[The history of bronchial asthma].

[The history of bronchial asthma]. 'Panta rhei': everything flows. The significance of bronchial asthma is currently changing to no less a degree than medicine itself. In order to know where we are, we must know where we have come from. The historical course of bronchial asthma to some extent reflects the history of medicine itself: the Hellenic systems were followed by Byzantine, Galenic teaching methods, while Humanism and the Renaissance were followed by the considerable fireworks of early modern medicine. This continued with Magendie's experimental revolution in the 19th century and, finally, analytic medical research up to today.


[Asthma and sleep].

[Asthma and sleep]. In asthmatics, nocturnal cough and dyspnea are much more common than generally known. Therefore, patients with asthma must be asked specifically whether they suffer from symptoms of asthma at night. Usually, nocturnal wheezing is a sign of a badly controlled asthma. Nocturnal bronchoconstriction appears to be an exaggeration of the normal circadian changes in airway calibre. The cause of this exaggeration is not well understood, and it's origin is presumably multifactorial. Careful treatment of nocturnal asthma is particularly important because many deaths due to asthma occur at night and because regular disturbance of sleep impairs performance during the day. Inhaled corticosteroids and beta 2 agonists, especially the new long-acting beta agonists, are first-line drugs for therapy.


[Neglected allergens].

[Neglected allergens]. The atopic symptoms manifest themselves mainly in hay fever or bronchial asthma. In a not inconsiderable number of cases, the question of oral complaints, connected with the intake of certain foodstuffs, is ignored in the medical anamnesis. Here, we are dealing with what is known as food-associated allergy syndrome, which is largely based on a cross reaction between certain types of pollen (birch, alder, hazel and mugwort) and food allergens (drupes, pomes, nuts, vegetables such as celery, carrots and fennel, etc.). Whereas following the intake of fruit the complaints are usually restricted solely to the oral cavity and the throat (aphthas, stomatitis, swelling of the lips and/or tongue, irritation of the hard palate, hoarseness and compulsive clearing of the throat), nuts and celery among others from the family Compositae often cause acute, allergic attacks with sometimes serious general symptoms such as laryngeal oedema, bronchial asthma, urticaria and even anaphylactic shock. In the sensitization against animal allergens, it must not be forgotten that the most powerful immunogens are to be found, for example, in the urine of small rodents (mice and rats). In the manufacture or application of fish food with red gnat larvae, people who are disposed to this will often react with an attack of bronchial asthma.


[Immunotherapy of asthma: pro and contra]. Specific immunotherapy (IT) introduced in 1911 for the treatment of asthma is still controversial, since many protocols have been devised empirically, some extracts are still poorly defined, the mechanisms of action are not yet clear and allergen injections can cause serious side effects. However, clinical efficacy of allergen-specific IT in hay fever with seasonal asthma and in selected patients with perennial asthma has been convincingly documented. For optimal effectiveness IT should be restricted to appropriately selected patients with proven IgE-mediated disease. IT has seldom the capacity to act as a curative treatment. However, a considerable reduction in symptoms and drug consumption is of sufficient benefit. The clinical efficacy of IT should not be solely compared to symptomatic therapy, since IT should be considered as a part of a multifactorial approach aimed at interfering broadly with the pathophysiology of allergic diseases.


[Chronic cough].

[Chronic cough]. Cough is a powerful physiological reflex mechanism that causes central airways to be cleared of foreign material and excess secretions. Chronic cough is a very common presenting symptom in general practice with a prevalence in the population of about 5%. As a general rule, persistent cough represents organic disease of the upper and lower airways, the lung parenchyma, the pulmonary circulation, the pleural space, the mediastinum and the upper gastro-intestinal tract. The most common cause is cigarette smoking, but virtually any chronic lung disease may be occasionally associated with cough. Complications of coughing are tussive syncopes, rib fractures, rupture of respiratory muscles and eventually hernias. Based on a detailed clinical history and physical examination, the investigation includes a chest radiograph, spirometry, and sputum smears. Radiography of the sinuses, bronchoscopy and upper gastro-intestinal endoscopy may be added. If the treatment of an underlying disease is successful, chronic cough may disappear. There are few 'antitussive' drugs with proven suppression of the cough reflex.


[Chronic bronchitis: when are antibiotics indicated?]. The role of bacterial infections in chronic obstructive pulmonary diseases is still poorly understood, and so is the importance of antimicrobial chemotherapy. Based on the present knowledge from clinical studies, it is suggested that antibiotic treatment should be initiated for seven to ten days in patients suffering from an 'Anthonisen type-1 exacerbation', i.e. clinical deterioration with a significant increase in sputum production and sputum purulence, but not in others. The best tolerated, least toxic and least expensive oral antibiotic with adequate activity against pneumococci and H. influenzae is probably most appropriate. These prerequisites are still best fit by aminopenicillins and cotrimoxazol.


[Chronic bronchitis: rare etiology].

[Chronic bronchitis: rare etiology]. Chronic bronchitis is defined for epidemiologic and clinical purposes as the presence of productive cough for three months in each of two successive years. Based on symptoms, the term 'chronic bronchitis', therefore, does not describe one distinct disease. It is rather a collective name for the clinical manifestation of numerous different congenital or acquired chronic diseases of the trachea, the bronchi and the bronchioli. Cigarette smoking is the most consistently important (and preventable) determinant of chronic bronchitis. There are, however, other rare etiologic factors, including malformations, tumors, recurrent aspirations and bronchiectasis. The latter often occur in association with systemic disorders such as cystic fibrosis, immotile cilia syndrome, immunodeficiency, alpha 1-antitrypsin deficiency and others.


[Chronic asthmatic bronchitis].

[Chronic asthmatic bronchitis]. Many patients with chronic obstructive pulmonary disease (COPD) episodically or continuously have asthmatic signs with a degree of reversibility in response to bronchodilators. In such cases, the diagnosis 'chronic asthmatic bronchitis' is often used, although the cause-effect relationship between COPD and asthmatic manifestations is not established. Hence, the 'chronic asthmatic bronchitis' is not a pathogenetic diagnosis, but rather a working diagnosis which implies a specific treatment of the reversible component of chronic airway obstruction. Certainly, the most important measure to avoid a rapid progression of COPD is the elimination of damaging agents by inhalation (smoking). In addition, it was a widely accepted belief that these patients require a continuous inhalation therapy with beta-agonists or anticholinergics. However, there is new evidence, indicating that a continuous treatment might accelerate the decline in ventilatory function and that a better long-term outcome might be achieved by on-demand inhalations.


[Wound management].

[Wound management]. The following article is a check-list for wound care giving some practical hints. Special interest has been given to the themes of local anesthesia and prevention of infections. The indications and limits of the ambulant wound care are also discussed. Finally, a short explanation is given for the treatment of wounds situated at delicate regions of the body.


[Ambulatory hand surgery].

[Ambulatory hand surgery]. The majority of surgical interventions about the hand can be done on an outpatient basis and in private practice; however, the surgeon must be well-trained in hand surgery and should master all forms of local and regional anesthesia, permitting an atraumatic technique. In addition, he must be prepared to handle any peri- and intraoperative complication and should be able to refer the patient to a close-by hospital in case of need. Since the aftercare appears to be of paramount importance for a successful outcome, the postoperative rehabilitation must be guaranteed as well. As all these conditions require qualified manpower and a good infrastructure, hand surgery is probably best performed within a small group of practising surgeons.


[Status of the family physician in ambulatory surgery]. Due to progress in anesthesia and new operating techniques, ambulatory surgery is advancing. The family doctor attends to the preoperative examination, the immediate postoperative care, the subsequent treatment and rehabilitation. To grant interdisciplinary collaboration, the hospital must establish exact instructions for preliminary examination and after-treatment as well as organize regular postgraduate meetings, thus intensifying relations between the family doctor and the surgeon.


[Ambulatory phlebectomy].

[Ambulatory phlebectomy]. Ambulatory phlebectomy has been done already in Greek and Roman times. It was since forgotten for many centuries, but it has been revived by Müller in 1956. Ambulatory phlebectomy is one of the most rewarding instances of ambulatory surgery. It consists of the comprehensive extraction of the varices through extremely small stab incisions, followed immediately by vigorous marching. It calls for team work: The surgeon performs the high ligation and stripping of the proximal third of the greater saphenous vein, and the phlebologist removes all the other varices. And it is an almost ideal treatment, as it provides efficiency as well as excellent cosmetic results at low costs and is also harmless.


[Ambulatory treatment of varicose veins]. Only a small part of the varicose veins need inpatient treatment. Restricting strippings to the diseased saphenous segments and the use of Muller's technique ('phlébectomie ambulatoire') permits the majority of patients to be treated on an ambulatory basis. In 1990 and 1991, 453 of 723 operations were performed under local anesthesia. 233 of the 686 insufficient long and short saphenous veins were treated by high ligation-with or without stripping-in local anesthesia. The limitations of ambulatory surgery are defined by the extension of the varices and by the presence of a seriously diseased long saphenous vein necessitating a stripping.


[Surgical indications for partial inpatient and ambulatory surgery of the lower extremities]. Outpatient (ambulatory) surgery has become widely accepted in free-standing outpatient surgery centres and in hospitals covering the field of hand surgery as well as, increasingly, the field of lower-extremity surgery. Three factors are decisive for secure ambulatory surgery: adequate material and personal resources guaranteeing a round-the-clock medical service, outpatient anesthesia which focuses mainly on the perioperative care of outpatient surgery, and a well-informed patient. Under these prerogatives the majority of surgical procedures of the lower extremities are performed on an outpatient basis without any undue risk. This includes also the diagnostic and operative arthroscopy of different joints.


[Ambulatory surgery at the surgical clinic and polyclinic of the Munich Technical University]. Day-care and especially short-stay surgery were found attractive logistics for surgery of the hand, inguinal hernia repair, laparoscopic cholecystectomy, invasive measures for tumor staging such as diagnostic laparoscopy and implantation of vascular ports for chemotherapy. This new way of surgical organization is a practical alternative to overcome increasing limitations of hospitalization capacities and to conserve everyday surgery which is necessary for the teaching of students and surgical beginners within otherwise highly specialized institutions.


[Ambulatory ophthalmologic surgery].

[Ambulatory ophthalmologic surgery]. In the past years, more procedures (including intraocular surgery) have been performed on an outpatient basis, thanks to the added safety of microsurgery. The decision of whether to operate on an outpatient basis should not just be based on the kind of procedure but more on the patient's suitability and on his social context. The patient must be able to come daily to the office, and eye medication must be applied as prescribed by a relative or a neighbour.


[Ambulatory pediatric surgery].

