Optical signature of erythrocytes by light scattering in microfluidic flows.

A camera-based light scattering approach coupled with a viscoelasticity-induced cell migration technique has been used to characterize the morphological properties of erythrocytes in microfluidic flows. We have obtained the light scattering profiles (LSPs) of individual living cells in microfluidic flows over a wide angular range and matched them with scattering simulations to characterize their morphological properties. The viscoelasticity-induced 3D cell alignment in microfluidic flows has been investigated by bright-field and holographic microscopy tracking, where the latter technique has been used to obtain precise cell alignment profiles in-flow. Such information allows variable cell probability control in microfluidic flows at very low viscoelastic polymer concentrations, obtaining cell measurements that are almost physiological. Our results confirm the possibility of precise, label-free analysis of individual living erythrocytes in microfluidic flows.

Multiplex single particle analysis in microfluidics.

A straightforward way to measure separated micrometric sized particles in microfluidic flow is reported. The light scattering profile (LSP) of each single particle is fully characterized by using a CMOS-camera based small angle light scattering (SALS) apparatus, ranging from 2° up to 30°. To ensure controlled particle passage through the incident laser, a viscoelastic 3D alignment effect by viscoelastic induced particle migration has been implemented in a simple and cost-effective microfluidic device. Different polystyrene particle sizes are measured in microfluidic flows and the obtained scattering signatures are matched with the Lorenz-Mie based scattering theory. The results confirm the possibility of using this apparatus for real multiplex particle analyses in microfluidic particle flows.

[Non-secretory myeloma syndrome]. / La sindrome del mieloma non secernente.

Non secretory myeloma is a rare and unusual form of myeloma, characterized by the absence of monoclonal component in serum and urine. This peculiarity is usually believed to be caused by the incapacity of neoplastic plasmacells to synthesize or secrete M-component, but it is probably due to several pathogenetic mechanisms which are different from case to case. The diagnosis can be delayed by the non specific clinical pattern, especially in those cases where skeletal radiological studies do not reveal lytic lesions. The authors report two recently diagnosed cases of non secretory myeloma, underlying the main clinical and laboratory findings which led to the diagnosis of this singular syndrome. The diagnostic suspicion is often based, beside the clinical pattern at the onset, on the absence of serum and urinary monoclonal component, on the increase of PCR, of beta 2 microglobulin and on low levels of serum immunoglobulins. CT scans, MRI and Tc 99 MIBI bone marrow radionuclide studies are also useful in evaluating the therapeutic response which cannot be based on quantitative variations of the M-component. The clinical suspicion is confirmed by the bone marrow aspiration and trephine biopsy, showing a typical infiltration by plasmacells at various degree of maturation.

[Carotenodermia: an erroneous diagnosis of jaundice]. / Carotenodermia: un'errata diagnosi di ittero.

Carotenoids are essential pigments in vegetal photosynthetic processes, but they also have important biological functions in animal physiology: beta carotene in particular represents provitamin A. The accumulation of carotenoids in a man results in a cutaneous hyperpigmentation very similar to jaundice: usually this happens in vegetarian subjects after an excessive food eating. In the described case, a situation similar to jaundice appeared in a 56 years old man affected by psychic disorders, his diet consisted for several years almost exclusively of eggs (an average of 27 eggs a day). As this type of food is very rich in carotenoids (especially lutein giving to yolk the characteristic colour), it is inevitable that, in addition to hypercholesterolemia, a consistent amount of carotenodermia is present. This recalls the possible antiaterogenal action of carotenoids.

DDAVP infusion in haemophilia A carriers: different behaviour of plasma factor VIII and von Willebrand factor.

1-desamino-8-D-arginine vasopressin (DDAVP) increases factor VIII (FVIII) and von Willebrand factor (vWF) levels in patients with haemophilia A and in some patients with von Willebrand disease. It is generally held that the increase of FVIII is a consequence of the increase of vWF. Carriers of haemophilia A generally, but not always, show plasma FVIII levels lower than vWF due to an abnormality in one of the two alleles of the FVIII gene. We investigated the time-course of plasma FVIII:C and vWF:Ag levels in 25 obligate carriers of haemophilia A after DDAVP infusion. In carriers with a normal FVIII to vWF ratio (> 0.8), DDAVP induced a progressive ratio decrease that reached levels significantly lower than that taken as cut-off to discriminate between low and normal values (0.68 +/- 0.1 vs before 0.912 +/- 0.18). In carriers with a borderline (0.7-0.8) or reduced (< 0.7) ratio DDAVP induced a further decrease in the FVIII/vWF ratio, albeit with a different kinetic; after an initial increase, values were lower than pre-DDAVP figures. In all subjects, following the post-DDAVP peak, plasma FVIII progressively decreased while vWF contemporaneously continued to increase. In contrast, DDAVP did not induce significant changes in the FVIII/vWF ratio in normal females, and the two molecules appeared to increase similarly throughout the observation period. These findings indicate that after DDAVP, FVIII increases less or for a shorter time than vWF, also in haemophilia A carriers who have a normal FVIII/vWF ratio. Hence, DDAVP may help identify haemophilia A carriers, especially subjects with normal or borderline ratios. Even though molecular biology procedures at present are the best and more reliable tools to identify the carrier state, DDAVP seems to improve the accuracy of haemostatic parameters.

