, a thromboxane synthetase inhibitor, significantly prolonged the time required for occlusion in the guinea-pigs, while these drugs were ineffective in the rats. The antithrombotic effect of vapiprost, a thromboxane A2 receptor antagonist, was more pronounced in the guinea-pigs than the rats. In conclusion, this model in guinea-pigs is more suitable for evaluating antithrombotic drugs, particularly, the action of which is exerted involving the prostaglandin cascade.


Non-specific influence of chemical modification upon the properties of antithrombin III:modification of carboxyl groups.

The ability of antithrombin III to inhibit thrombin was observed to be rapidly inactivated upon specific modification of carboxyl groups. The loss of activity, upon treatment with nitrotyrosyl ester in the presence of 1-cyclohexyl-3-(2-morpholinoethyl) carbodiimide metho-p-toluenesulfonate, was concomitant to the incorporation of 2 moles of nitrotyrosine per mole of inhibitor indicating the modification of only two carboxyl groups. Moreover, the modification occurred with loss, also, of the ability of the native protein to bind tightly to heparin. The modified antithrombin III retained a reduced affinity for heparin (eluting at 0.3M NaCl from heparin Agarose) and was observed to be a competitive inhibitor of the heparin-dependent rate of inhibition of thrombin by native antithrombin III. However, FAB-MS (fast atom bombardment mass spectroscopy) analysis of digests of modified material gave no indication that modification was localized to specific Asp or Glu residues. It is concluded that the loss of activity is due to deleterious change in conformation during modification. These findings, together with our previous report upon tryptophan modification of antithrombin III [1] suggest that the nature of the molecule is such that considerable care must be taken in interpretation of results when investigating the structure/function relationships of this protein by chemical modification.


Studies of the platelet fibrinogen receptor in Glanzmann patients and uremic patients.

The purpose of the present study was to investigate the binding of fibrinogen to the platelet fibrinogen receptor. Glycoprotein (GP) IIIa was measured utilizing a fluorescein isothiocyanate (FITC)-labelled monoclonal antibody and an Ortho Spectrum III flow cytometer. The number of binding sites per platelet was calculated to be 30,200. Using this technique it appears possible not only to diagnose Glanzmann's thrombasthenia but also to identify carriers. In uremic patients a slightly lower number of GPIIIa molecules per cell than in control subjects was found. Treatment with erythropoietin had no significant effect on the expression of GPIIIa. Thrombin, and to a less extent ADP, increased the binding of FITC-conjugated fibrinogen to normal platelets but had no significant effect on the expression of GPIIIa.


[Lumbar disk prolapse treated with chymopapain].

We report results from 108 consecutive patients followed up for one year after chymopapain injection. The patients were selected on strict clinical and radiological criteria. In nine patients (8%) the result was poor, and they were surgically treated within one year after the injection. 99 (92%) patients improved and after one year 87 of these (81% of the total material) had returned full time to their previous occupation. The only serious complication was one case of septicemia and possible discitis. The patient made a full recovery after antibiotic treatment. On the basis of these results, we shall continue to use chymopapain injection to treat selected patients with sciatica caused by herniated lumbar discs.


[New therapeutic possibilities for acquired clonal blood diseases and myelodysplasia].

Examples of patients are used as a basis for discussing the treatment of severe aplastic anaemia with clonal chromosomal aberrations in haematopoietic cells, the aplastic form of paroxysmal nocturnal haemoglobinuria and myelodysplasia, with allogeneic bone marrow transplantation. Transplantation with marrow from an HLA-identical sibling donor has curative potential in selected patients with these disorders. The procedure should preferably be carried out before the patients have received massive treatment for the complications of marrow failure. The use of matched unrelated bone marrow donors is still at the investigation stage.


[Rehabilitation of patients with brain stem damage].

We describe seven patients with serious brain stem damage who were admitted to Sunnaas Rehabilitation Hospital over a period of two years (1989-91). Our patients had quadriplegia and anarthria with some or completely preserved cognitive function. They experienced varying degrees of restitution, but all remained severely impaired. Important areas for rehabilitation include communication, alimentation, mobility, emotional reactions, medical complications and daily living arrangements. Severely impaired patients can enhance their quality of life by use of technical devices. Minimal motor function is necessary to control a switch, but preserved cognitive function is essential.