[Ambulatory pediatric surgery]. The authors refer about their experience in ambulatory pediatric surgery performed in pediatric clinics or in their own practice. Indications are listed, conditions, advantages and disadvantages are discussed. 562 operations were completed from February 1991 to January 1992, 181 (32%) under practice conditions with an experienced anesthesiologist. No complications had to be reported, and no patient was hospitalized due to surgical or anesthetic complications. But indications for ambulatory surgery have to be strictly noted, and only children in excellent health should be anesthesized. The decision about operability has to be made by the anesthesiologist in charge.


[Ambulatory hernia surgery].

[Ambulatory hernia surgery]. Ambulatory surgery for hernia repair is not generally used in Switzerland. Tradition, patients' expectations and the insurance system still favour hospitalization. Nationwide, the mean length of stay amounted to 8.7 days in 1990. A five-year experience is presented, using transversalis fascia repair for uncomplicated unilateral hernia and encouraging immediate ambulation. In 530 patients, the mean duration of hospital stay was 4.4 days. In 446 of these cases, local anesthesia was used, and two thirds of the patients were discharged by the second postoperative day. Thus, it seems possible to gradually approach short-stay surgery for inguinal hernia repair even in Switzerland.


[Ambulatory laparoscopic cholecystectomy?]. Commonly, after laparoscopic cholecystectomy, patients will be discharged from the hospital on the second or the third postoperative day and return to full activities about a week after surgery. Some reports from the USA demonstrate that laparoscopic cholecystectomy can be done on an outpatient basis. But these as well as all operative procedures are not without risk, and we prefer a short hospitalization. Outpatient laparoscopic cholecystectomy is performed because cost containment has become a major issue in American medicine.


[Ambulatory surgery--urology].

[Ambulatory surgery--urology]. Similar to other surgical specialties, there are in urology a considerable number of interventions that may be performed on an outpatient basis. This holds true also for the rapidly evolving endoscopic urology. Well-established and new indications are discussed and modern operative techniques described. However, the move to more outpatient or day surgery with fewer and shorter hospital stays will, in Switzerland, mostly depend on the health care financing system or on 'who pays for what'.


[Ambulatory proctologic surgery].

[Ambulatory proctologic surgery]. An increasing number of proctological procedures may be performed on outpatients under extensive local anesthesia or by posterior perineal bloc. Precise selection criteria should be observed. Results of 1233 outpatients procedures are reported.


Lung sound intensity in patients with emphysema and in normal subjects at standardised airflows. A common auscultatory finding in pulmonary emphysema is a reduction of lung sounds. This might be due to a reduction in the generation of sounds due to the accompanying airflow limitation or to poor transmission of sounds due to destruction of parenchyma. Lung sound intensity was investigated in normal and emphysematous subjects in relation to airflow. Eight normal men (45-63 years, FEV1 79-126% predicted) and nine men with severe emphysema (50-70 years, FEV1 14-63% predicted) participated in the study. Emphysema was diagnosed according to pulmonary history, results of lung function tests, and radiographic criteria. All subjects underwent phonopneumography during standardised breathing manoeuvres between 0.5 and 2 1 below total lung capacity with inspiratory and expiratory target airflows of 2 and 1 l/s respectively during 50 seconds. The synchronous measurements included airflow at the mouth and lung volume changes, and lung sounds at four locations on the right chest wall. For each microphone airflow dependent power spectra were computed by using fast Fourier transformation. Lung sound intensity was expressed as log power (in dB) at 200 Hz at inspiratory flow rates of 1 and 2 l/s and at an expiratory flow rate of 1 l/s. Lung sound intensity was well repeatable on two separate days, the intraclass correlation coefficient ranging from 0.77 to 0.94 between the four microphones. The intensity was strongly influenced by microphone location and airflow. There was, however, no significant difference in lung sound intensity at any flow rate between the normal and the emphysema group. Airflow standardised lung sound intensity does not differ between normal and emphysematous subjects. This suggests that the auscultatory finding of diminished breath sounds during the regular physical examination in patients with emphysema is due predominantly to airflow limitation.


Effect of methacholine induced bronchoconstriction on the spectral characteristics of breath sounds in asthma. Analysis of breath sounds by digital techniques offers an attractive non-invasive method of monitoring changes in airway calibre. Asthmatic breath sounds have been analysed and related to changes in forced expiratory volume in one second (FEV1). Bronchoconstriction was induced with methacholine in six asthmatic subjects on two occasions and changes in FEV1 and breath sound spectra were measured. Audible wheeze appeared after a mean (SE) fall in FEV1 of 35% (6.3%) but the level was not reproducible within patients. The mean and median frequency of the spectra of breath sounds correlated with the percentage of predicted FEV1 (r = -0.5 and -0.6 respectively; p < 0.001). Inclusion of the quartile frequencies in a stepwise multiple regression reduced the residual variance by a further 9%. Detecting changes in airway calibre by this method of sound analysis so far produces qualitative data only and will not yield quantitative data in individual patients.


A cost description of an adult cystic fibrosis unit and cost analyses of different categories of patients. There is little information on the costs of running an adult cystic fibrosis centre. The aim of this study was to provide detailed costs to assist funding and planning for these patients. The cost of a regional adult cystic fibrosis centre serving 119 cystic fibrosis patients, categorised according to four treatment regimens, was determined. District health authority, family health service authority, and voluntary resources used from April 1989 to March 1990 were determined, with appropriate bases for allocation of costs and patient based costs from local information. The total annual cost of treating the 119 patients was 980,646 pounds, with an average cost 8241 pounds per patient. An outpatient reviewed at three monthly intervals cost 2792 pounds a year; an outpatient receiving intravenous antibiotics cost 8606 pounds; an inpatient receiving intravenous antibiotics cost 13,501 pounds; and a patient needing a high level of care cost 19,955 pounds. Medication accounted for 57% (561,395 pounds) of the total cost. This analysis has helped us to secure funding for patients with cystic fibrosis and it facilitates the prediction of future requirements. The study also indicates the limitations of using average patient costs and difficulties as a result of the poorly structured British National Health Service accounting and information systems.


Comparison of polymerase chain reaction amplification of two mycobacterial DNA sequences, IS6110 and the 65kDa antigen gene, in the diagnosis of tuberculosis. Knowledge of the sequences of mycobacterial genes and the availability of DNA amplification techniques have raised the possibility that identification of mycobacterial DNA may offer a rapid and specific diagnostic test for tuberculosis. The correlation between the presence of Mycobacterium tuberculosis DNA and clinical tuberculosis, however, is not known. This study compared the results of polymerase chain reaction amplification of two M tuberculosis DNA sequences, IS6110 and the gene encoding the 65kDa heat shock protein (65kDa Ag), from sputum, bronchoscopy washings, and bronchoalveolar lavage fluid and related these findings to the presence of active and past tuberculosis. Highly specific primers were used for amplification of IS6110 and 65kDa Ag DNA. Analysis was performed on one or more samples from 87 patients. IS6110 DNA was identified in samples from all six patients with active tuberculosis, from 15 to 18 patients with past tuberculosis, from five of nine contacts of patients with tuberculosis, and from nine of 54 patients with lung disease unrelated to tuberculosis. The 65kDa Ag DNA was identified in samples from all patients with active and past tuberculosis, from contacts of patients with tuberculosis, and from 14 of 42 patients with non-tuberculous lung diseases. These data suggest that the presence of IS6110 DNA correlates more closely with a tuberculosis related diagnosis than that of 65kDa Ag DNA and that both DNAs are found in most subjects with past tuberculosis or contacts of patients with tuberculosis. This may limit the clinical usefulness of these tests.


Generation of cytolytic T cells in individuals infected by Mycobacterium tuberculosis and vaccinated with BCG. Macrophage activation by cytokines provides only a partial explanation of antimycobacterial immunity in man. Because cytolytic T lymphocytes have been shown to contribute to immunity in animal models of intracellular infection, the generation of mycobacterial antigen specific cytotoxic T cells was examined in the peripheral blood of patients with tuberculosis. Subjects comprised 36 patients with active tuberculosis (18 newly diagnosed) and 32 healthy volunteers, of whom 25 had had BCG vaccination and seven were Mantoux negative. The ability of purified protein derivative (PPD) stimulated peripheral blood lymphocytes to lyse autologous, mycobacterial antigen bearing macrophages was examined by using a chromium 51 release assay. PPD stimulated lymphocytes from normal, Mantoux positive, BCG vaccinated subjects produced high levels of PPD specific cytolysis, whereas lymphocytes from unvaccinated, uninfected subjects caused little or no cytolysis. The generation of cytolytic T lymphocytes by patients with tuberculosis was related to their clinical state. Those with cavitating pulmonary disease or lymph node tuberculosis generated PPD specific lymphocytes with cytotoxic ability similar to that of those from Mantoux positive control subjects, whereas lymphocytes from patients with non-cavitating pulmonary infiltrates showed poor antigen specific cytolysis. After seven days of stimulation with PPD in vitro, lymphoblasts contained both CD4+ and CD8+ cells. Mycobacterial antigen specific cytolysis was restricted to the CD4+ cell population and was blocked by monoclonal antibodies directed against major histocompatibility class II (MHC) antigens. CD4+ cytolytic T cells can lyse autologous macrophages presenting mycobacterial antigen and were found in patients with cavitating pulmonary tuberculosis or tuberculous lymphadenitis and in normal, Mantoux positive control subjects. The ability to generate these T cell responses seems to be a marker for response to mycobacteria and may contribute to tissue damage in tuberculosis. These responses do not provide protective immunity against Mycobacterium tuberculosis but may help in disease localisation.


Height and age adjustment for cross sectional studies of lung function in children aged 6-11 years. No standard exists for the adjustment of lung function for height and age in children. Multiple regression should not be used on untransformed data because, for example, forced expiratory volume (FEV1), though normally distributed for height, age, and sex, has increasing standard deviation. A solution to the conflict is proposed. Spirometry on representative samples of children aged 6.5 to 11.99 years in primary schools in England. After exclusion of children who did not provide two repeatable blows 910 white English boys and 722 girls had data on FEV1 and height. Means and standard deviations of FEV1 divided by height were plotted to determine whether logarithmic transformation of FEV1 was appropriate. Multiple regression was used to give predicted FEV1 for height and age on the transformed scale; back transformation gave predicted values in litres. Other lung function measures were analysed, and data on inner city children, children from ethnic minority groups, and Scottish children were described. After logarithmic (ln) transformation of FEV1 standard deviation was constant. The ratios of actual and predicted values of FEV1 were normally distributed in boys and girls. From the means and standard deviations of these distributions, and the predicted values, centiles and standard deviation scores can be calculated. The method described is valid because the assumption of stable variance for multiple regression was satisfied on the log scale and the variation of ratios of actual to predicted values on the original scale was well described by a normal distribution. The adoption of the method will lead to uniformity and greater ease of comparison of research findings.


