Analysis of APTT Mixing Test Results in Factor Ⅷ Inhibitor-Positive Hemophilia Patients / 中国实验血液学杂志

OBJECTIVE@#To analyze the results of activated partial thromboplastin time (APTT) mixing test in coagulation factor Ⅷ inhibitor-positive hemophilia patients, so as to increase the value of APTT mixing test in the screen of factor Ⅷ inhibitor.@*METHODS@#Eighty plasmas samples with different titers of coagulation factor Ⅷ inhibitors had been collected and diluted for routine immediate APTT mixing test and at 37 ℃ 2 hours incubation APTT mixing test. Fifteen samples were selected for immediate and normal temperature incubation for 15 min, 30min, 1 hour, 2 hours and 37 ℃ for 30 min, 1 hour, 2 hours APTT mixing test.@*RESULTS@#The results of APTT mixing test were significantly correlated with the titers of coagulation factor Ⅷ inhibitors. The ROC curve result showed that the best diagnostic cut-off value for 2 hours incubation APTT mixing test at 37 ℃ to determine the presence or absence of coagulation factor Ⅷ inhibitors was 43.8 s (sensitivity and specificity was 85.90% and 100%, respectively), while the best diagnostic cut-off value for distinguishing high-titer and low-titer Ⅷ inhibitors was 52.4 s (sensitivity and specificity was 98.18% and 95.65%, respectively). The critical coagulation factor Ⅷ inhibitor titer that could not be corrected by immediate APTT was 5.14 BU/ml, while that could not be corrected by 37 ℃ 2 hours incubation APTT was 1.31 BU/ml. Paired samples t -test was performed on the APTT mixing test results at different times and temperatures, and the differences were statistically significant (P < 0.05).@*CONCLUSIONS@#The APTT mixing test can be used as a screening index for coagulation factor Ⅷ inhibitors. APTT mixing test result shows a significant time-temperature dependence with lower titers of coagulation factor Ⅷ inhibitor. Patients with hemophilia who cannot be corrected by immediate APTT mixing test should be alert to the possibility of high titer of coagulation factor Ⅷ.

Factors influencing thrombelastography in pregnancy / 中南大学学报(医学版)

OBJECTIVES@#The number of gestational women has been increased in recent years, resulting in more adverse pregnancy outcomes. It is crucial to assess the coagulation function of pregnant women and to intervene in a timely manner. This study aims to analyze the influencing factors on thrombelastography (TEG) and explore the evaluation of TEG for gestational women.@*METHODS@#A retrospective study was conducted on 449 pregnant women who were hospitalized in the obstetrics department in Xiangya Hospital of Central South University from 2018 to 2020. We compared the changes on the TEG parameters among normal pregnant women between different age groups, different ingravidation groups, and different stages of pregnancy groups. The influence on TEG of hypertensive disorders in pregnancy (HDP) and gestational diabetes mellitus (GDM) as well as two diseases synchronization was explored.@*RESULTS@#Compared with the normal second trimester women, the R values and K values of TEG were increased, and α angle, CI values and LY30 values were decreased in third trimester women (all P<0.05). Compared with normal group, the R values and CI values of TEG of the HDP group have significant difference (both P<0.05). There were no significant difference of TEG between the GDM group, the HDP combined with GDM group and the normal group (all P>0.05). Multiple linear regression analysis showed that the influencing factors for R value in TEG were weeks of gestation (P<0.001) and mode of conception (P<0.05), for α angle was weeks of gestation (P<0.05), for MA value was mode of conception (P<0.05), and for CI value was weeks of gestation (P<0.05). The analysis of correlation between TEG with platelet (PLT) and coagulation routines represented that there was a correlation between TEG R values and activated partial thromboplastin time (APTT) (P<0.01), and negative correlation between TEG CI values and APTT (P<0.05). There was a negative correlation between TEG K values and FIB (P<0.05). The correlation of α angle (P<0.05), MA values (P<0.01) and CI values (P<0.05) with FIB were positive respectively.@*CONCLUSIONS@#The TEG parameters of 3 stages of pregnancy were different. The different ingravidation approach has effect on TEG. The TEG parameters were consistent with conventional coagulation indicators. The TEG can be used to screen the coagulation status of gestational women, recognize the abnormalities of coagulation and prevent the severe complication timely.

Comparative Analysis of Thromboelastogram and Coagulation Items in Mongolian Patients with Thrombosis / 中国实验血液学杂志

OBJECTIVE@#To investigate the age distribution of Mongolian patients with cerebral infarction caused by thrombosis and the correlation and consistency between thromboelastography (TEG) and four parameters of coagulation.@*METHODS@#The age distribution of 298 Mongolian patients with cerebral infarction treated in Affiliated Hospital of Inner Mongolia Minzu University from January 2020 to December 2021 and their TEG, four items of routin coagulation and platelet count were analyzed retrospectively. The correlation and consistency of above-mentioned two detection methods were statistically analyzed.@*RESULTS@#The onset age of 298 Mongolian patients with cerebral infarction was mainly 61-70 years old, accounting for 38.3%, followed by 51-60 years old, accounting for 26.8%. The R time detected by TEG was linearly correlated with PT and APTT（r=0.186，r=0.152）. K value, MA value and α-Angle measured by TEG was linearly correlated with Fib (r=-0.364，r=0.616，r=0.359), K value, MA value and α-Angle measured by TEG was linearly correlated with Plt (r=0.318，r=0.519，r=0.301). The R time detected by TEG was consistent with PT and APTT, and the Kappa values were 0.252 (P<0.001), 0.336 (P<0.001). K, MA, and α-Angle measured by TEG was consistent with Fib, the Kappa values were 0.265 (P<0.001), 0.289 (P<0.001) and 0.290 (P<0.001), respectively; K、MA and α-Angle measured by TEG was consistent with Plt, the Kappa values were 0.276 (P<0.001), 0.285 (P<0.001) and 0.302 (P<0.001), respectively.@*CONCLUSION@#The onset age of Mongolian patients with cerebral infarction caused by thrombosis is mainly 61-70 years old, followed by 51-60 years old. The onset age shows a younger trend. There is a significant correlation between TEG and coagulation, but the consistency is weak, therefore, the two methods can not be replaced each other.