[Helicobacter pylori and gastrointestinal tract diseases].

We review the bacteriological, epidemiological and pathogenetic aspects of Helicobacter pylori and related diseases of the gastrointestinal tract. It is concluded that H. pylori seems to be at least one of several etiological factors for diseases such as chronic gastritis and duodenal ulcer. It may also be an important cofactor in the development of gastric carcinoma.


[Diagnosis of Helicobacter pylori infection. Rapid urease test, microscopy of smears and culture from ventricular biopsy compared with the 14C-urea breath test].

By employing the 14C-urea breath test as the reference method we determined the specificity and sensitivity of three bioptic methods for diagnosis of Helicobacter pylori infection in 103 subjects. All biopsy specimens were obtained from the gastric antrum. For culture the specificity was 100%. Its applicability was reduced, however, by a low sensitivity (73.8%) and a delay of several days before the final result was available. Microscopy of Loeffler-stained biopsy smears yielded a specificity of 100% and a sensitivity of 92.9%, but the method was regarded time-consuming. The rapid urease test yielded a specificity of 98.4% and a sensitivity of 85.7%. Being quick, simple and inexpensive the rapid urease test is well suited for routine use in gastroscopy.


[Rhabdomyolysis in self-induced poisoning. A prospective study].

In a prospective study of 103 patients hospitalized for self-poisoning the incidence of rhabdomyolysis (creatine kinase > 1000 U/l) was nearly 7%. A further 9.7% had elevated creatine kinase activity, but lower than 1000 U/l. Two patients showed clinical symptoms of rhabdomyolysis at time of admission; one after heroin and the other after salicylate intoxication. Both developed renal failure, and one of them underwent peritoneal dialysis. The high incidence of rhabdomyolysis found in the study suggests that creatine kinase activity should be considered in all cases of intoxication admitted to hospital. Rhabdomyolysis may often present no symptoms even in conscious patients, and serious complications can be limited by preventive measures if rhabdomyolysis is recognized early.


[Rapidly progressing glomerulonephritis].

20 patients with rapidly progressive glomerulonephritis were treated at the nephrological section, Medical Department A, Haukeland Hospital from 1973 to 1988. Nine patients had an idiopathic type of nephritis, while seven patients had this type of glomerulonephritis secondary to systemic lupus erythematosus, endocapillary glomerulonephritis, Henoch-Schönleins purpura or Wegener's granulomatosis. Four patients had antibodies to glomerular basement membrane. All renal biopsies showed extracapillary proliferation and tubular cell damage. All patients were given immunosuppressive treatment with corticosteroids and cytotoxic drugs. Nine patients who were admitted to the hospital from 1973 to 1978 were not treated with plasmapheresis, 11 patients from 1978-1988 were all treated with plasmapheresis. After one year of observation, six of the nine patients in the first group had died, while this applied to only two in the group treated with plasmapheresis. Early diagnosis and plasma exchange, in addition to immunosuppression, seems to be the best treatment for these patients.


[Ultrasonic examination of the breast].

Ultrasonography can be a valuable adjunct to mammography in the evaluation of breast pathology. Breast sonography can differentiate a cyst from a tumour. Fibroadenomas and carcinomas can often present characteristic ultrasonic features but, as a rule, ultrasonography does not give a confident diagnosis of benign or malignant tumour. Ultrasound-guided needle biopsies and preoperative localization of non-palpable lesions can be performed. Breast sonography should be regarded as an adjunct to mammography. The practical role of ultrasonography in a breast-imaging centre will depend on the quality of the triple diagnostics.


[Prevention of acute renal failure in muscular injuries].

Rhabdomyolysis may be caused by sustained, continuous pressure to skeletal muscle. The syndrome is characterized by hypovolemia, hyperkalemia and release of excessive amounts of myoglobin to the circulation. If untreated, the syndrome becomes complicated by potentially fatal acute renal failure. Two case reports are presented which illustrate the importance of early and aggressive fluid substitution where forced alkaline diuresis seemed to prevent life threatening renal complications.


[A record of procedures--its use and usefulness. Evaluation of a tool for general practitioners in Telemark].