Nasal ventilation to facilitate weaning in patients with chronic respiratory insufficiency. The non-invasive technique of nasal intermittent positive pressure ventilation (NIPPV) has an established role in providing domiciliary nocturnal ventilatory support in patients with chest wall disorders, neuromuscular disease, and chronic obstructive lung disease. NIPPV was used to simplify ventilatory management and assist the return of spontaneous breathing in patients with chronic respiratory insufficiency who had failed to wean from conventional intermittent positive pressure ventilation (IPPV). A trial of NIPPV was carried out in 22 patients with weaning difficulties. Nine patients had chest wall disorders or primary lung disease, six had neuromuscular conditions, and seven had cardiac disorders with additional pulmonary disease. Conventional IPPV via an endotracheal tube or tracheostomy had been continued postoperatively in nine patients and 13 had been ventilated after acute cardiorespiratory decompensation. Conventional IPPV had been continued for a median of 31 days (range 2-219). Eighteen patients were successfully transferred to NIPPV and discharged home a median of 11 days (range 8-13) after starting this type of ventilation. Sixteen patients remain well 1-50 months after hospital discharge and 10 of these continue on domiciliary nocturnal NIPPV. Seven patients have returned to work. NIPPV can be used to facilitate the return of spontaneous breathing and to reduce the need for intensive care accommodation in patients with an acute exacerbation of chronic respiratory insufficiency that requires intubation and IPPV.


Lung function testing in adults with preferential nasal breathing. Three adult patients with asthma with preferential nasal breathing were found to have a typical pattern of lung function test results with substantial between test variation. This condition can be identified as a cause of unsatisfactory performance in respiratory tests by observing the patient's reaction after the nostrils have been occluded.


Bronchopulmonary Kaposi's sarcoma in patients with AIDS. Kaposi's sarcoma in HIV antibody positive patients may affect the lungs. This study describes the presentation, chest radiographic appearances, and pulmonary function test abnormalities in patients with AIDS who had tracheobronchial Kaposi's sarcoma. Twenty nine (8%) of 361 consecutive HIV antibody positive patients undergoing bronchoscopy for respiratory symptoms had tracheobronchial Kaposi's sarcoma. Eight patients had intercurrent infections and one had previously received chemotherapy for cutaneous Kaposi's sarcoma; these patients were excluded. Seven of the remaining 20 patients had localised Kaposi's sarcoma (lesions confined to the trachea or the subsegments of one lobe) and 13 had widespread Kaposi's sarcoma (affecting the trachea and one lobe or the subsegments of more than one lobe); 19 patients also had cutaneous and palatal Kaposi's sarcoma. Seven patients, four with widespread disease, had a normal radiograph. All patients had reduced transfer factor (TLCO) and transfer coefficient (KCO) but only those with widespread disease had reductions in forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF). Follow up pulmonary function testing in seven patients (median three months later) showed further reductions in TLCO. All four patients who received no treatment had progressive radiographic abnormalities; bronchoscopy in two patients showed progressive tracheobronchial disease, and two patients had further reductions in FEV1 and FVC. In three patients treated with chemotherapy palliation of symptoms was achieved but two had further reductions in FEV1 and FVC and the radiograph deteriorated. Bronchoscopy showed regression of disease in only one patient. Pulmonary Kaposi's sarcoma produces abnormalities of TLCO even in patients with localised disease; airflow obstruction may occur in patients with widespread disease. Bronchoscopic reassessment of the extent of disease may not accurately reflect response to chemotherapy.


Bronchopulmonary Kaposi's sarcoma in patients with AIDS. Kaposi's sarcoma is the most common secondary neoplasm to complicate HIV infection and may cause pulmonary disease. A prospective study was carried out in 140 consecutive patients who were HIV seropositive and required bronchoscopy for new respiratory symptoms of at least two weeks' duration, with either a chest radiographic abnormality or abnormality of pulmonary function. The patients were classified into those with single local endobronchial lesions of Kaposi's sarcoma or generalised widespread lesions. Before bronchoscopy all patients had routine simple pulmonary function tests and chest radiography. Thirty nine (21%) patients had evidence of cutaneous Kaposi's sarcoma. Nineteen of the 39 were found to have endobronchial Kaposi's sarcoma lesions at bronchoscopy, but none of those who did not have cutaneous Kaposi's sarcoma. Respiratory symptoms of cough and breathlessness and radiographic abnormalities were attributed to Kaposi's sarcoma in this group, except in four patients who had concomitant pneumocystis pneumonia. Eight patients had local endobronchial Kaposi's sarcoma lesions and 11 had extensive lesions. Patients with extensive lesions had more widespread radiographic abnormalities; four of the patients with local endobronchial lesions had normal chest radiographs. All patients had reduced transfer factor for carbon monoxide and transfer coefficient, whereas patients with extensive endobronchial lesions also had reductions in forced expiratory volume in one second and forced vital capacity. Median survival (with palliative chemotherapy with vincristine and bleomycin) was only seven months. In three patients who needed further diagnostic bronchoscopy endobronchial lesions had regressed while they were having chemotherapy. This study suggests that endobronchial Kaposi's sarcoma is a relatively common finding in patients with AIDS and is particularly common in patients with cutaneous Kaposi's sarcoma who present with respiratory illness. Endobronchial Kaposi's sarcoma causes respiratory disease and abnormalities of pulmonary function. Pulmonary Kaposi's sarcoma should be considered as a possible cause for respiratory illness in any patient with cutaneous Kaposi's sarcoma.


Pulmonary Kaposi's sarcoma in Africa.

Pulmonary Kaposi's sarcoma in Africa. A study was carried out to identify the main clinical radiological and bronchoscopic features of HIV related Kaposi's sarcoma of the lung in African patients. Forty seven HIV positive patients with epidemic Kaposi's sarcoma who had clinical or radiological respiratory changes were investigated by simple lung function tests and fibreoptic bronchoscopy. The most common respiratory symptoms in the 47 patients were persistent cough in 42, haemoptysis in 23, and breathlessness in 38. A restrictive spirometric pattern was most common. The mean (SD) forced expiratory volume in one second (FEV1) was 1.88 (0.62) 1 with a forced vital capacity (FVC) of 2.66 (0.87) 1 and a FEV1/FVC% of 73.2 (7.5). On the chest radiograph 26 patients had diffuse reticulonodular shadows, 11 focal nodular shadows, seven a pleural effusion, and one a substantial increase in vascular markings; in two the radiograph was normal. At bronchoscopy characteristic discrete lesions were easily visible in 37 patients and were often bright red. Multiple nodules were seen in 11, flat or early plaque lesions in 12 (14 had both), proximal flat lesions and diffuse infiltration in three, diffuse infiltration alone in four, and masses in two; one had normal appearances at bronchoscopy. One patient had Pneumocystis carinii and two had a single bacterial pathogen cultured from the bronchoalveolar lavage fluid. Only two of 29 bronchoscopic biopsies showed classical histological Kaposi's sarcoma. After cytotoxic treatment 20 patients have died, with an overall median survival of 70 days. In this African population symptomatic pulmonary Kaposi's sarcoma was common, with lesions seen in all but one patient at bronchoscopy. Coexistent infection was uncommon. Prognosis was poor despite treatment.


An audit of the clinical investigation of pleural effusion. Pleural aspiration with pleural biopsy is advised for the investigation of pleural effusion. The clinical investigation of pleural effusion in a group of teaching hospitals was audited with reference to adequacy and diagnostic value of sampling procedures. A retrospective review of case records of all patients investigated for pleural effusion during an eight month period was performed. The records of 112 patients, age range 16-91 years, who underwent 150 procedures were reviewed. Microbiology samples were obtained from 137 procedures, of which five provided a positive culture, including one for mycobacteria. Cytology samples were obtained from 145 procedures though approximately two thirds of samples were less than the recommended 30 ml. The pleural biopsy rate was 30%, varying from 0% in general or thoracic surgery to 68% in thoracic medicine (thoracic surgeons carried out thoracoscopy). Twenty nine per cent of pleural biopsy samples were of poor quality. The complication rate was 2% for aspiration alone, and 4% for aspiration plus biopsy. The sensitivity of the first diagnostic procedure for a diagnosis of malignancy or tuberculosis was 53% for cytology alone, 50% for biopsy alone and 72% for cytology plus biopsy. The samples obtained from pleural aspiration and biopsy in the initial investigation of pleural effusion are often inadequate. Further education is necessary to improve the quantity and quality of specimens submitted for histological and cytological examination.


High resolution computed tomography as a predictor of lung histology in systemic sclerosis. The relative proportions of fibrosis and inflammation seen by open lung biopsy examination is a predictor of disease outcome in fibrosing alveolitis. This study was designed to assess the ability of high resolution computed tomography to predict the histological appearance of open lung biopsy specimens from patients with systemic sclerosis. Twenty abnormal biopsy specimens from 12 patients were assessed; abnormalities were categorised as fibrotic (fibrosis exceeding inflammation) or inflammatory (inflammation equal to or exceeding fibrosis). Computed tomography appearances were scored for the lobe from which the biopsy specimen was taken; scans were graded from parenchymal opacification alone through to a reticular pattern alone. Two lobar appearances were identified on computed tomograms: amorphous parenchymal opacification equal in extent to reticulation (grade 3) and a predominantly reticular pattern (grade 4). There was a significant association between a fibrotic histological appearance and a grade 4 computed tomogram, and between an inflammatory histological appearance and a grade 3 computed tomogram. Computed tomography grade 4 was associated with a fibrotic histological appearance in 12 out of 13 lobes, and grade 3 with an inflammatory histological appearance in four out of seven lobes. Computed tomography discriminated between biopsy specimens that were predominantly fibrotic and a smaller group with a larger amount of inflammation.


The airway microvasculature and exercise induced asthma. It has been proposed that exercise induced asthma is a result of "rapid expansion of the blood volume of peribronchial plexi" (McFadden ER, Lancet 1990;335:880-3). This hypothesis proposes that the development of exercise induced asthma depends on the thermal gradient in the airways at the end of hyperpnoea. The events that result in exercise induced asthma are vasoconstriction and airway cooling followed by reactive hyperaemia. We agree that the airway microcirculation has the potential for contributing to the pathophysiology of exercise induced asthma. We do, however, question whether reactive hyperaemia, in response to airway cooling, is the mechanism whereby hyperpnoea provokes airways obstruction in asthmatic patients. Further, we question whether vasoconstriction accompanies dry air breathing and whether an abnormal temperature gradient and rapid rewarming of the airways are prerequisites for exercise induced asthma. From published experiments we conclude that dry air breathing is associated with vasodilation and increase in airway blood flow rather than vasoconstriction and a decrease in blood flow to the airways. We propose that the stimulus for the increase in airway blood flow is an increase in osmolarity of the airway submucosa. This osmotic change is caused by the movement of water to the airway lumen in response to evaporative water loss during hyperpnoea. The increase in airway blood flow may occur directly or indirectly by the osmotic release of mediators. Exercise induced asthma is most likely to be due to the contraction of bronchial smooth muscle caused by the same mediators. Whether it is enhanced or inhibited by alterations in airway blood flow is not yet established in man.