Delayed double reading of whole blood clotting test (WBCT) results at 20 and 30 minutes enhances diagnosis and treatment of viper evenomation

The whole blood clotting test (WBCT) is a simple test of coagulation that is often used in the assessment, diagnosis, and therapeutic monitoring of snakebite patients in sub-Saharan Africa. WBCT requires only a clean glass tube and several milliliters of venous blood and is ideal for use in poorly equipped health centers throughout the rural areas where 95% of snakebites occur. However, questions surrounding the accuracy and reliability of the test remain unanswered due to variations in testing conditions and a lack of comparative research with which to validate them. This is the first study to evaluate WBCT results at both 20-min (WBCT20) and 30-min (WBCT30) reading times in the same group of snakebite patients. Methods In order to define the best reading time, the authors compared the results of serial WBCT evaluation at both 20 and 30 min after collection in 23 patients treated for snake envenomation in Bembèrèkè, northern Benin. Results WBCT results were identical at both reading times in patients without coagulopathy or when coagulation was restored permanently following a single dose of antivenom. Out of 17 patients with coagulopathy, 14 showed discrepancies between WBCT20 and WBCT30 results in at least one pair of serial evaluations. These could be completely contradictory results (e.g. normal clot at WBCT20 and no clot at WBCT30) or a marked difference in the quality of the clot (e.g. no clotting activity at WBCT20 and an unstable partial clot at WBCT30). WBCT discrepancies were encountered most frequently in three situations: initial normalization of hemostasis following antivenom therapy, detection of a secondary resumption of coagulopathy, or final restoration of hemostasis after a secondary resumption had occurred. Conclusions This study suggests that the WBCT is robust and that a sequential reading should improve the diagnosis and monitoring of venom-induced coagulopathies. It also indicates the possibility of discrepancies in the sensitivity of WBCT20 and WBCT30 for detecting the resolution or reoccurrence of coagulopathy and identifies how these findings, if confirmed, may be used to increase the efficacy and efficiency of antivenom treatment in the field.(AU)

Delayed double reading of whole blood clotting test (WBCT) results at 20 and 30 minutes enhances diagnosis and treatment of viper evenomation

The whole blood clotting test (WBCT) is a simple test of coagulation that is often used in the assessment, diagnosis, and therapeutic monitoring of snakebite patients in sub-Saharan Africa. WBCT requires only a clean glass tube and several milliliters of venous blood and is ideal for use in poorly equipped health centers throughout the rural areas where 95% of snakebites occur. However, questions surrounding the accuracy and reliability of the test remain unanswered due to variations in testing conditions and a lack of comparative research with which to validate them. This is the first study to evaluate WBCT results at both 20-min (WBCT20) and 30-min (WBCT30) reading times in the same group of snakebite patients. Methods In order to define the best reading time, the authors compared the results of serial WBCT evaluation at both 20 and 30 min after collection in 23 patients treated for snake envenomation in Bembèrèkè, northern Benin. Results WBCT results were identical at both reading times in patients without coagulopathy or when coagulation was restored permanently following a single dose of antivenom. Out of 17 patients with coagulopathy, 14 showed discrepancies between WBCT20 and WBCT30 results in at least one pair of serial evaluations. These could be completely contradictory results (e.g. normal clot at WBCT20 and no clot at WBCT30) or a marked difference in the quality of the clot (e.g. no clotting activity at WBCT20 and an unstable partial clot at WBCT30)...

Comparación de la detección foto óptica vs. electromecánica del coágulo / Comparison of mechanical vs. optical clot detection / Comparação da detecção foto-óptica vs. eletromecânica do coágulo

El objetivo de este estudio fue determinar si la detección foto óptica del coágulo es equivalente a la detección electromecánica al realizar el tiempo de protrombina (TP), el tiempo de tromboplastina parcial activado (APTT) y el dosaje de fibrinógeno (FBG). Se estudiaron 258 pacientes consecutivos que concurrieron al laboratorio para realizar estudios de hemostasia. Se utilizaron tres coagulómetros: ACL TOP (foto-óptico) y STArt y Destiny plus como detección electro mecánica. EL TP, APTT y FBG fueron realizados en todos los equipos antes de transcurridas tres horas de la toma de la muestra. Se obtuvo una buena correlación entre los resultados obtenidos con ambos métodos de detección TP (%): (ACL TOP vs. STArt R=0,989; ACL TOP vs. Destiny plus R=0,988), APTT: (ACL TOP vs. STArt R=0,938; ACL TOP vs. Destiny Plus R=0,989), y FBG (ACL TOP vs. STArt R=0,97; ACL TOP vs. Destiny Plus R=0,984). La diferencia de los resultados entre plataformas son menores al error total permitido establecido por los criterios de CLIA (ETa TP y APTT =15% y FBG 20%) en el 95% de las muestras. En los tres coagulómetros evaluados, correctamente mantenidos y calibrados, la detección foto-óptica arrojó resultados equivalentes a la detección electromecánica.