Different organization of von Willebrand factor oligomers in type-2A and -2B von Willebrand disease variants: effects of DDAVP infusion and protease inhibitors.

Plasma von Willebrand factor (vWf) displays a complex pattern of repeating multimers, whose heterogeneous size distribution seems to depend on the proteolytic cleavage of the constituent vWf subunit. Smaller vWf multimers are thought to derive by proteolytic cleavage of the larger forms. To clarify the relationship between large multimer representation and the structure of small vWf oligomers, DDAVP was infused in patients with type-2A and -2B von Willebrand disease (vWd) variants which lack circulating high vWf forms. Before infusion, high-resolution multimer analysis demonstrated a more pronounced representation of the satellite bands of each oligomer, mainly concerning fast-moving components, especially in type 2B vWd. After DDAVP, in type-2A vWd each oligomer displayed a different organization depending on whether restoration of large vWf multimers occurred. The lack of large vWf multimer restoration, as shown in citrated samples, was associated with the fast band being significantly more represented than the slower, and almost similar to the central component. In contrast, when the high-molecular-weight vWf forms were restored, as occurred in the samples collected in the presence of protease inhibitors, the relative representation of the fast- and slow-moving bands was similar to that of normal samples. In type-2B vWd, regardless of the anticoagulant used, DDAVP infusion did not restore large vWf multimers, and each oligomer displayed a significant increase in both the central band and fast-moving satellite, the fast being even more highly represented. These findings suggest that, regardless of the origin, the disappearance of large circulating multimers in type-2A and -2B vWd induces an increased representation of the fast-moving satellite of the low-molecular-weight multimers. Moreover, the time course of large and low/intermediate multimer decrease and increase provides a further demonstration that low vWf multimers derive from the larger ones, and that mainly the fast-moving band of the oligomer is involved.

Demonstration that venous occlusion fails to release von Willebrand factor multimers.

The acute simultaneous release of tissue plasminogen activator (t-PA) and von Willebrand factor (vWF) from endothelial cells in response to a variety of agonists including thrombin, DDAVP, histamine and adrenalin has been described. In the present study we investigated the effect of venous occlusion on the circulating levels of t-PA and vWF, as well as the molecular organization of vWF in 20 normal subjects. After occlusion a significant increase in plasma t-PA levels was observed even after the values were corrected for haemoconcentration. Venous occlusion also enhanced plasma vWF values, but the increase was abolished when the correction for haemoconcentration was introduced. Following venous occlusion, no circulating abnormally large vWF multimers were detected in the subjects studied. These forms are normally not present in the circulation and are released from endothelial cells through the regulated vWF pathway; their absence therefore seems to demonstrate that this pathway is not activated after venous occlusion. Since occlusion does not enhance vWF synthesis, the increase in vWF observed in the subjects investigated may be fully attributed to haemoconcentration.

EDTA dependent pseudothrombocytopenia caused by antibodies against the cytoadhesive receptor of platelet gpIIB-IIIA.

AIMS: To clarify the mechanisms involved in the development of EDTA dependent pseudothrombocytopenia, particularly the platelet receptors. METHODS: Platelets were measured in 33 patients with pseudothrombocytopenia, using different anticoagulants to collect blood samples (direct test). The results were compared with the counts obtained by adding patients' serum or immunoglobulins to normal blood samples (indirect test). The role of platelet function was explored using ASA, PGE1, and apyrase as platelet inhibitors. The contribution of platelet receptor/s was investigated using antigens to gpIb-IX and gpIIb-IIIa monoclonal antibodies. Immunoglobulin class was estimated by the ability of IgG, IgA, and IgM antibodies to prevent platelet clumping. RESULTS: Agglutinating antibodies were IgA in 40%, IgG in 30%, and IgM in 10% of patients studied. Both patients' serum and immunoglobulins induced platelet clumping in normal samples anticoagulated with EDTA (indirect test). This was prevented by incubation of blood samples at 37 degrees C and almost completely inhibited by the platelet inhibitors ASA, PGE1, and apyrase. Pseudothrombocytopenia was also entirely prevented by an antigen to gpIIb-IIIa monoclonal antibody that recognises fibrinogen and the von Willebrand factor binding site. Pseudothrombocytopenia was almost completely abolished after the addition of RGD peptide, the recognition sequence of cytoadhesive proteins. CONCLUSIONS: These findings suggest that EDTA dependent pseudothrombocytopenia is caused by agglutinating antibodies that recognise cytoadhesive receptors on platelet gpIIb-IIIa and that an efficient platelet metabolism is required.