Percutaneous visceral pleural biopsy with fenestrated cup biopsy forceps. When there is an exudative pleural effusion often both the parietal and the visceral pleura are affected, but the usual practice is to perform a percutaneous parietal pleural biopsy alone for diagnosis. Percutaneous visceral pleural biopsy was carried out in 20 patients with exudative pleural effusions with fenestrated cup biopsy forceps. In all 20 biopsies pleural tissue was obtained and it was diagnostic in 19 cases. The procedure is painless and appears safe.


Acute and long term respiratory damage following inhalation of ammonia. A lifelong non-smoker who was the victim of a massive accidental exposure to anhydrous ammonia gas was followed up for 10 years. In the acute phase the patient presented with severe tracheobronchitis and respiratory failure, caused by very severe burns of the respiratory mucosa. After some improvement he was left with severe and fixed airways obstruction. Isotope studies of mucociliary clearance, computed tomography, and bronchography showed mild bronchiectasis. It is concluded that acute exposure to high concentrations of ammonia may lead to acute respiratory injury but also to long term impairment of respiratory function.


Expandable metal stents for tracheal obstruction: permanent or temporary? A cautionary tale. An expandable metal stent inserted via a long term tracheostomy successfully relieved life threatening respiratory obstruction due to benign tracheal stenosis. Later the patient's tracheostomy suction catheter became stuck on the stent and dislodged it. The stent was removed electively, without damaging the trachea, with a rigid biopsy forceps.


Occupational asthma due to polyethylene shrink wrapping (paper wrapper's asthma). Occupational asthma due to the pyrolysis products of polyvinyl chloride (PVC) produced by shrink wrapping processes has previously been reported. The first case of occupational asthma in a shrink wrap worker using a different plastic, polyethylene, is reported; the association was confirmed by specific bronchial provocation testing.


Occupational asthma induced by the fungicide tetrachloroisophthalonitrile. A 48 year old male farmer had recurrent episodes of dyspnoea, shortness of breath, and wheezing after being in his plastic greenhouse when the fungicide tetrachloroisophthalonitrile had been sprayed. A bronchial provocation test with a control challenge and a patch skin test confirmed that his asthma was induced by tetrachloroisophthalonitrile.


Apparent lack of synergism between heparin and dihydroergotamine in prevention of deep vein thrombosis after elective hip replacement: a randomised double-blind trial reported in conjunction with an overview of previous results. We report the results of a double-blind, randomised trial of venous thrombosis (VT) prevention in 117 patients having elective hip replacement where low dose heparin alone (5,000 IU sodium heparin given subcutaneously [sc] 8 hourly until the seventh postoperative day) was compared with low dose heparin plus dihydroergotamine (DHE; 0.5 mg, given 8 hourly by sc injection). The trial end point consisted of VT discovered through bilateral ascending venography done routinely on the seventh postoperative day. VT developed in 34% of patients given heparin/DHE (95% confidence interval = 22% - 47%) compared with 24% in those given low dose heparin alone (95% confidence interval = 14% - 37%; p = 0.34), difference = 10% (95% confidence interval = -7% to +26%). Corresponding figures for the incidence of proximal (above-knee) thrombosis were 17% and 14% (95% confidence intervals = 8% - 29% and 6% - 25% respectively). These results are discussed in the context of a detailed overview of published evidence concerning VT prevention with heparin/DHE after hip replacement and we conclude it is unlikely that heparin/DHE is markedly superior to low dose heparin alone in this clinical setting.


Ventilation-perfusion lung scanning and the diagnosis of pulmonary embolism: improvement of observer agreement by the use of a lung segment reference chart. To test the hypothesis that the systematic use of a lung segment reference chart can improve the inter- and intra-observer agreement for the interpretation of ventilation-perfusion lung scans. A randomized trial. Ventilation-perfusion lung scans were obtained in a series of 220 consecutive patients with clinically suspected pulmonary embolism. Ventilation-perfusion scans were randomly allocated to one of two series each consisting of 110 ventilation-perfusion lung scans. The first series of lung scans was interpreted according to the routine diagnostic approach, and the second series was interpreted with the mandatory use of a lung segment reference chart on which observed ventilation and perfusion defects were drawn. The two nuclear medicine physicians agreed a priori on the diagnostic criteria of the classification scheme. Lung scans were classified as normal, non-high probability, or high probability for pulmonary embolism. The extent of disagreement between the nuclear medicine physicians (inter-observer disagreement) and the lack of internal consistency of each nuclear medicine physician (intra-observer disagreement) was assessed by the percentage disagreement and by kappa statistic. Inter-observer disagreement which was 20% in the first series, decreased significantly in the second series to 7%; P = 0.003. Intra-observer disagreement for the first series was 10% and 22% for the nuclear medicine physicians, respectively. Intra-observer disagreement for the second series of lung scans decreased significantly for one nuclear medicine physician (intra-observer disagreement, 0%; P less than 0.01), whereas intra-observer disagreement was reduced to 10% for the other nuclear medicine physician (P = 0.09). Inter- and intra-observer disagreement were significantly reduced when two nuclear medicine specialists interpreted ventilation-perfusion lung scans according to the routine diagnostic approach plus the use of a lung segment reference chart. The use of the lung segment reference chart for the interpretation of lung scans is likely to improve the management of patients with clinically suspected pulmonary embolism.


Early activation of hemostasis during cardiopulmonary bypass: evidence for thrombin mediated hyperfibrinolysis. In 14 consecutive patients undergoing cardiopulmonary bypass for coronary bypass surgery the time course of coagulation and fibrinolysis markers were measured, e. g. plasma levels of thrombin-antithrombin III (TAT) complexes, cross-linked fibrin degradation products (XIFDP) and plasmin-alpha 2-antiplasmin complexes (PAP). TAT levels exceeded the 90% baseline percentile already during CPB (after opening of aortic clamp) in 10 patients, whereas PAP and XIFDP exceeded their 90% percentile in only one patient at this time. Concerning fibrinolysis markers PAP and XIFDP the majority of patients showed elevations higher than their 90% baseline percentile only 1 h postoperation. Correlation analysis revealed significant dependencies between TAT levels during and at the end of CPB and PAP levels 1 h postoperation (R = 0.55 and R = 0.56 respectively). Furthermore, 1 h postoperation XIFDP levels were significantly correlated with both TAT and PAP. Peak XIFDP levels at the same time correlated with blood loss via thoracic drains (R = 0.56). Thus, we suggest that hyperfibrinolysis in patients undergoing CPB is at least partly due to hypercoagulation. Clinically, this may implicate that intensified anticoagulation could prevent hyperfibrinolysis and reduce postoperative blood loss.


The effect of insulin treatment on the balance between tissue plasminogen activator and plasminogen activator inhibitor-1 in type 2 diabetic patients. Beside hypercoagulation and hyperactivated platelets disturbances of the fibrinolytic system towards hypofibrinolysis have been reported to be associated with both glycemic and lipidemic derangement in diabetic patients. In the present prospective follow-up study the effect of 16 weeks insulin treatment and glycemic regulation on plasma levels of tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1), the main regulators of fibrinolysis, was investigated in 19 type-2 diabetic patients with secondary failure to sulphonylureas. A similar glycemic regulation was obtained in a control group of 10 type 2 diabetic patients with sufficient metabolic response to strict dietary treatment and continuation of sulphonylurea treatment. Compared to 27 healthy subjects levels of tPA and PAI-1 were not significantly increased in type 2 diabetic patients before metabolic intervention. Although a hypofibrinolytic state due to an increase of PAI-1 levels was previously reported in obese hyperinsulinemic patients, no effect of insulin treatment on both tPA- and PAI-1 levels was observed in the present study including patients with only slightly increased body mass index (median 26.0 kg/m2). By correlation analysis PAI-1 levels were significantly related to serum cholesterol (R = 0.52) and glycemic control (glucose R = 0.41) in the whole group of diabetic patients at entry and in both subgroups after 16 weeks of treatment (insulin group: cholesterol R = 0.46, HbA1c R = 0.51; sulphonylurea group: cholesterol R = 0.59, HbA1c R = 0.58). In healthy subjects tPA and PAI-1 was correlated to serum insulin (R = 0.54, R = 0.56) and triglycerides (R = 0.46, R = 0.40).(ABSTRACT TRUNCATED AT 250 WORDS)


Detection of asymptomatic deep vein thrombosis by real-time B-mode ultrasonography in hip surgery patients. The aim of this study was to prospectively evaluate the accuracy of real-time B-mode ultrasonography in the diagnosis of asymptomatic proximal deep vein thrombosis (DVT) in hip surgery patients. Venography was adopted as the gold standard. We studied 100 consecutive patients undergoing hip surgery: 60 patients for hip fracture and 40 patients for elective hip replacement. Bilateral real-time B-mode ultrasonography was performed prior to bilateral venography. The two diagnostic procedures were performed on the same day by different investigators unaware of the assigned prophylatic regimen for DVT. Compressibility of the vein segment was adopted as the single criterion for DVT. Venography was performed and judged by radiologists unaware of the ultrasonography results. In 13 limbs venography was either impossible to perform or not adequate for judgement. Ultrasonography and an adequate venography was obtained in 187 limbs. A venography proven DVT was observed in 49 limbs (26.2%) and a proximal DVT in 21 limbs (11.2%). All the patients were asymptomatic for DVT. The sensitivity and specificity of real time B-mode ultrasonography for proximal DVT were 57% (95% confidence interval: C.I. 36-80) and 99% (C.I. 99-100), respectively and the positive and negative predictive values were 93% (C.I. 73-100) and 95% (C.I. 91-97), respectively. The sensitivity and specificity for overall DVT were 25% (C.I. 11-38) and 99% (C.I. 97-100), respectively and the positive and negative predictive values were 92% (C.I. 73-100) and 79% (C.I. 76-85), respectively. Our data indicate that real-time B-mode ultrasonography for its high specificity could make venography unnecessary in patients with positive results.(ABSTRACT TRUNCATED AT 250 WORDS)


A six year prospective study of fibrinogen and other risk factors associated with mortality in stable claudicants. A total of 333 patients with stable intermittent claudication at recruitment were followed up for 6 years to determine risk factors associated with subsequent mortality. Cardiovascular diseases were the underlying cause of death in 78% of the 114 patients who died. The strongest independent predictor of death during the follow-up period was the plasma fibrinogen level, an increase of 1 milligram being associated with a nearly two-fold increase in the probability of death within the next 6 years. Age, low ankle/brachial pressure index and a past history of myocardial infarction also increased the probability of death during the study period. The plasma fibrinogen level is a valuable index of those patients with stable intermittent claudication at high risk of early mortality. The results also provide further evidence for the involvement of fibrinogen in the pathogenesis of arterial disease.