A loose-leaf book of procedures has been published earlier. The aim of this evaluation was to study the use of this book in the county of Telemark, and the possible effect of the book on the quality of the letters notifying admission to hospital. A questionnaire has been sent twice to all general practitioners in Telemark. In addition, the medical directors of two hospital departments have evaluated the quality of the letters of admission before and after the distribution of the book. The results are interesting, and show that the book is widely used in the county of Telemark.


[Quality assurance in hospitals. Evaluation of the old and new system for medication routines at the Sentralsjukehuset in Rogaland autumn 1990/spring 1991 and 1992].

The routines for ordination and documentation of medication were found to be inadequate in our hospital. A new ordination system was introduced in 1991 based on the following principles: 1) All ordinations/seponations must be signed by a doctor. 2) Each day, all medication must be considered and signed by a doctor. 3) Ordinations by telephone must be signed later by a doctor. 4) The original ordination must be used when drugs are prepared. 5) Nurses must sign for supplied doses. The old and new system was evaluated in a medical and a surgical ward. In the medical ward the change of system had reduced errors of documentation from 20% to 1.8%, and in the surgical ward from 33% to 8%. The new ordination system has resulted in better patient documentation and has improved the hospital's written records.


[Cancer in Pasvik. II. Pollution from Nikel--no relationship after all?].

Previous medical investigations have indicated a connection between heavy metal pollution from the metallurgical industry in the Russian town of Nikel on the Kola peninsula and an observed increase of incidence of cancer among the Norwegian population living near the Russian border. This report contains the latest measurements of heavy metals in the local environment and discusses exposure levels in relation to possible health effects. It is concluded that exposure to heavy metals via food, water and air is considered so low as to be unlikely to cause any increase in incidence of cancer. Thus, the previously held hypothesis of a connection between heavy metal pollution from Nikel and cancer in Pasvik is not confirmed.


[Torsades de pointes ventricular tachycardia induced by disopyramide at therapeutic serum concentration].

We describe a patient who developed torsades de pointes ventricular tachycardia after several years of treatment with disopyramide. The case demonstrates that measuring disopyramide serum concentration provides limited information about correct dosages. Life-threatening arrhythmias may arise even at recommended doses and therapeutic serum concentration. Clinical trials have shown that class Ic antiarrhythmic drugs, and perhaps all class I antiarrhythmics, may increase the risk of serious arrhythmias and sudden death in certain groups of patients. Aspects of the pharmacology of disopyramide are discussed, with particular emphasis on the variable plasma protein binding and the narrow therapeutic specter. This complexity seems to be the most important reason for the limited reliability of serum concentration measurements for predicting the best dosage for the individual patient.


[Treatment of mentally retarded in psychiatry].

The reform decentralizing the special care of the mentally retarded in Norway has caused concern within the Norwegian psychiatric community. The frequency of psychiatric disturbances and behaviour problems in this population is known to be high, and closing down special institutions may eventually direct more mentally retarded persons to psychiatric hospitals. Behaviour problems like poor communication skills, lack of social skills and self-care, and disruptive behaviours seem to cause more concern than the actual diagnosis. However, the same behaviour problems are found in psychiatric hospital populations, for instance among chronic schizophrenics. From a behaviour modification point of view these behaviours can be treated regardless of diagnosis. The article describes how a psychiatric hospital unit can apply behaviour modification resulting in a better life for an otherwise untreatable patient. It is recommended that behaviour modification techniques should be used concurrently with other methods of treatment used in psychiatry. As well as being potentially helpful to psychiatric patients, behaviour modification techniques will make psychiatry better equipped to treat mentally retarded people in need of psychiatric care.


[Psychiatric consultations at a somatic central hospital. Review of 383 referrals over 3 years].

We present an analysis of all psychiatric consultations with inpatients in the somatic wards at the Central Hospital in Alesund over a period of three years. About 1% of the patients were referred for psychiatric consultation. Most of these patients had no previous experience of psychiatry. Mean age was 45 years (range 16-90), and 56% were females. The reasons for referral were assessment of suicidal behaviour (47%), depression (16%) and psychosis (11%). The most common psychiatric diagnoses were personality disorders (16%), affective disorders (14%) and alcohol and drug abuse and dependence (14%). About 10% were admitted to psychiatric wards, and 21% were referred to psychiatric outpatient clinics. The referring physicians were satisfied with the psychiatric consultation service.