The aim of this study was to determine whether two distinct methodologies based on optical or mechanical clot detection are comparable. Prothrombin time (PT), activated partial thromboplastine time (APTT) and fibrinogen results obtained with mechanical method using two different coagulometers are compared with those obtained by photo optical method within three hours of blood collection. The statistical analysis demonstrated an excellent correlation between optical or mechanical platform for TP, APTT and FBG. TP (%) showed (ACL TOP vs. STArt R=0.989; ACL TOP vs. Destiny Plus R=0.988), APTT: (ACL TOP vs. STArt R=0.938; ACL TOP vs. Destiny Plus R=0.989) y FBG (ACL TOP vs. STArt R=0.97; ACL TOP vs. Destiny Plus 0.984). The differences between optical or mechanical clot detection results are lower than the total error allowable in 95% of the studied samples. To conclude with, the three coagulometers evaluated have maintenance performed and are calibrated according to the international guidelines, and the results obtained with an optical or mechanical clot detection method are equivalent.

O objetivo deste estudo foi determinar se a detecção foto-óptica do coágulo é equivalente à detecção eletromecânica ao realizar o tempo de protrombina (TP), o tempo de tromboplastina parcial ativado (APTT) e a dosagem de fibrinogênio (FBG). Foram estudados 258 pacientes consecutivos que concorreram ao laboratório para realizar estudos de hemostasia. Foram utilizados três coagulómetros: ACL TOP (foto-óptico) e STArt e Destiny plus como detecção eletromecânica. O TP, APTT e FBG foram realizados em todos os equipamentos antes de decorridas três horas da tomada da amostra. Uma boa correlação foi conseguida entre os resultados obtidos com ambos os métodos de detecção TP (%): (ACL TOP vs. STArt R=0,989; ACL TOP vs. Destiny plus R =0,988), APTT: (ACL TOP vs.STArt R=0,938; ACL TOP vs. Destiny Plus R=0,989), e FBG (ACL TOP vs. STArt R=0,97; ACL TOP vs. Destiny Plus R=0,984). A diferença dos resultados entre plataformas é menor ao erro total permitido estabelecido pelos critérios de CLIA (ETa TP e APTT =15% e FBG 20%) em 95% das amostras. Nos três coagulómetros avaliados, corretamente mantidos e calibrados a detecção foto-óptica lança resultados equivalentes à detecção eletromecânica.

Tromboelastometría ROTEM® delta vs. tromboelastografía clásica y pruebas tradicionales de hemostasia / Thromboelastometry ROTEM® delta vs Thromboelastography and classical hemostasis tests / Tromboelastometria ROTEM® delta vs. tromboelastografia clássica y testes tradicionais de hemostasia

La tromboelastometría (TEM) y tromboelastografía (TEG) describen la interacción entre factores de coagulación, fibrinógeno, plaquetas y sistema fibrinolítico en tiempo real, evaluando las características cinéticas y viscoelásticas del coágulo. El objetivo del estudio fue correlacionar parámetros de TEM y TEG, con tiempo de protrombina (TP), tiempo de tromboplastina parcial activado (APTT), fibrinógeno y recuento plaquetario. Se estudió una población comparativa de TEM-TEG de 27 muestras y de TEM-Pruebas clásicas de coagulación de 141 muestras de pacientes con distintas patologías, tratamientos anticoagulantes y procedimientos quirúrgicos. Los TEMogramas fueron: Tromboelastómetro ROTEM® delta (Tem International GmbH) con reactivos INTEM (ácido elágico + Ca+2), EXTEM (factor tisular + Ca+2) y FIBTEM (EXTEM con Inhibidor de plaquetas); TEG: reactivo Cl2Ca, Tromboelastógrafo (D Hellige). Se efectuaron TP (% actividad), APTT (seg) y Fibrinógeno (mg/dL) con reactivos HemosIL (Instrumentation Laboratory) y coagulómetros ACL TOP. Se usó el Test de Pearson (IBM, SPSS 22). Se obtuvieron correlaciones: Muy buenas: a) amplitudes TEM y TEG, r=0,879 y 0,843, p<0,001, para EXTEM e INTEM, b) amplitudes FIBTEM con Fibrinógeno r=0,912, p<0,001, c) tiempos de coagulación (reacción) y de formación del coágulo (amplitud 20 mm), INTEM y TEG r=0.918 y 0,919, p<0,001, d) Lisis máxima EXTEM y TEG r=0,937, p<0,001. Moderadas: a) tiempo formación del coágulo, EXTEM y TEG r=0,782 p<0,001, b) amplitudes con fibrinógeno y plaquetas, r=0,718 y 0,611, p<0,001 para EXTEM, 0,680 y 0,545, p<0,001 para INTEM; c) tiempo de coagulación INTEM y APTT r=0,693, p<0,001. Los parámetros de TEM y TEG correlacionaron muy bien, a excepción del tiempo de coagulación con EXTEM y TEG, dado que utilizan distinto principio para activar coagulación. El análisis de las pruebas clásicas confirmó la alta correlación entre amplitudes del FIBTEM y niveles de fibrinógeno y la mejor correlación entre los tiempos de coagulación del INTEM con APTT que los de EXTEM con TP.