Immunoglobulin fractions isolated from patients with antiphospholipid antibodies prevent the inactivation of factor Va by activated protein C on human endothelial cells. We studied the effect of purified immunoglobulins (Ig) from 21 patients with antiphospholipid antibodies (aPL) on factor Va degradation by activated protein C (aPC) on cultured human umbilical vein endothelial cells (HUVEC). Sera from patients were tested on an ELISA aPL assay to determine the isotype with aPL activity. HUVEC were incubated with purified IgG or IgM fraction from controls or patients. Activated PC and factor Va were then added and factor Va degradation was measured after several reaction times. 13 of 14 IgM and 8 of 10 IgG from patients showed an inhibitory effect on factor Va degradation by aPC when compared with control Ig. We also observed the same inhibitory effect with patients' Ig on studying the degradation of factor Va by aPC in a purified system containing aPC, protein S and phospholipids. These results suggest that aPL antibodies disturb the anticoagulant activity of aPC, which may contribute to the thrombotic tendency of these patients.


A rapid monoclonal antibody-based enzyme immunoassay (EIA) for the quantitative determination of soluble fibrin in plasma. Soluble fibrin is considered as a molecular marker for intravascular fibrin formation, and impending thrombotic events. Most of the existing assays are less suitable for routine clinical applications and their specificity may be limited. We have developed a sandwich-type EIA with a fibrin-specific MoAb described by us before (Proc Natl Acad Sci 1989; 86: 8951) as the capture antibody. An other MoAb (G8; Thromb Haemostas 1988; 60: 145) with an epitope in the carboxyl-terminal sections of the fibrin alpha-chains, was labeled with peroxidase and used as the tagging antibody. The EIA is calibrated against plasma spiked with known concentrations of soluble fibrin. The time-to-result of the EIA is only 1.5 h. Concentrations as low as 0.5 micrograms soluble fibrin/ml plasma are readily measureable. Heparin has no effect on the results. Fibrinogen and fibrin(ogen) degradation products are not detected. The values of fibrinopeptide A and soluble fibrin values found with the "COA-SET soluble fibrin" assay correlated well with the soluble fibrin values found with our EIA i.e. r = 0.998 and 0.984, respectively. The run-to-run variabilities were 7.9% and 6.6% for samples with low and high soluble fibrin concentrations, respectively. The within-run variabilities were 2.5, 1.8, 4.0 and 4.6% for samples with 1, 0.5, 0.25 and 0.125 micrograms soluble fibrin/ml, respectively. The sensitivity, specificity, accuracy and short time-to-result make our EIA suitable for routine clinical applications and the monitoring of the effectivity of heparinization.


Antiphospholipid antibody positive sera enhance endothelial cell procoagulant activity--studies in a thrombosis model. The effect of sera and IgG from 12 patients with systemic lupus erythematosus (SLE) on the endothelial cell (EC) procoagulant activity (PCA) was investigated in an in vitro thrombosis model. Six of the 12 SLE sera contained antiphospholipid antibodies (aPL). EC were stimulated for 8 h at 37 degrees C with or without 50 pM tumor necrosis factor (TNF) in culture medium containing 20% patient or control serum. Then the endothelial cell matrix (ECM) was isolated and subsequently exposed in a perfusion chamber to circulating normal whole blood, anticoagulated with low molecular weight heparin (LMWH). The PCA of the ECM was determined as the amount of generated fibrinopeptide A (FPA) in samples taken before and after perfusion. Furthermore, cross sections were made of the perfused matrix and analyzed for platelet adhesion and aggregate formation. All six aPL containing sera induced a small, but significant increase of ECM procoagulant activity. When added in combination with a low dose of TNF (50 pM), a synergistic enhancement of ECM procoagulant activity was found. The FPA generation was increased to 150-614% from the values obtained after stimulation with TNF and control serum. Also a shift towards the formation of larger platelet thrombi was observed. After stimulation with TNF and patient serum the surface of ECM covered with large aggregates (greater than 5 microns) was increased by 124-329% compared to the results obtained after stimulation with control serum and TNF. When patient sera were depleted from IgG the effects were strongly decreased.(ABSTRACT TRUNCATED AT 250 WORDS)


The prevalence of factor XII deficiency in 103 orally anticoagulated outpatients suffering from recurrent venous and/or arterial thromboembolism. One hundred and three patients suffering from recurrent venous thrombosis, recurrent arterial thromboembolism and/or recurrent myocardial infarction and 50 healthy subjects were tested for Hageman factor (FXII) coagulant activity and antigen. Among the 103 patients we identified 15 subjects with FXII deficiency (15%), 3 with protein C deficiency (3%) and 3 with protein S deficiency (3%). Combined FXII and protein C, protein S or antithrombin III deficiency was not observed. The 103 patients were divided into subgroups according to the type of thrombotic complication. Among patients with exclusively recurrent venous thromboembolism 8% (p = 0.153) were deficient in FXII. Among patients suffering from recurrent arterial thromboembolism and/or myocardial infarction, the incidence of FXII deficiency was significantly higher (20%, p less than 0.003). In 67% of the patients with FXII deficiency a positive family history of thrombosis could be established. In contrast, only 32% of all venous and 28% of all arterial thrombosis patients had a positive family history. We believe that reduced levels of FXII should be considered as a risk factor in the development of thromboembolism. Consequently, more attention should be payed to the measurement of FXII when evaluating thromboembolic risk factors especially in cases of recurrent arterial thromboembolism and/or myocardial infarction.


Molecular cloning and cell-free expression of mouse antithrombin III. The homology between antithrombin III (AT-III) of mouse, of man, and that of other species was investigated. Preliminary experiments showed that mouse AT-III inhibited human alpha-thrombin efficiently (second order rate constant [K2nd] 5.8 x 10(3) M-1 s-1) as compared to human AT-III (K2nd 6.7 x 10(3) M-1), but was not recognized on immunoblots by antibodies that recognized both human and rabbit AT-III. In order to compare AT-III from different species at the molecular level, a cDNA clone for murine AT-III was isolated from a lambda ZAP mouse liver cDNA library on the basis of hybridization to a rabbit AT-III cDNA probe. The 1509 bp murine AT-III cDNA consists of a 1398 bp open reading frame, preceded by a 15 bp 5' untranslated region, followed by a 75 bp 3' untranslated region. The deduced primary protein structure consists of a 32 amino acid signal sequence, with a mature portion of 433 residues. Mature murine AT-III is 89% identical to its human counterpart, 86% identical to bovine AT-III, and 82% identical to that of the rabbit. Constructs lacking the nucleotides encoding the signal sequence were engineered and expressed in a cell-free system. The resulting 47 kDa non-glycosylated translation product was capable of being cleaved by human alpha-thrombin, of forming SDS-stable complexes with the protease, and of binding to immobilized heparin. Isolation of the murine AT-III cDNA will make feasible molecularly defined experiments with murine AT-III in the mouse system.


Anticoagulant activity of beta 2-glycoprotein I is potentiated by a distinct subgroup of anticardiolipin antibodies. Plasmas of 16 patients positive for both IgG anticardiolipin (aCL) antibodies and lupus anticoagulant (LA) antibodies were subjected to adsorption with liposomes containing cardiolipin. In 5 of these plasmas both the anticardiolipin and the anticoagulant activities were co-sedimented with the liposomes in a dose-dependent manner, whereas in the remaining cases only the anticardiolipin activity could be removed by the liposomes, leaving the anticoagulant activity (LA) in the supernatant plasma. aCL antibodies purified from the first 5 plasmas were defined as aCL-type A, while the term aCL-type B was used for antibodies in the other 11 plasmas, from which 2 were selected for this study. Prolongation of the dRVVT was produced by affinity-purified aCL-type A antibodies in plasma of human as well as animal (bovine, rat and goat) origin. aCL-type B antibodies were found to be devoid of anticoagulant activity, while the corresponding supernatants containing LA IgG produced prolongation of the dRVVT only in human plasma. These anticoagulant activities of aCL-type A and of LA IgG's were subsequently evaluated in human plasma depleted of beta 2-glycoprotein I (beta 2-GPI), a protein which was previously shown to be essential in the binding of aCL antibodies to anionic phospholipids. Prolongation of the dRVVT by aCL-type A antibodies was abolished using beta 2-GPI deficient plasma, but could be restored upon addition of beta 2-GPI. In contrast, LA IgG caused prolongation of the dRVVT irrespective of the presence or absence of beta 2-GPI.(ABSTRACT TRUNCATED AT 250 WORDS)


A comparison of methods for the measurement of activated factor VII. A number of different methods are available for the measurement of factor VIIa. Almost all of these employ ratios of two different measurements of factor VII. In order to determine which is the most sensitive to activated factor VII we have compared currently available methods in the following groups: two patients with haemophilia A following treatment with activated recombinant factor VII (rVIIa); 6 normal plasmas during cold promoted activation of factor VII; normal individuals (n = 23); and patients with unequivocal disseminated intravascular coagulation (DIC, n = 19). Factor VII was measured in an amidolytic assay (VII:Amid) and an antigen assay (VII:Ag). Clotting activity was measured using rabbit (VII:C Rab), human (VII:C Hum) and bovine (VII:C Bov) thromboplastin. Of the clotting assays the most sensitive to the presence of factor VIIa was that which utilised bovine thromboplastin. Amidolytic and immunological measurements were unaffected by the activity state of factor VII. The ratios VII:C Rab/VII:Ag and VII:C Rab/VII:Amid were insensitive to activated factor VII. The ratios most sensitive to the presence of factor VIIa were VII:C Bov/VII:Amid and VII:C Bov/VII:Ag. The ratios VII:C Bov/VII:C Rab and VII:C Bov/VII:C Hum are less sensitive but have the advantage for epidemiological studies of narrower reference ranges.


Effect of DDAVP on endotoxin-induced intravascular coagulation in rabbits. We have evaluated the effect of 1-Deamino-8D-arginine vasopressin (DDAVP) on an experimental model of intravascular coagulation (DIC) induced in rabbits by injection of 20 micrograms kg-1 h-1 during 6 h of E. coli lipopolysaccharide. DDAVP significantly ameliorated the platelet drop and fibrinogen decrease (p less than 0.01) induced by endotoxin in control animals. A significant reduction in factor XII consumption (p less than 0.01) and a decrease in the generation of endotoxin induced PAI-1 activity in rabbits circulation was also observed (p less than 0.005). Moreover, fibrin deposition in kidneys of rabbits receiving DDAVP was significantly reduced as compared to control animals. Finally, the mortality rate in the control group was significantly higher than in DDAVP-treated rabbits (p less than 0.01). The hemostatic changes induced by DDAVP correlated with lower fibrin deposition and reduction in mortality rates.