Acquired factor VIII:C inhibitor in a patient with Sjögren's syndrome: successful treatment with steroid and immunosuppressive therapy.

A 57-year-old woman affected with Sjögren's syndrome without bleeding history developed spontaneous hematomas at the arms, the left foot and the thigh, cutaneous hemorrhages and hematuria. Routine coagulation tests showed a prolongation of activated partial thromboplastin time associated with a marked reduction of factor VIII activity (VIII: C 5%). Other deficiencies of blood coagulation factors, especially von Willebrand factor, were excluded. Measurement of factor VIII inhibitor revealed an activity of 26.4 Bethesda units/ml. These findings were consistent with the diagnosis of acquired hemophilia A due to the presence of a factor VIII inhibitor. The patient was treated with a combination of prednisone and azathioprine. The therapy led, in a few months, to a significant reduction of factor VIII: C inhibitor and she did not require replacement therapy. Furthermore, there was a complete remission of the bleeding tendency. Long-term therapy for about 3 years induced the complete disappearance of the inhibitor and a full normalization of coagulation tests.

A new variant of von Willebrand's disease (type I Padua): doublet-organized plasma von Willebrand factor oligomers in the presence of all size multimers.

Type I von Willebrand's disease (vWd) is characterized by a concomitant decrease in plasma of von Willebrand factor antigen (vWf:Ag) and vWf ristocetin cofactor activity (vWf:RCoF), associated with the presence of all-size multimers. As a rule, there is no evidence of intrinsic abnormality in vWf. We describe a family with type I vWd with an abnormal plasma vWf multimer pattern. Analysis of plasma vWf multimeric structure by short-SDS-agarose gel electrophoresis showed an abnormal banding pattern for each vWf oligomer, which was organized as a doublet instead of the normal triplet. The electrophoretic mobility of each component appeared to be normal. Multimeric analysis on a long gel showed all the bands that were detectable in normal subjects, but unlike normals the fast moving satellite stained as the major component. The platelet vWf multimer pattern was normal. The infusion of DDAVP normalized vWf:Ag, vWf:RCoF and VIII:C, but not the abnormal multimer pattern observed on both short- and long-gel electrophoresis. The return of factor VIII/vWf complex to the baseline condition was more rapid than that observed in normal subjects or classic type I vWd patients. Analysis of the subunit fragments in the patients' plasma vWf demonstrated a relatively greater proportion, compared to the normal counterpart, of a 115(140)-kD fragment, which derives from the aminoterminal region of the mature molecule; in contrast, no intact subunit was detectable. These findings indicate a new, previously unreported, variant of type I vWd, which is characterized by plasma vWf oligomers organized as doublets, instead of triplets. The reduced post-DDAVP half-life, and the abnormal subunit fragments of vWf, suggest a molecule characterized by an increased susceptibility to proteolytic degradation. As a result, the decrease in circulating vWf levels may be due to an instability of the abnormal vWf, rather than, or in addition to, a decrease in its synthesis.

First report of combined factor VII Padua defect and von Willebrand's disease due to casual association of the two defects.

We report a family with a combined factor VII Padua defect and von Willebrand's disease (vWd). The propositus is a 9-year-old child with a moderate bleeding tendency who appeared to be heterozygous for both factor VII Padua and type I vWd. The diagnosis of factor VII Padua was based on a normal factor VII antigen and factor VII activity which was low with rabbit brain thromboplastin but normal with ox brain thromboplastin. Type I vWd was diagnosed because of a concomitant decrease of von Willebrand factor antigen (vWf:Ag) and vWf ristocetin-cofactor activity (vWf:RCoF), associated with the presence of vWf multimers of all sizes in plasma and platelets. The parents were not consanguineous but came from the same isolated river Piave valley in North Eastern Italy where the factor VII Padua defect was first described. The father had the factor VII Padua defect but was clinically asymptomatic in accordance with the heterozygous state. The propositus's mother had type I vWd and was mildly symptomatic. The propositus' sisters, who were clinically asymptomatic, were both heterozygotes for factor VII Padua. The infusion of DDAVP normalized the factor VIII/vWf pattern in all patients. In the propositus, in contrast to the mother and normal subjects, showed a more rapid clearance both of vWf and factor VIII. The same pattern, albeit to a lesser degree, was also observed in the father.