Thromboelastometry (TEM) and thromboelastography (TEG) describe the interaction between coagulation factors, fibrinogen, platelets and fibrinolytic system in real time by the evaluation of the kinetic and viscoelastic characteristics of the clot. The objectives of the study were to correlate TEM with TEG parameters, and with prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen and platelet count. A comparative population of 27 TEM-TEG samples was studied and of TEM-classical coagulation tests of 141 samples from patients with different pathologies, under anticoagulant treatments and surgical procedures. The TEMograms were: Tromboelastometry ROTEM® delta (Tem International GmbH) with INTEM reactants (ellagic acid + Ca2+), EXTEM (tissue factor + Ca2+) and FIBTEM (EXTEM with platelet inhibitor); reactant TEG: Cl2Ca, Tromboelastograph (D Hellige). PT were performed (% activity), APTT (sec) and Fibrinogen (mg/dL) with HemosIL (Instrumentation Laboratory) and ACL TOP coagulometers. The Pearson Test was used (IBM,SPSS 22). The following correlations were obtained: Very good: a) TEM and TEG amplitudes, r=0.879 and 0.843, p<0.001, for EXTEM and INTEM, b) FIBTEM amplitudes with Fibrinogen r=0.912, p<0.001, c) coagulation times (reaction) and clot formation (20 mm amplitude), INTEM and TEG r=0.918 and 0.919, p<0.001, d) Maximum Lysis EXTEM and TEG r=0.937, p<0.001; and Moderate: a) clot formation EXTEM and TEG r=0.782 p<0.001; b) fibrinogen and platelet amplitudes, r=0.718 and 0.611, p<0.001 for EXTEM, 0.680 and 0.545, p<0.001 for INTEM; c) coagulation time INTEM and APTT r=0.693, p<0.001. TEM and TEG parameters correlate very well, except for the coagulation time with EXTEM and TEG, given they use a different principle to activate coagulation. The analysis of the classic tests confirmed the high correlation between FIBTEM amplitudes and the levels of fibrinogen and a better correlation between INTEM coagulation times with APTT than those of EXTEM with TP.

A tromboelastometria (TEM) e tromboelastografia(TEG) descrevem a interação entre fatores de coagulação, fibrinogênio, plaquetas e sistema fibrinolítico em tempo real, avaliando as características cinéticas e viscoelásticas do coágulo. O objetivo do estudo foi correlacionar parâmetros de TEM e TEG, com tempo de protrombina (TP), tempo de tromboplastina parcial ativado (APTT), fibrinogênio e contagem de plaquetas. Foi estudada uma população comparativa de TEM-TEG 27 amostras e de TEM-Testes clássicos de coagulação de 141 amostras de pacientes com diversas patologias, tratamentos anticoagulantes e procedimentos cirúrgicos. Os TEMogramas foram: Tromboelastômetro ROTEM® delta (Tem International GmbH) com reagentes INTEM (ácido elágico + Ca2+), EXTEM (fator tissular + Ca2+) e FIBTEM (EXTEM com Inibidor de plaquetas); TEG: reagente Cl2Ca, Tromboelastógrafo (D Hellige). Foram realizados TP (% atividade), APTT (seg) e Fibrinogênio (mg/dL) com HemosIL (Instrumentation Laboratory) e coagulômetros ACL TOP. Utilizou-se o Teste de Pearson (IBM,SPSS 22). Foram obtidas correlações: Muito boas: a) amplitudes TEM e TEG, r=0,879 e 0,843, p<0,001, para EXTEM e INTEM, b) amplitudes FIBTEM com Fibrinogênio r=0,912, p<0,001, c) tempos de coagulação (reação) e de formação do coágulo (amplitude 20 mm), INTEM e TEG r=0.918 e 0,919, p<0,001, d) Lise máxima EXTEM e TEG r=0,937, p<0,001. Moderadas: a) tempo formação do coágulo, EXTEM e TEG r=0,782 p<0.001, b) amplitudes com fibrinogênio e plaquetas, r=0,718 y 0,611, p<0,001 para EXTEM, 0,680 e 0,545, p<0,001 para INTEM; c) tempo de coagulação INTEM e APTT r=0,693, p<0,001. Os parâmetros de TEM e TEG correlacionaram muito bem, exceto o tempo de coagulação com EXTEM e TEG, devido a que utilizam diferente princípio para ativar coagulação. A análise dos testes clássicos confirmou a alta correlação entre amplitudes do FIBTEM e níveis de fibrinogênio e a melhor correlação entre os tempos de coagulação do INTEM com APTT que os de EXTEM com TP.

Generalidades del sistema de la coagulación y pruebas para su estudio / Overwiew of the Coagulation System and laboratory tests for its study

En la década de los años sesenta, se describió la cascada de la coagulación como una secuencia de eventos enzimáticos iniciada por dos vías, la intrínseca y la extrínseca, las cuales convergían en una vía común para generar una enzima multifuncional, denominada trombina. La principal función de esta enzima consistía en transformar el fibrinógeno, en fibrina, una proteína que se polimeriza espontáneamente para formar la base estructural del coágulo. Posteriormente, se propuso el Modelo Celular según el cual la coagulación no es la consecuencia de vías de activación enzimáticas secuenciales, sino de una red de interacciones entre proteínas plasmáticas y transmembranas, así como, varios tipos celulares, que permiten la formación de complejos enzimáticos altamente eficientes con la finalidad de generar trombina. Esta revisión explica en detalle ambos enfoques, además, aborda las diferentes funciones que cumple la trombina dentro de la hemostasia y los mecanismos de inhibición que regulan la coagulación. Finalmente, se describen diferentes pruebas empleadas en la actualidad para evaluar la funcionalidad del sistema de coagulación, como: el tiempo de tromboplastina parcial activado, el tiempo de protrombina, el tiempo de trombina, el tiempo de reptilasa, el tiempo de coagulación por ecarina y el uso de sustratos cromogénicos para evaluar cada factor de la coagulación. Finalmente, dado a que la generación de trombina es clave dentro de la coagulación y a que el potencial de generar trombina puede indicar propensión a desarrollar eventos trombóticos o hemorrágicos, en este trabajo se presentan los métodos existentes para determinar la generación de trombina.