Tissue plasminogen activator release in chronic venous hypertension due to heart failure. In order to study the effects of chronic venous hypertension due to heart failure on blood fibrinolytic activity, tissue plasminogen activator (t-PA) antigen, plasminogen activator inhibitor 1 (PAI-1) antigen, t-PA activity and PAI activity were measured before and after venous occlusion of the arm for 20 min in 15 patients with right-sided heart failure, 15 patients with left-sided heart failure, and 30 control healthy subjects. Central venous pressure, measured by observing the jugular veins, was above 15 cm of the blood column in all patients with right-sided heart failure, and normal (below 8 cm) in all patients with left-sided heart failure and control subjects. There was no difference in the basal concentrations of t-PA (11.0, 10.2 and 10.8 ng/ml; all values medians) and PAI-1 antigens and their activities between right and left-sided heart failure and the control subjects. After the occlusion, t-PA antigen increased significantly less in right-sided heart failure (28.6 ng/ml) than in left-sided heart failure and the control subjects (54.5 and 45.9 ng/ml, respectively). It was concluded that the poor increase in fibrinolytic activity that had already been reported in patients with heart failure, was due to low t-PA release during occlusion and not to a high basal PAI level. It was limited to the patients with right-sided heart failure and was probably the consequence of chronic systemic venous hypertension.


Fibrin clot lysis by thrombolytic agents is impaired in newborns due to a low plasminogen concentration. Although thrombolytic drugs have been extensively used in adults, there is sparse information on their effectiveness in newborns whose fibrinolytic system differs significantly from adults. The purpose of this study was to determine if low plasma levels of plasminogen in cord plasma limited the therapeutic effectiveness of thrombolytic agents. Urokinase (UK), streptokinase (SK) and tissue plasminogen activator (TPA) were compared for their ability to lyse washed 125I-labelled adult or cord fibrin clots suspended in cord or adult plasma. 125I-labelled fibrin clots were prepared by recalcifying cord or adult plasma spiked with labelled fibrinogen and then placed into cord or adult plasma which contained either saline or differing amounts of a specific thrombolytic agent. After a 60 min incubation, the remaining 125I-fibrin in clots released 125I-fibrin fragments, and concentrations of fibrinogen, alpha 2-antiplasmin, and plasminogen in the bathing plasma were measured and compared to starting values. Cord fibrin clots were more resistant than adult fibrin clots to all thrombolytic drugs tested (p less than 0.001). On average, the cord system retained 27% more 125I-fibrin in clots, and released 32% less 125I-fibrin fragments into plasma. Fibrinogenolysis was also decreased in cord plasmas compared to adult plasmas. The degree of fibrinolysis and fibrinogenolysis in cord plasma increased to adult values when plasminogen concentrations were increased in the bathing plasma. Thus, cord fibrin clots have an impaired response to thrombolytic agents secondary to low levels of plasminogen.(ABSTRACT TRUNCATED AT 250 WORDS)


Thrombolytic activity of two chimeric recombinant plasminogen activators (FK2tu-PA and K2tu-PA) in rabbits. The aim of this study was to evaluate the thrombolytic activity of two hybrid plasminogen activators (HPAs) in a rabbit jugular vein thrombosis model. In the two HPAs the kringle-2 domain (K2tu-PA) or the finger and the kringle-2 domains (FK2tu-PA) of tissue-type plasminogen activator (t-PA) are linked to the catalytic protease domain of single chain urokinase type plasminogen activator (scu-PA). The two HPAs were compared with rt-PA and scu-PA on a weight/weight basis. K2tu-PA, FK2tu-PA, rt-PA and scu-PA were infused at doses of 0.4, 0.8 and 1.2 mg/kg over 3 h. Saline served as control. Saline produced 11 +/- 2% thrombolysis. The three doses of K2tu-PA led to 38 +/- 4%, 66 +/- 5% and 89 +/- 7% thrombolysis, respectively; the three doses of FK2tu-PA: 18 +/- 3%, 29 +/- 5% and 33 +/- 6%, respectively; the three doses of rt-PA 32 +/- 2%, 49 +/- 3% and 68 +/- 6%, respectively; the three doses of scu-PA 16 +/- 2%, 24 +/- 3% and 32 +/- 4%, respectively. K2tu-PA and rt-PA showed a statistically significant higher thrombolytic activity than FK2tu-PA and scu-PA at the three tested doses (p less than 0.01). The thrombolytic activity of K2tu-PA was significantly higher than rt-PA at the two higher doses (p less than 0.01). Both K2tu-PA and rt-PA produced a statistically significant reduction of fibrinogen, alpha 2-antiplasmin and plasminogen 3 h after the start of the infusions of the two higher doses.(ABSTRACT TRUNCATED AT 250 WORDS)


Synergistic antithrombotic properties of G4120, a RGD-containing synthetic peptide, and argatroban, a synthetic thrombin inhibitor, in a hamster femoral vein platelet-rich thrombosis model. The synergistic antithrombotic properties of G4120, a synthetic Arg-Gly-Asp (RGD) containing peptide which strongly inhibits platelet aggregation, and of Argatroban, a synthetic thrombin inhibitor, were examined in a reproducible quantitative hamster femoral vein platelet-rich mural thrombosis model. Bolus injections of G4120 and Argatroban inhibit thrombus formation in a dose-dependent way; 50% inhibition (ID50) is obtained with 11 micrograms/kg G4120 and with 2 mg/kg Argatroban. Combined bolus injections of 3 micrograms/kg G4120 with 0.5, 0.75 or 1 mg/kg Argatroban and of 1 mg/kg Argatroban with 1.5 or 3 micrograms/kg G4120 caused linear dose-dependent inhibition of thrombus formation, whereas 3 micrograms/kg G4120 or 1 mg/kg Argatroban alone had very little effect (less than 20% inhibition). ID50 was obtained with the combination of 3 micrograms/kg G4120 and 0.5 mg/kg Argatroban, corresponding to an equi-effective fractional combination of 0.62 with a 95% confidence interval of 0.50 to 0.74. Alternatively the ID50 was obtained with the combination of 1 mg/kg Argatroban and 1.3 micrograms/kg G4120, corresponding to an equi-effective fractional combination of 0.52 with a 95% confidence interval of 0.18 to 0.86. In both instances these results are indicative of a significant synergistic interaction. Bolus injection of 10 mg/kg aspirin, 100 U/kg heparin or the combination did not inhibit thrombus formation. The synergistic effect of the combination of platelet inhibiting RGD-peptides and synthetic thrombin inhibitors could be useful in the prevention of arterial occlusion with platelet-rich thrombus in patients with ischemic heart disease following thrombolytic therapy or angioplasty, although this combination is not expected to reverse platelet thrombus formation.


Mass contents of inositol 1,4,5-trisphosphate and 1,2-diacylglycerol in human platelets stimulated with a thromboxane analogue and thrombin. Mass contents of inositol 1,4,5-trisphosphate (IP3) and 1,2-diacylglycerol (DG) were measured in U46619-stimulated human platelets. 1 microM of U46619 induced maximum responses in aggregation, 5-hydroxytryptamine (5HT) secretion and increase in intracellular free Ca2+ concentration ([Ca2+]i). Aggregation was almost comparable to that induced by maximal dose (1 U/ml) of thrombin, while 5HT release was almost half. The initial [Ca2+]i peak in response to U46619 was about half of thrombin stimulation. Production of IP3 and DG was, however, less than one tenth of that seen in thrombin stimulation. The profile (time course and concentration-dependency) of IP3 formation did not correlate with that of [Ca2+]i, suggesting that U46619 stimulates IP3-dependent and -independent Ca2+ mobilization. DG production was small but sustained for more than 5 min. These findings support the recent hypothesis that aggregation is regulated by a delayed accumulation of DG. The low level of 5HT secretion could be explained by the low production of second messengers, IP3 and DG.


Effect of stimulation on the stabilization of platelet-fibrinogen interactions. The interaction between fibrinogen and stimulated platelets is a multiphasic process that culminates in the stabilization of ligand binding and reduced accessibility of bound fibrinogen to exogenous antibody. The present study was designed to further explore platelet-fibrinogen interactions by examining the effect of agonist on bound fibrinogen expression and interaction with stimulated platelets as a function of time after ligand binding. Two agents were identified, Zn2+ and phorbol myristate acetate (PMA), which support progressive decreases in bound fibrinogen expression on platelets, but fail to support the stabilization of fibrinogen binding. Sixty min after binding to platelets, approximately 80% of bound fibrinogen remained reversibly associated with Zn(2+)- or PMA-treated platelets and failed to associate with the Triton X-100 insoluble cytoskeleton. In contrast, polyclonal anti-fibrinogen antibody binding decreased by more than 66%. Over the same time course, fibrinogen binding to control platelets, stimulated with thrombin or ADP, was not only accompanied by a 70% decrease in antifibrinogen antibody binding, but also an inability of EDTA or excess exogenous fibrinogen to dissociate more than half of platelet-associated fibrinogen, as well as the progressive association of bound fibrinogen with the platelet cytoskeleton. Costimulation of platelets with ZnCl2 and thrombin or ZnCl2 and ADP enhanced overall fibrinogen binding but not the EDTA-resistant component, and prevented the recovery of irreversibly bound fibrinogen with the Triton X-100 insoluble cytoskeleton. Costimulation of PMA- or Zn(2+)-treated platelets with low doses of A23187, however, restored the stabilization of platelet-fibrinogen interactions.(ABSTRACT TRUNCATED AT 250 WORDS)


On the significance of different aequorin loading techniques on intracellular aequorin discharge, baseline calcium, platelet aggregation and aequorin-indicated Ca(2+)-transients. The study compares the decay of intracellular luminescence activity (Lmax), the levels of basal [Ca2+]i in resting platelets, and agonist-induced peak [Ca2+]i-signals in platelets loaded with aequorin using the EGTA-, DMSO- and hypoosmotic shock treatment (HOST)-techniques. The highest load of intracellular aequorin with almost unchanged luminescence activity during 4 h was achieved with HOST. Lmax decreased linearly in EGTA- and HOST-platelets, but the decay rate and the levels of basal [Ca2+]i were significantly lower in HOST-platelets. Platelet aggregation and aequorin-indicated [Ca2+]i-rise induced by thrombin and collagen were similar in EGTA- and HOST-platelets. In HOST-platelets, ADP-induced platelet aggregation was always accompanied by aequorin-signals, while at a similar time point, aequorin-signals were absent in 3 of 5 cases in EGTA-platelets. The initial aequorin loading was highest in DMSO-platelets, but Lmax described an exponential decay, which was most pronounced when DMSO-platelets were maintained in Ca(2+)-free buffer (R2 = 0.86). Agonist-induced platelet aggregation was significantly reduced in DMSO-platelets: thrombin-stimulation was accompanied by a significantly lower and delayed [Ca2+]i-rise and no aequorin-signal was obtained in response to ADP in 3 of 5 cases. The study shows that in addition of being a rapid loading-technique, the criteria of high intracellular aequorin load with low luminescence consumption, low basal [Ca2+]i and completely preserved platelet functions are most convincingly met by the HOST-method.