[Pregnant diabetics. A retrospective study of pregnancy and labor in women with type 1 diabetes in Sør-Rogaland 1982-90].

Foetal mortality and morbidity rates are higher among pregnant diabetics than in the general population of pregnant women. From 1982 to 1990, 59 pregnant diabetics were closely supervised by a dedicated outpatient team. Throughout the pregnancies the insulin demand increased, and metabolic control improved. 78 babies were born. The perinatal mortality rate was 3.9%. Major congenital anomalies occurred in 6.4%. The presence of maternal diabetic complications was associated with a higher rate of perinatal complications. The risk of anomalies and high birth weight increased with poor metabolic control. Diabetic women of childbearing age should therefore receive advice before any planned pregnancy.


[Smoking habits of pregnant women in municipalities of Asker and Baerum].

Smoking in pregnancy is unequivocally harmful to both foetal and maternal health. Earlier investigations in Norway among pregnant women who smoke have demonstrated a prevalence of smoking of around 40% and that some women stop smoking as soon as the pregnancy is confirmed (around 20%). This investigation reports only 16% smokers among pregnant women registered at 18th week of pregnancy in the two municipalities of Asker and Baerum. Average daily consumption was 8.6 cigarettes, and 65% of the women stated that they smoked more than five cigarettes per day. 97% expressed a positive interest in quitting smoking, and 76% had tried to quit earlier. 77% had a partner who was a daily smoker. An assessment of level of education showed that 82% had completed 12 years of schooling and 23% reached a higher educational level. We conclude that the relatively low incidence of daily smoking among pregnant women in these two municipalities should inspire the initiation of active intervention programmes.


[Kasabach-Merritt syndrome. A differential diagnosis in thrombocytopenia].

The Kasabach-Merritt syndrome consists of hemangioma in association with thrombocytopenia and localized consumption coagulopathy. It is primarily a disease of childhood, but may be seen in adult patients too. When untreated, it involves considerable risk of mortality. Two adult patients are described. The disease can be cured by surgery. We discuss different options for treatment when surgery is not feasible.


[Abdominal wall hematoma].

We describe three case reports of hematomas in the abdominal wall muscles and discuss etiology, diagnostic findings and treatment. Abdominal wall hematomas are uncommon, and the condition is often misdiagnosed. One of our patients was laparotomised owing to suspected appendicitis, and one patient presented a tuberculous abscess that may have been an infected hematoma. Ultrasonographic examination or CT gives the correct diagnose. Conservative management is the treatment of choice unless bleeding is severe or the course is complicated by infection.


[Insulin pen in the treatment of childhood diabetes].

37 diabetic children changed from insulin syringes, with individually adapted mixtures of rapid and intermediate acting insulin, to a regimen involving use of an insulin pen (Insuject, Novo Nordisk, Copenhagen) and standard insulin mixtures. During the study an attempt was made to arrive at an optimal regimen for each child by selecting from among the following available insulin preparations (proportion rapid/intermediate acting in parentheses): Velosulin (100/0), Initard (50/50), Mixtard (30/70), Combitard (15/85), and Insulatard (0/100). The 35 families who completed the one-year study maintained that the Insuject pen made the injection procedure much easier. The pen proved to motivate the children to perform the injection without help. No effort was made to increase the number of daily injections, but seven families changed from two to three daily doses on their own initiative. The HbAlc at zero, three, six, nine and 12 months were as follows (SD in parentheses): 7.5 (1.2); 7.9 (1.5); 7.6 (1.2); 7.8 (1.4); and 7.9 (2.1). We conclude that the Insuject insulin pen is a safe and reliable instrument in childhood diabetes. Good metabolic control can be obtained with commercial insulin mixtures given 2-3 times daily.


[Failed induced abortion. Pregnancy continuing after induced abortion].

Operations classified as induced abortion fail, i.e. the pregnancy continues, in approximately 0.05% of the cases. Termination procedures before 7-8 weeks of gestation and wrong assessment of the size of the uterus imply significantly increased risk of failed abortion. The article describes current methods for early termination of pregnancy, as well as preoperative procedures and postoperative advice aimed at avoiding or detecting failed induced abortions.