In the sixties, the clotting cascade was proposed, which describes the coagulation process as a sequence of enzymatic events initiated by two different pathways, the intrinsic and the extrinsic pathways, converging on a common pathway, to generate a multifunctional enzyme, thrombin, whose main function is to convert fibrinogen into fibrin, a protein that polymerizes spontaneously to form the building block of a hemostatic clot. Later, it was proposed a cell-based model of the hemostasis according to that coagulation does not occur as a consequence of linear sequential enzyme activation pathways, but rather via a network of simultaneous interactions between plasmatic and transmembrane proteins, as well as several cellular types, that allow the formation of highly efficient enzymatic complexes that lead to thrombin generation. In this review, we summarize these two approaches highlighting the functions of thrombin within the hemostasis and the inhibition mechanisms that regulate the blood coagulation. Moreover, we described different tests that are used to assess the function of the coagulation system, such as: activated partial thromboplastin time, prothrombin time, thrombin time, reptilase time, ecarin clotting time, and the use of chromogenic substrates to evaluate individual coagulation factors. Finally, because of thrombin generation is a fundamental part of the blood coagulation and, an estimation of how well a particular individual can generate thrombin may correlate with either a risk of bleeding or thrombosis, we also include the existing methods to evaluate the potential of thrombin generation in an individual.

El "chaco": arcilla medicinal comestible del altiplano peruano y sus propiedades en la patología digestiva / The "Chaco": eatable medicinal clay in the Peruvian highlands and his properties in digestive diseases

Los pobladores del altiplano peruano-boliviano consumen una sustancia natural conocida como "chaco", muy difundida desde la época precolombina y apreciada por sus propiedades digestivas. El Chaco es una arcilla medicinal comestible que es usada en forma de suspensión con agua para cohibir molestias dispépticas o manifestaciones ácido-pépticas. En esta contribución damos a conocer aspectos físico-químicos de la composición del Chaco, estudios experimentales en animales que evalúan su efecto antiulceroso y una prueba in vitro que estudia su propiedad antiácida. El mecanismo de acción terapéutico propuesto se debe a una acción citoprotectora sobre la mucosa gástrica por mecanismos independientes de la inhibición de la secreción ácida, ya que no posee propiedad antiácida in vitro. Además tiene una capacidad de adsorción a distintas moléculas orgánicas debido a su gran superficie externa y carga tetraédrica que hace que interaccione con sustancias polares como el agua y toxinas. El otro propósito de esta contribución especial, es reconocer la coexistencia de la "Medicina Tradicional" y la "Medicina Occidental", situación que conlleva a la necesidad de la investigación preclínica de diversos recursos naturales.

The inhabitants of the peruvian-bolivian plateau consume a natural substance known as "Chaco", widespread since pre-Columbian era and appreciated for its digestive properties. The Chaco is an edible medicinal clay that is used as slurry with water to restrain dyspeptic discomfort or acid-peptic manifestations. In this contribution we present physicochemical aspects of the composition of the Chaco, experimental animal studies that evaluate its antiulcer effect and in vitro test that studies the antacid property. The proposed mechanism of therapeutic action is due to a cytoprotective effect on the gastric mucosa by independent mechanisms of acid secretion inhibition, as it has no antacid property in vitro. Also it has an adsorptivity to different organic molecules due to their large surface area and tetrahedral charge that makes it to interact with polar substances such as water and toxins. The other purpose of this special contribution is to recognize the coexistence of "Traditional Medicine" and "Western Medicine", a situation which leads to the need for preclinical research of various natural resources.

Evaluación de la hemostasia en niños con Síndrome de Ehlers-Danlos tipo III / Hemostasis evaluation in children with type III Ehlers-Danlos syndrome

Introducción: Aunque no se ha demostrado la existencia de alteraciones de la hemostasia que formen parte del cuadro clínico del síndrome de Ehlers-Danlos, se han reportado diversas alteraciones de la coagulación en casos aislados, como son eficiencia y alteraciones de la movilidad electroforética de la fibronectina, disfunción de la agregación plaquetaria con prolongación del tiempo de sangramiento, deficiencia de factores VIII, IX, XII y XIII y aumento de la sensibilidad a la aspirina, entre otras. Objetivo: Evaluar la existencia de alteraciones de la hemostasiaen niños con síndrome de Ehlers-Danlos tipo III. Métodos: Se realizó una investigación aplicada, observacional, descriptiva y transversal en 305 niños con síndrome de Ehlers-Danlos tipo III para evaluar, en aquellos con historia de manifestaciones hemorrágicas, la existencia de alteraciones de la hemostasia.Previa suspensión de drogas con acción antiagregante plaquetaria, a todos los pacientes se les realizaron estudios decoagulación y función y agregación plaquetaria. Resultados: En 181 pacientes se encontró historia de sangramiento espontáneo o traumático, predominantemente cutáneo-mucoso. Elcoagulograma fue normal en todos los casos y el extendido de sangre periférica mostró la presencia de macroplaquetas y escasa formación de grumos como alteración frecuente. Las pruebas de agregación y función plaquetaria evidenciaron la existencia de trastornos cualitativos con predominio de la disminución de la agregación con ADP, sola o combinada con epinefrina y colágeno, y con menor frecuencia trastornos de la disponibilidad de los fosfolípidos plaquetarios. La mayoría de estos pacientes habían utilizado antihistamínicos (ketotifeno) por diversas causas. Conclusiones: Se reporta la presencia de defectos cualitativos plaquetarios en niños con síndrome de Ehlers-Danlos tipo III destacándose el papel de la utilización de drogas antihistamínicas en la aparición de manifestaciones hemorrágicas en estos pacientes