Low molecular weight fibrinogen degradation products stimulate the release of growth factors from endothelial cells. Cultured porcine aortic endothelial cells (PAEC) constitutively produce and secrete in their culture medium mitogens collectively called endothelial cell-derived growth factors (EDGFs). Incubation of PAEC with fibrinogen-degradation products (FDPs) obtained by plasmin digestion of highly purified fibrinogen caused an increased release of EDGFs, as assessed by [3H]-thymidine incorporation in 3T3 mouse fibroblasts. The effect was time-dependent and correlated with the degree of fibrinogenolysis. It was accompanied by elongation of the cells. Neither increase in EDGFs release nor cell damage was observed when non-degraded fibrinogen was incubated with endothelial cells. Low molecular weight fibrinogen degradation products (LMWFDPs) (M(r) less than or equal to 10,000), and the higher molecular weight fibrinogen fragments D and E were tested under the same conditions. Only the LMWFDPs caused elongation and damage to PAEC and a marked stimulation (up to 12 fold) of EDGFs release. A low density growth assay revealed that the released EDGFs were mitogenically active on the same PAEC. The activity of the released EDGFs was time and dose dependent on both 3T3 fibroblasts and PAEC, indicating that LMWFDPs caused enhanced release of EDGFs that can act in paracrine and autocrine fashion. This study suggests an additional role for fibrinogenolysis contributing to wound healing, and possibly to atherosclerosis.


The de-endothelialized rat carotid arterial graft: a versatile experimental model for the investigation of arterial thrombosis. A novel model of arterial thrombosis was developed. A mechanical endothelium-denuding injury was created (using a scalpel blade) on harvested, freezer-stored rat carotid arteries. Vessel length of 5 mm. were grafted into the femoral arteries of recipient Sprague-Dawley rats using microvascular anastomotic technique. Patency rates in untreated animals were compared with those in animals receiving systemic aspirin or heparin. The control group patency after 2 hours of flow was 15%, while grafts in aspirin- and heparin-treated animals achieved 35% and 95% patency rates, respectively. Uninjured non-frozen carotid grafts in untreated animals yielded a 95% patency rate, while frozen grafts achieved an 80% patency. Therapeutic levels of aspirin, heparin, and urokinase were confirmed through tail bleeding and whole blood clotting tests, as well as platelet aggregation studies and scanning electron microscopy of the graft lumenal surfaces. A long-term series using syngeneic grafts placed in recipients (Lewis-to-Lewis) and employing systemic heparinization demonstrated maintenance of patency for 4 weeks. Scanning electron microscopy revealed good re-endothelialization, well advanced by one week. Histology confirmed the regrowth of endothelial cells, but showed sparse cellular repopulation of medial and adventitial layers. The mechanical injury model was compared to enzymatic de-endothelialization (using trypsin or collagenase), for which patency rates were similar (10% and 0%, respectively). Trypsin de-endothelialized vessels were tested in vitro for the amount of active trypsin remaining bound to the lumenal surface; no detectable activity was found when trypsin inhibitor was applied following trypsin treatment. The versatility of allowing both in vitro evaluation and in vivo patency assessment demonstrates the uniqueness and value of this new model, offering an avenue toward more direct investigations of surface-mediated thrombotic processes.


Sphingosine inhibits factor Xa-catalyzed prothrombin activation on the surface of cultured calf pulmonary artery endothelium perturbed by hydrogen peroxide. The effects of hydrogen peroxide on factor Xa-catalyzed prothrombin activation on the surface of vascular endothelial cells, and the inhibitory effect of sphingosine on prothrombin activation were studied in cultured calf pulmonary artery endothelial cells (CPAEC). Hydrogen peroxide enhanced factor Xa-catalyzed prothrombin activation on the cell surface in a time and dose-dependent manner. Sphingosine, a potent inhibitor of protein kinase C and the extrinsic pathway of blood coagulation, showed a partial inhibition of prothrombin activation on the surface of CPAEC. When cells were perturbed by hydrogen peroxide, sphingosine inhibited prothrombin activation and displaced factor Xa bound to the cell surface.


Effects of cyclooxygenase inhibitors on ex vivo cysteinyl-leukotriene production by whole human blood allowed to clot spontaneously. Comparison to stimulated blood. In ex vivo experiments we have investigated the effects of single oral administrations of aspirin (100 or 1000 mg) or ibuprofen (200 or 1200 mg) on the formation of immunoreactive thromboxane (TX) B2 and cysteinyl-leukotrienes (LT) by whole human blood in vitro. Whole human blood was allowed to clot spontaneously and in addition, in the presence of the chemotactic tripeptide f-Met-Leu-Phe (FMLP, 1 microM), or the non-physiological ionophore A 23187 (10 microM). Oral pretreatment with aspirin or ibuprofen led to dose-dependent inhibition of the TXB2 production in the presence of any of the stimuli used. After drug pretreatment the cysteinyl-LT production was not significantly enhanced in blood stimulated with FMLP or allowed to clot spontaneously as compared to values prior to oral drug administration. However, pronounced inhibition of the cyclooxygenase pathway was accompanied by an enhanced cysteinyl-LT formation when ionophore A 23187 was used as a stimulus. This could also be shown in experiments where the cyclooxygenase inhibitors were added in vitro. The higher oral dose of aspirin reduced the ex vivo cysteinyl-LT production in spontaneously clotting blood. By reverse phase HPLC immunoreactive cysteinyl-LT were characterized as a mixture of LTD4 and LTE4 as well as small amounts of LTC4. The data show that in the presence of therapeutic cyclooxygenase inhibitors no enhanced formation of cysteinyl-LT occurs in human blood in vitro after physiological stimuli such as contact activation of the clotting cascade or FMLP.


Changes of the fibrinolytic system in liver dysfunction: role of portal hypertension. The contribution of hemodynamic changes to the pathogenesis of accelerated fibrinolysis in liver disease was investigated in rats. In animals with hepatic lesions induced by a 7-week inhalation of carbon tetrachloride there was a significant increase in blood t-PA activity and PAI activity, with no significant change in portal pressure. Following a 10-min portal vein occlusion there was a marked increase in portal pressure and t-PA activity and a significant decrease in PAI activity. Following ligation of both portal vein and hepatic artery, t-PA activity increased to a higher extent and PAI activity was reduced to a lesser extent than changes found in portal-stenosed rats. Our data suggest that high t-PA circulating levels in liver disease could be related not only to the reduced t-PA clearance as a consequence of liver injury but also to hemodynamic changes.


Combined inherited protein S and heparin co-factor II deficiency in a patient with upper limb thrombosis: a family study. A 42-year-old Italian woman presenting with spontaneous deep vein thrombosis of the right arm, was found to have inherited a deficiency of both protein S (PS) and heparin co-factor II (HC II). The two defects seemed to segregate independently, since her son exhibited only a HC II deficiency while one of her sisters manifested only the PS defect. All affected patients appeared heterozygous for one or other or both deficiency states. The proposita and her sister exhibited a congenital PS deficiency consisting of normal or near normal levels of total PS antigen and C4b-binding protein (C4b-BP) but a moderate reduction both of free PS antigen and of PS functional activity. In addition, the proposita and her son had half normal levels of HC II antigen and activity. Except for the proposita, all were asymptomatic. Inherited deficiencies either of PS or of HC II have been associated with thrombotic manifestations. Since the proposita had an inherited combined defect of the two proteins, severe thrombotic events might be expected. However, this was not found to be the case. The role of HC II deficiency in the pathogenesis of thrombosis whether alone or combined remains to be fully investigated.


An animal model of fibrinolytic bleeding based on the rebleed phenomenon: application to a study of vulnerability of hemostatic plugs of different age. The primary bleeding time is prolonged when tested during the infusion of both plasminogen activators and anticoagulants, and such sites frequently exhibit rebleeding after initial hemostatic control. This study describes an animal (rabbit) model which distinguishes fibrinolytic from anticoagulant hemorrhage and further applies the model to the study of hemostatic plugs of increasing age. In this model, rebleeding occurred from hemostatically-stable ear puncture sites induced prior to infusion of streptokinase (SK) or recombinant tissue-plasminogen activator (rt-PA), but not of heparin or hirudin. This distinction was apparent even for lesions induced only 15 minutes prior to the infusion and fibrinolytic bleeding was observed in such lesions induced up to 24 hours earlier. Post-infusion sites bled more quickly than did pre-infusion sites, and there was a gradual decrease in susceptibility of such prior trauma sites for rebleeding, evidenced not only by a lower proportion of sites that rebled, but also by a longer lag time after starting SK or rt-PA before such rebleeding occurred. At the dosages tested, SK showed a trend (not statistically significant) toward more sites that rebled, while rt-PA showed a trend towards a longer duration of rebleeding. Thus, this animal model of rebleeding appears to be unique for fibrinolytic agents and allows for more detailed study of the physiological mechanisms of such bleeding and for a multifaceted comparison of the bleeding potential of plasminogen activators.


Interaction of factor VIII with phospholipids: role of composition and negative charge. Radiolabelled human anti-FVIII:C antibody was affinity-purified according to its ability to bind to factor VIII-phospholipid (FVIII-PL) complexes, yielding a fraction directed against the phospholipid binding-site (PL-site antibody). This antibody was used as a specific probe for FVIII binding to PL vesicles containing a variety of natural and synthetic PLs. Of purified PLs tested for FVIII binding, phosphatidyl serine (PS) and phosphatidic acid (PA) were highly active, phosphatidyl inositol (PI) much less so, and both phosphatidyl ethanolamine (PE) and phosphatidyl choline (PC) inactive: the apparent dissociation constant (Kd app) for FVIII binding to PS:PC vesicles showed a strong dependence on PS content. Free-flow electrophoresis of vesicles confirmed FVIII binding to PS:PC required both net negative charge and specific head-group: neither PS vesicles given a positive charge with stearylamine nor PC vesicles made negative with dicetyl phosphate bound FVIII. It is concluded that the negative charge required for FVIII binding must be presented on the phospholipid surface in the correct orientation: phosphatidyl serine supplies this charge in coagulant-active PL preparations.