Combined haemophilia A and type I von Willebrand's disease: a family study including an evaluation of the effects of DDAVP infusion.

A family with concurrent haemophilia A and type I von Willebrand's disease (vWd) is described. The propositus was affected by both disorders. The propositus' mother was an obligate carrier of haemophilia A being the daughter of a haemophilic. The father and sister were affected by vWd. The sister was also a possible carrier of haemophilia A. This is the first report of both disorders occurring simultaneously. The infusion of 1-desamino-8-d-arginine vasopressin (DDAVP) induced, in the propositus, a normalization of circulating levels of vWf, with a less pronounced enhancement of factor VIII:C. In the father, the response to DDAVP infusion of factor VIII/vWf complex was normal. In the mother, the time-course of factor VIII:C was characterized, after a peak at 30 min, by a progressive decrease until 2 hours after infusion, in contrast to vWf which appeared further increased at the same times. Therefore, the low factor VII:C/vWf:Ag ratio, already present before infusion, became significantly more pronounced 2 hours after DDAVP. Similar findings were observed in another obligate carrier of the family, in the propositus' sister and in 10 other haemophilia A carriers, belonging to different kindreds. In all patients, even when the basal factor VIII:C/vWf:Ag ratio was normal, two hours after DDAVP it decreased in agreement with the haemophilia A carrier state.

Impaired release of tissue plasminogen activator (t-PA) following DDAVP infusion in von Willebrand's disease with low platelet von Willebrand factor content.

Tissue plasminogen activator (t-PA) and von Willebrand factor (vWF) are both released by vascular endothelial cells after the infusion of DDAVP. Such release has not been observed in patients with severe von Willebrand's disease (vWD). In the present work we demonstrate that the degree of simultaneous DDAVP-induced release of t-PA and vWF, in patients with vWD, is strictly related to the platelet vWF content. Twelve patients with type I, and three patients with type III vWD were studied. The type I vWD group included three patients with reduced platelet vWF content (platelet-low) and nine patients with normal levels (platelet-normal). In all patients studied the plasma t-PA levels were within the normal range. No significant change in either t-PA or vWF was observed after DDAVP in the patients with undetectable levels of platelet vWF (type III vWD). A mild increase was found in those patients with type I platelet-low, while in type I platelet-normal vWD the response was similar to that observed in normal subjects. The release of the two molecules appeared, therefore, to be linked to platelet vWF content and the rates of increase in both t-PA and vWF were similar in each group of patients studied. Since platelets are regarded as a tissue compartment of vWF our findings seem to suggest that the presence of vWF and its release from endothelial cells is required for a normal concomitant release of t-PA. In contrast, post-DDAVP release of vWF seems to be independent from that of t-PA since it was normal in a patient with congenital deficiency of t-PA release.

Discrepant increase in factor VIII: C and von Willebrand factor after DDAVP infusion in a patient with variant von Willebrand's disease.

We have studied a patient with von Willebrand's disease (vWd) whose von Willebrand factor (vWf) multimer patterns showed significant decreases of all but the major fast moving vWf multimer (promoter). Bleeding time (BT) was very prolonged, there was almost no ristocetin-induced platelet aggregation (RIPA) and vWf levels were very low. The factor VIII: C/vWf: Ag ratio appeared to be higher than normal because of the relatively increased concentration of factor VIII: C. The infusion of DDAVP normalized BT, improved RIPA and restored normal factor VIII: C levels, these effects lasted for 5 h even though only a slight increase of vWf: Ag and vWf: RCoF was observed. RIPA was completely inhibited by an anti-glycoprotein (GP) Ib monoclonal antibody that recognizes the ristocetin-induced vWf binding site. Plasma vWf multimer analysis revealed only slight increases of all components and an additional, more pronounced representation of vWf protomer. These data suggest that the patient has an abnormal vWf molecule characterized by a greater ability to carry factor VIII than would be expected from the vWf levels. Furthermore, since the vWf protomer was the only significant vWf component present both before and after DDAVP infusion we hypothesize that some of the haemostatic functions of the patient's vWf may depend on it.