Introduction: Although the existence of hemostasis disorders as part of type-III Ehlers-Danlos syndrome has not been confirmed, several coagulation alterations have been reported in isolated cases such as: deficiencies and modification in electrophoresis mobility of fibronectin, dysfunction of platelet aggregation with lengthening of bleeding time, deficiency of VIII, IX, XII and XIII factors and increase of aspirin sensitivity, among others. Objective: Evaluate the existence of hemostasis disorders in children with type III Ehlers-Danlos syndrome. Method: an applied, observational, descriptive and cross-sectional research was carried out in 305 children suffering from type-III Ehlers_Danlos syndrome to evaluate in those having history of hemorrhagic manifestations, the existence of alterations of the hemostasis. Previous suspension of drugs with platelet anti-aggregation action, coagulation and platelet aggregation function studies were carried out. Results: The study revealed that 181 patients presented history of spontaneous or traumatic bleeding mainly mucous-cutaneous. Coagulogram was normal in all cases and peripheral-blood smears showed the presence of macro-platelets and deficient formation of clots as the most frequent alteration. Aggregation and platelet function tests evidenced the presence of qualitative disorders, where a decrease of aggregation prevailed with the use of adenosine diphosphate (ADP), alone or combined with epinephrine and collagen, and with less frequency, disorders of of platelet phospholipids availability. The majority of these patients presented history of long-lasting use of antihistamines (ketotifen) due to diverse causes. Conclusions: The occurrence of these qualitative platelet defects in children with EDS-type III is reported, standing out the role of the use of antihistamine drugs on the onset of the hemorrhagic symptoms in these patients

Coagulopatía asociada a transfusión masiva / Coagulopathy associated to massive transfusion

La coagulopatía asociada a transfusión masivaes un importante problema clínico. Los pacientesque presentan hemorragias severas son tratadosen forma empírica guiados por evidencias clínicas.A su vez, la producción de los hemocomponentespor parte del Banco de sangre requiere de tiempo,equipamiento, personal capacitado, además de losinsumos correspondientes, lo que genera un altocosto económico; son un recurso limitado y no estánexentos de efectos adversos. La tromboelastografíaaporta una interpretación fisiopatológica delmotivo del sangrado, y por lo tanto, permitiría unamejor elección de la droga y/o del soporte transfusional.Tanto el método TEG como el métodoROTEM son estudios altamente sensibles y específicos,permiten evaluar el estado hemostáticoen tiempo real y a la cabecera del paciente, lo quederiva en una mejor elección de la terapeútica a implementar.Algunos de los interrogantes a resolverson la injerencia del uso de estas pruebas sobre lamortalidad de pacientes que presentan sangradosmasivos, evaluar el costo/beneficio de la implementaciónde esta técnica dada la necesidad de personalentrenado para el manejo de la técnica y lainterpretación de los resultados, la validación de latécnica y la implementación de protocolos de transfusióny/o drogas hemostáticas para las distintascausas de sangrado masivo.

Coagulopathy secondary to massive transfusionis a well-known clinical problem. Patients with severebleeding are treated empirically, guided onlyby clinical evidence. At the same time, blood banksrequire time, equipment, trained staff in addition tothe appropriate supplies to produce blood products.These are expensive scarce resources and theymay have undesirable side effects. Thromboelastographyprovides an physiopathologic explanationof bleeding, and for this reason it would allow a betterchoice of drugs and/or transfusional support.TEG as well as ROTEM have high sensibility andspecificity. They help to establish the patient’s haemostaticstate at bedside in real time, and thus helpto choose the best treatment. There are still somequestions to be answered, such as the benefit inmortality when this test is used in patients with massivebleeding; the cost benefit of the implementationof this technique given the necessity of trained stafffor the use of the device and the interpretation ofthe results, the validation of the technique and theimplementation of guidelines for transfusion and/oruse of haemostatic drugs in patients with massivebleeding from different causes.

In vivo evaluation of homeostatic effects of Echis carinatus snake venom in Iran

Background: The venom of the family Viperidae, including the saw-scaled viper, is rich in serine proteinases and metalloproteinases, which affect the nervous system, complementary system, blood coagulation, platelet aggregation and blood pressure. One of the most prominent effects of the snake venom of Echis carinatus (Ec) is its coagulation activity, used for killing prey. Materials and methods: Subfractions F1A and F1B were isolated from Ec crude venom by a combination of gel chromatography (Sephadex G-75) and ion exchange chromatography on a DEAE-Sepharose (DE-52). These subfractions were then intravenously (IV) injected into NIH male mice. Blood samples were taken before and after the administration of these subfractions. Times for prothrombin, partial thromboplastin and fibrinogen were recorded. Results and conclusions: Comparison of the prothrombin time before and after F1A and F1B administrations showed that time for blood coagulation after injection is shorter than that of normal blood coagulation and also reduced coagulation time after Ec crude venom injection. This difference in coagulation time shows the intense coagulation activity of these subfractions that significantly increase the coagulation cascade rate and Causes to quick blood coagulation. The LD50 of the Ec crude venom was also determined to be 11.1 µg/mouse. Different crude venom doses were prepared with physiological serum and injected into four mice. Comparison of the prothrombin times after injection of subfractions F1A and F1B showed that the rate of mouse blood coagulation increases considerably. Comparing the partial thromboplastin times after injecting these subfractions with this normal test time showed that the activity rate of intrinsic blood coagulation system rose sharply in mice. Finally, by comparing the fibrinogen time after subfraction injections and normal test time, we can infer intense activation of coagulation cascade and fibrin production.(AU)

Pruebas del coagulograma y componentes de la hemostasia. Utilidad para diagnosticar las diátesis hemorrágicas / Tests of coagulation and hemostasis components. Usefulness for diagnosing hemorrhagic diathesis

El coagulograma comprende un conjunto de pruebas que exploran la participación de todos los componentes de la hemostasia: endotelio vascular, actividad plaquetaria, factores plasmáticos y fibrinolíticos. Con frecuencia, la ejecución de estas pruebas resulta compleja para el personal técnico, por lo que la profundización en el conocimiento e interpretación de los resultados de cada una de estas, debe redundar en el fortalecimiento y preparación de los profesionales de la salud. En el presente trabajo se describen las principales pruebas del coagulograma convencional, el principio y los valores de referencia de cada una, así como las posibles enfermedades de acuerdo con la alteración del sistema hemostático que corresponde a la alteración del coagulograma, con el objetivo de brindarle al médico una información básica para la correcta ejecución y adecuada interpretación de los resultados