Effects of antithrombotic drug, Y-20811 on mural thrombus formation and intimal thickening following intimal injury. Inhibitory effect of Y-20811 on platelet thrombus formation induced by mechanical intimal injury and subsequent intimal fibrous thickening was studied. In the short term experiment, polyethylene tubing was inserted into the rabbit aorta and was drawn out one hour after with or without Y-20811 administration, then the rabbits were sacrificed. In the experiment for the quantitative analysis of platelet adhesion, 51Cr-labeled platelets were used. Radioactivities of 2cm length of the injured segment of the thoracic aorta and the proximal 2cm of the normal segment were measured. Radioactivity of the injured segment was significantly lower in rabbits treated with Y-20811 than the control ones. The mean thickness (area of thrombi/length of injured intima) and the maximal thickness of the mural thrombi in the Y-20811-treated rabbits were significantly lower than those in control rabbits. De-endothelialized area showed raised platelet thrombi in the control group and diffuse thin-layered platelet sheets in Y-20811-treated rabbits. In the long term experiment, polyethylene tubing was indwelled for 24 hours. Rabbits were sacrificed 10 days after drawing out the tubing. Through the experiment Y-20811 was injected intravenously every 24 hours. There was no significant difference between the control group and the Y-20811-treated one in both mean thickness and maximal thickness of the intimal fibromuscular thickening. The experiments indicate that Y-20811 has an inhibitory effect on platelet thrombus formation following intimal injury, but subsequent myointimal thickening is not inhibited by the drug.


Congenital protein C deficiency and myocardial infarction:concomitant factor VII hyperactivity may play a role in the onset of arterial thrombosis. A 29-year-old man with congenital protein C deficiency and acute myocardial infarction is reported. Four hours after the onset of chest pain, he was treated intravenously with tissue-type plasminogen activator. Subsequent coronary angiography revealed only slight stenosis of the left anterior descending coronary artery without any atherosclerosis. The propositus, his brother, and his mother, showed low levels of both protein C activity and antigen, while plasma thrombomodulin levels were normal. His grandfather had died from acute myocardial infarction at 38 years of age. We investigated several other risk factors for arterial thrombosis, including factor VII, fibrinogen, heparin cofactor II, lipoprotein (a), and anticardiolipin antibodies. No other haemostatic abnormalities apart from factor VII hyperactivity were detected in this family. To study the effects of protein C and factor VII on procoagulant activity, prothrombin time was measured after the addition of activated protein C and factor VII to protein C-deficient plasma. The prothrombin time ratio decreased along with an increase in the factor VII level. It also decreased with a decrease in the activated protein C level. These findings indicated that the procoagulant activity of factor VII was enhanced by low protein C levels, suggesting that concomitant factor VII hyperactivity may cause acute myocardial infarction in patients with protein C deficiency.


Cathepsin G, a regulator of human vitamin K, dependent clotting factors and inhibitors. Cathepsin G was used in vitro to digest human factor VII and factor IX. Clotting assays indicated that the proteinase affected a rapid loss in coagulant activity while in the presence of calcium ions the activity was almost totally protected. SDS-polyacrylamide gel electrophoresis indicated the removal of a peptide from each zymogen, VII-L from factor VII and IX-L from factor IX. This lead to the formation of VII-H and IX-H respectively. N-terminal analysis of the VII-H and IX-H products and COOH-terminal analysis of the VII-L and IX-L products confirmed that cathepsin G had cleaved position Phe40:Trp41 in factor VII and factor IX. The cleavage site is the same as that when cathepsin G is reacted with factor II, factor X and protein C. The unique action of cathepsin G may be part of a regulatory system for controlling the coagulant activity of vitamin K dependent clotting in vivo.


Endogenous heparinase-sensitive anticoagulant activity in human plasma. In this paper we show that an anticoagulant activity, which we measure by thrombin time, appears in human plasma after its exhaustive proteolytic digestion. This activity is extremely heat stable, it is resistant to chondroitin ABC lyase (E.C.4.2.2.4) and heparan sulfate lyase (E.C.4.2.2.8), it is sensitive to heparin lyase (E.C.4.2.2.7) and to nitrous acid treatment: we suggest that it can be identified as authentic heparin. The amount present in 1 ml of plasma of healthy subjects corresponds to 0.1-0.2 I.U. of standard heparin (150 I.U./mg). Proteolytically digested human plasma was submitted to ion-exchange chromatography on DEAE-Sephacel and the anticoagulant activity in the fractions eluted at the different molarities of NaCl was measured by thrombin time. This analysis shows that the anticoagulant activity elutes at very low ionic strength. The possibility that interactions of the endogenous heparin with proteins or protein fragments are responsible for the difficulty in isolating heparin from human plasma is discussed.


Endoglycosidase H digestion of Yukb (Pena) alloantigen. We characterized a platelet specific alloantigen (Yukb). In immunoblotting, anti-Yukb antibody was found to react with both 110 kDa and 96 kDa bands under nonreducing condition. Immunoblotting followed by separation by two-dimensional electrophoresis (isoelectric focusing/SDS-PAGE) showed that the 96 kDa band had a pI of 5.1-5.8, while the 110 kDa band had a pI of 5.2-5.7. The 96 kDa band was identified as glycoprotein (GP) IIIa on the basis of periodic acid Schiff staining, but the 110 kDa band was not characterized. These results implied that it is difficult to determine differences in antigenic epitopes between Yukb and PlA1 antigens by the electrophoresis. Yukb antigen, unlike PlA1 antigen, was partially destroyed by chymotrypsin treatment. Furthermore, endoglycosidase H digestion resulted in loss of the Yukb epitope, while the PlA1 determinant was retained on the three bands with lower molecular weights after endoglycosidase H digestion. The transfer of Yukb antigens recognized by anti-Yukb antibody into the supernatant of platelets treated with endoglycosidase H was also found using mixed passive hemagglutination test. The results indicated that the Yukb epitope might be located to the endoglycosidase H digested N-linked high mannose carbohydrate chains of GP IIIa or hybrid type chains of GP IIIa, which is different from the location of PlA1 epitope.


Antithrombin III, C1 inhibitor, methylglyoxal, and polymorphonuclear leukocytes in the development of vascular complications in diabetes mellitus. Under conditions closely approximating those in vivo (100 mM sodium carbonate pH 7.3 with 0.9% NaCl, 37 degrees C), antithrombin III (AT III) and the C1 inhibitor (C1-INH) are inactivated by methylglyoxal (MG) with pseudofirst-order kinetics and second-order rate constants of 25.2 and 7.8 M-1 min-1, respectively. A study of the functional status of neutrophils from patients with diabetes mellitus (DM) prompts an idea that under hyperglycemia in the diabetic organism the polymorphonuclear leukocytes (PML) endure 'arousal' that is identical or analogous to their activation. Indeed, nonstimulated PML from DM patients display (i) an almost sixfold higher luminol-dependent chemiluminescence and (ii) a double rate of oxygen uptake as compared with those from healthy donors, and (iii) are capable of MG formation in the presence of acetoacetate, which in vivo may be an additional source of this inactivator of AT III and C1-INH in diabetic patients. Conditions leading to ketosis or lactic acidosis are discussed, and a probable scenario is proposed for the organismic deterioration in DM.


Pharmacological profile of a native dermatan sulfate. We performed different "in vivo" investigations to study the pharmacological properties of a native DS: anti-thrombosis by the stasis model, bleeding potential by tail transection bleeding time and template bleeding time, and profibrinolysis by a growing thrombus model and by an established thrombus model. The results suggest that DS is a safe antithrombotic drug by i.v. administration without bleeding potential, even at very high doses (up to 16 mg/Kg). DS has shown a protective index of at least 4 in contrast to heparin that has shown a protective index of 1. The profibrinolytic models so far studied did not evidence a clear profibrinolytic contribution to the antithrombotic properties of DS, but showed a prolonged antithrombotic action that cannot be explained only by the heparin cofactor II potentiation.


Evaluation of plasma D-dimer in the diagnosis and in the course of fibrinolytic therapy of deep vein thrombosis and pulmonary embolism. Blood samples were obtained from patients with deep venous thrombosis (DVT) or pulmonary embolism (PE) after angiographic confirmation as well as during fibrinolytic therapy with streptokinase. Plasma cross-linked fibrin degradation products were measured by a quantitative enzyme-linked immunoassay that recognizes the D-Dimer epitope. 24 patients with PE showed elevated D-Dimer levels (median; 25%-, 75%-quartile) (3,250 ng/ml; 1,270 ng/ml, 6,940 ng/ml) as well as 38 patients presenting with DVT (2,330 ng/ml; 1,760 ng/ml, 3,980 ng/ml). The sensitivity for the diagnosis of PE was 92%, for diagnosis of DVT 89% resp. 100%, depending on the cut-off limit. The D-Dimer level showed a correlation (r = 0.64) to the angiographically documented severity of PE quantified by the Miller's score, in contrast to DVT, where no such correlation could be found. During fibrinolytic therapy median levels rose from 3,020 ng/ml to 63,000 ng/ml within 8 hours and then fell within 6 days to 2,930 ng/ml. 10 patients with PE showed a good correlation (r = 0.72) between the reduction of Miller's score within 72 hours and D-Dimer 24 hours after the onset of therapy. In 17 patients with fibrinolytic treatment of DVT no correlation between D-Dimer and clot lysis could be found. These findings indicate that D-Dimer can provide additional information in the diagnostic procedure of suspected PE. During fibrinolytic therapy of PE with streptokinase, D-Dimer could serve as an early prognostic parameter of successful thrombolysis.


Comparative studies in vitro and ex vivo on the anticoagulant effect of a reversible and an irreversible tripeptide inhibitor of thrombin. Comparative studies on the anticoagulant effect of D-Phe-Pro-Arg-H (ALD) and D-Phe-Pro-Arg-CH2Cl (CMK) were carried out in order to estimate whether the reversible or the irreversible tripeptide inhibitor of thrombin would be more suitable to develop as a novel anticoagulant. Conventional screening assay methods in vitro were focused on the functional stability of the compounds in whole blood and blood components while ex vivo the changes in whole blood clotting time under parenteral application of the inhibitors were investigated. The efficacy of ALD relative to that of CMK was found to depend on the complexity of the test systems. Thus CMK was the more inhibitory in citrated plasma, but ALD showed the higher potency in whole blood. When incubated in various systems such as human whole blood, serum, solutions of isolated plasma proteins, digestive juices and tissue homogenates, respectively, the inhibitory activity of ALD showed only slight decreases for several hours while marked or substantial loss of activity was observed with CMK under identical conditions. ALD administered parenterally to rabbits proved to be powerful anticoagulant; CMK exhibited only a weak and transient anticoagulant effect presumably due to its ability to bind irreversibly to various plasma and tissue proteins. Accordingly, the reversible inhibitor ALD should be more suitable to develop as an anti-coagulant than CMK, its irreversibly acting analogue.