Coagulogram comprises a set of tests, which explore the participation of all components of hemostasia: vascular endothelium, platelet activity, plasma and fibrinolytic factors. Often, the technical staff finds complex to do these tests, so deepening knowledge, understanding, and interpreting the results of each of these tests should result in strengthening and training of health professionals. This paper describes the main conventional coagulation tests, the beginning and the reference values of each of them, and the possible diseases according to the alteration of the hemostatic system corresponding to the alteration of coagulation, with the aim of providing medical background information for the proper performance and proper interpretation of results

Effect of natural honey on human platelets and blood coagulation proteins

Present study was conducted to determine the effects of honey on blood hemostasis, in-vitro effect of honey was observed on platelet aggregation and blood coagulation employing, activated partial prothrombin time [aPTT], prothrombin time [PT], thrombin time [TT] and fibrinogen levels in blood. Honey samples showed moderate inhibition of platelet aggregation with IC[50] 5-7.5%. The coagulation assays showed that at higher concentrations [>/= 15%] honey samples increased whole blood clotting time. When assayed in platelet poor plasma [PPP], honey samples significantly [P >/= 0.005] prolonged aPTT, PT, and TT. The honey samples [at 3.75% and 7.5% concentrations] cause mean increment of aPTT = 19 +/- 10% and 62 +/- 10%; PT 6 +/- 5% and 40 +/- 5%; TT 35 +/- 15% and 112 +/- 30% respectively. Moreover, PPP isolated from whole blood pre-incubated with honey samples [9.0% for 10 minutes] showed mean prolongation of aPTT, PT and TT of 45 +/- 21%, 26 +/- 9% and 105 +/- 24% respectively. Interestingly, incubation of honey at 6.25% and 11.75% concentrations in PPP considerably [P >/= 0.005] reduced fibrinogen levels i.e. 13 +/- 4% and 86 +/- 30% respectively. The present study outlines the inhibitory effect of natural honey on platelet aggregation and blood coagulation. These observations provide first line data for modulatory role [s] of honey on process of hemostasis

Avaliação do desempenho analítico do coagulômetro automatizado Sysmex® Ca-1500: experiência do Hospital de Clínicas da UFPR / Performance evaluation of the Automated Coagulation Analyzer Sysmex® Ca-1500: experience of the Hospital de Clínicas of UFPR

O Sysmex® CA-1500 é um analisador automatizado de coagulação que detecta a formação de fibrina por princípio ótico.A avaliação do seu desempenho analítico foi realizada através de testes de precisão, reprodutibilidade, arraste e linearidade, além de ensaios para verificar a influência de fatores pré-analíticos como relação anticoagulante / sangue e hemólise nas determinações deTP, TTP, TT e fibrinogênio. Além disso, os resultados de TP e TTP foram correlacionados com os obtidos no coagulômetro ST4, Diagnostica STAGO, que utiliza o método eletromagnético para a detecção do coágulo de fibrina. Observou-se grande variação dosresultados sobre a influência da hemólise (TP: 0,91 a 2,33%; TTP: 1,37 a 6,54% e TT: 1,38 a 12,72%) e relação anticoagulante/sangue (TP: 1,39 a 659,3%; TTP: 2,93 a 275,2%, TT: 4,0 a 128% e fibrinogênio: 3,4 a 32,2%), quando comparados com amostras sem hemólise e com a relação anticoagulante /sangue de 1:9. A porcentagem de arraste foi (TP: 0,75%, TTP: 0,50% e fibrinogênio: 5,65%). Aprecisão intraensaio para TP, TTP, TT e fibrinogênio obteve CV < 3% para plasmas normais e patológicos, assim como a reprodutibilidade interensaios em plasma normal liofilizado e pool de plasmas de pacientes normais. As correlações para TP e TTP entre os doiscoagulômetros avaliados obteve valores de r ≥ 0,90. A linearidade foi boa até aproximadamente 650 mg/dL de fibrinogênio e obteve r = 0,981. Os resultados obtidos demonstraram que o CA-1500 realiza os testes de coagulação com desempenho analítico satisfatório.

The Sysmex® CA-1500 is an automated coagulation analyzer that detects the formation of fibrin clot by optical principle.The evaluation of its analytical performance was accomplished through tests of precision, reproducibility, linearity and carryover, as well as tests to check the influence of pre-analytical factors such as the anticoagulant / blood ratio and hemolysis on the determinations of PT, PTT, TT and fibrinogen. Moreover, the results of PT and PTT were correlated with those obtained in the ST4 coagulometer, Diagnostica Stago, using the eletromagnetic method for the detection of fibrin clot. We found great variation inresults under the influence of hemolysis (PT: 0,91 to 2,33%, PTT: 1,37 to 6,54% and TT: 1,38 to 12,72%) and anticoagulant / blood ratio (PT: 1,39 to 659,3%, PTT: 2,93 to 275,2%, TT: 4,0 to 128% and fibrinogen: 3,4 to 32,2%) compared with samples withouthemolysis and the ratio of 1:9 anticoagulant / blood. The percentage of carryover was (PT: 0,75%, PTT: 0,50% and fibrinogen: 5,65%). The intra-assay precision for PT, PTT, TT and Fibrinogen had CV < 3% for normal and abnormal plasmas, as well as interassayreproducibility in normal lyophilized plasma and normal pooled plasma. The correlations between TP and TTP on the two evaluated coagulometers obtained r values ≥ 0,90. The linearity was good up to about 650 mg/dl of fibrinogen and obtained r = 0,981. The results showed that CA-1500 perform coagulation tests with satisfactory analytical performance.

Usefulness of Silica Clotting Time for Detection of Lupus Anticoagulants / 대한진단검사의학회지

BACKGROUND: The presence of lupus anticoagulants (LA) is a strong risk factor for thrombosis in antiphospholipid syndrome. We investigated the usefulness of addition of silica clotting time (SCT) to the pre-existing dilute Russell's viper venom test (dRVVT) for detection of LA. Also, we analyzed differences in the thrombotic features and the characteristics of antiphospholipid antibodies between dRVVT and SCT. METHODS: A total of 167 patients positive for LA or anti-cardiolipin (anti-CL) antibody and 76 healthy controls were enrolled. The dRVVT and SCT were used for detection of LA. Anti-CL, anti-beta2-glycoprotein I (anti-beta2 GPI) and anti-prothrombin (anti-PT) antibodies were measured using commercial ELISA kits. RESULTS: In detection of thrombosis, the sensitivity of the combined test of SCT and dRVVT was 56.4%, which was higher than that of dRVVT alone (46.2%) or SCT alone (23.1%). The specificity of the combined test (80.9%) was comparable to that of dRVVT (81.9%). Also, odds ratio for predicting thrombosis was higher in the combined test than in dRVVT or SCT alone. When normalized LA ratio of the two tests was compared, the group of patients with higher ratio of SCT showed significantly higher prevalence of recurrent abortion and higher positivity of IgG types of anti-CL, anti-beta2 GPI and anti-PT than the group with higher ratio of dRVVT. CONCLUSIONS: Addition of SCT to dRVVT can improve the detection sensitivity of thrombosis in LA test. And the high normalized LA ratio of SCT may be a useful parameter for detection of recurrent abortion.

Adequação de um sistema de hemodiálise em eqüinos / Adequacy of hemodialysis system in horses

Realizou-se a adequação da técnica de hemodiálise com eqüinos, distribuídos em quatro grupos experimentais de seis animais cada. Os animais do grupo I foram submetidos a cateterismo central unilateral (grupo-controle); os do grupo II foram submetidos a cateterismo central unilateral com cateter duplo-lúmen e a uma sessão de hemodiálise de seis horas; os do grupo III a cateterismo central unilateral com cateter duplo-lúmen e duas sessões de hemodiálise de seis horas e os do grupo IV a cateterismo central bilateral com cateter monolúmen e a uma sessão de hemodiálise de seis horas. Empregaram-se xilazina 10 por cento (0,4mg/kg) e acepromazina 2 por cento (0,008mg/kg) via intravenosa para sedação. Foram utilizados dois hemodialisadores conectados em série, do tipo fibras ocas, baixo fluxo, membrana de polissulfona e área de 1,8m². O fluxo sangüíneo médio foi de 319,18±97,41ml/minuto, associado a um fluxo de dialisato de 500ml/min. A anticoagulação foi feita com heparina sódica em 100UI/kg para primming, repetida na dose de 53,86±18,61UI/kg/hora. Foram avaliados: tempo de coagulação, tempo de protrombina, tempo de tromboplastina parcial ativada e contagem plaquetária, e verificado trombocitopenia nos grupos dialisados. O melhor acesso vascular foi proporcionado pelo cateterismo unilateral com cateter lúmen-duplo (Grupos II e III), podendo a técnica de hemodiálise ser empregada na espécie eqüina, com dialisadores de alta eficiência, em sessão de seis horas de diálise.

Hemodialysis adequacy was studied in four groups with six horses in each: the treatments: group I animals were submitted to unilateral central venous catheter (control group); group II animals were submitted to unilateral central venous double lumen catheter and one six-hour session of hemodialysis; group III horses were submitted to unilateral central venous double lumen catheter and to two six-hour session of hemodialysis, and group IV horses were submitted to bilateral central venous mono lumen catheter and to one six-hour session of hemodialysis. Xilazine 10 percent (0.4mg/kg) and acepromazine 2 percent (0.008 mg/kg) were iv administrated for sedation. Two hollow fiber, 1.8m² low flux polyssulfone hemodialysis apparatus were used in a connected serie. The mean blood flux was 319.18±97.41ml/min with a dialisate flux of 500ml/min. Anticoagulation was performed with sodium heparin, 100UI/kg for priming at the dose of 53.86±18.61UI/kg/h. Anticoagulation monitoring was performed by clotting time, protrombin time, tromboplastin activated time, and platelet number. Decrease in platelet number was detected in groups submitted to dialysis. The best vascular access was performed with double lumen catheter and the hemodialysis may be used in equine practice, with high performance dialyze used in six- hour session.

Laboratory studies in coagulation disorders.

It is important to go in a stepwise approach to diagnose spectrum of bleeding disorders, so that minimum tests are undertaken to make a definitive diagnosis and to avoid unnecessary tests and laboratory load. Depending on the abnormalities observed in the short screening, extended screening tests can be performed followed by specialized diagnostic tests. Bleeding time is prolonged in thrombocytopenia and platelet function disorders (PFD). If platelet count is normal, extended screening tests such as RVVT, PF3 availability and clot retraction can be performed. Russel viper venom directly activates FX, in presence of PF3, is an indicator of common pathway of coagulation. However, if there is deficiency of PF3 as obtained in PFD and APTT PT are normal, its prolongation indicates PFD. These can be tested invitro by performing RVVT with and without inosithin it is highly suggestive of underlying PFD. In such cases, diagnostic tests for PFD such as platelet aggregation with ADP, ADR, AA, Collagen and Ristocetin can be performed followed by electron microscopy if possible. Few of the interesting cases also have been discussed in the text.