Diabetes-like alterations in hemostatic parameters after growth hormone administration for one week in normal man.

Excess production of growth hormone (GH) in poorly controlled diabetes is believed to be a causal factor in the development of diabetic angiopathy, the mechanism(s) of which is unknown. The present study was undertaken to determine whether exogenous growth hormone would specifically change some quantities and functional parameters known to often be abnormal in long-standing diabetes and thought to result from the development of vascular lesions in general. The authors studied capillary resistance, factor VIII coagulant antigen (F VIII:Ag), von Willebrand factor (vWf:Ag), fibronectin, fibrinogen, and tissue-type plasminogen activator (t-PA) before, during, and after 1 week's subcutaneous GH administration (6 IU per day divided into two doses). Capillary resistance decreased insignificantly, but returned to higher levels (p less than 0.05) 1 week after withdrawal. F VIII:Ag, vWf:Ag, fibronectin, and fibrinogen all increased significantly during GH treatment. Except for F VIII:Ag, these quantities returned to pre-medication levels 7 days after termination of GH administration. The present results may contribute to the clarification of the role of GH hypersecretion in diabetic microangiopathy and macroangiopathy.

The anti-inflammatory effect of organo-heparinoid cream after bilateral mandibular osteotomies.

The aim of the present study was to compare the effect on swelling after bilateral osteotomies of the mandible of treatment with organo-heparinoid (Hirudoid) cream and that of a placebo cream. 12 patients (7 female, 5 male), median age of 29.5 years, were included in the study. 5 patients received bilateral sagittal-split procedures for symmetrical mandibular advancement, and 7 patients received bilateral mandibular osteotomies for symmetrical mandibular set-back. Each of the 2 operated sides were randomized for treatment with active medication or placebo; 1.5 g of the active- or placebo cream were carefully rubbed into the skin above the masseteric muscle 4 times a day for 4 days. Periodic identical CT-scans were performed to evaluate swelling; patients were CT-scanned preoperatively and once or twice postoperatively. 3 variables were used to assess the swelling: (1) thickness of the subcutis; (2) maximum thickness of the masseteric muscle; (3) cross-sectional area of the soft tissues facial to the ramus of the mandible. No significant differences in postoperative swelling could be demonstrated between the 2 treatments. There were no detectable systemic effects of the treatment with organo-heparinoid.

Female haemophilia A in a family with seeming extreme bidirectional lyonization tendency: abnormal premature X-chromosome inactivation?

We studied a female child with mild classical haemophilia A, presenting with a F VIII deficiency similar to that detected in her maternal grandfather. Investigations on several occasions showed that the obligate carrier mother of the proposita had normal VIII:C activity, whereas her likewise obligate carrier sister had a typical carrier VIII:C/vWf:Ag pattern. The child was a phenotypically normal female with normal karyotype. Her father had no clinical or biochemical signs of haemophilia A. RFLP-analysis using DX13 and St14 probes each elicited one allele (5.8 and 3.4 kb, respectively) segregating along with the affected F VIII gene from the hemizygous grandfather to both his daughters and further to the haemophilic female child. The paternity of the child was analyzed using various red cell and HLA antigens and RFLP by p29C, a probe detecting polymorphic hypervariable TaqI and PstI fragments in the pseudoautosomal areas of the X- and Y-chromosomes. All results obtained were concordant with the declared paternity. RFLP-analysis, using single (Pst I) and double digestion (Pst I/Hha I) of DNA and a PGK probe, revealed a remarkable difference in hybridization fragments, strongly suggesting hypermethylation, and in consequence, preferential X-chromosome inactivation in the proposita. This points to extreme lyonization as the most plausible explanation for haemophilia A in this female child. A familial tendency to abnormal premature X-chromosome inactivation is speculated.

Surgical treatment of severe periodontitis in a haemophilic patient with inhibitors to factor VIII. Report of a case.

This report describes the surgical treatment of advanced periodontitis in a haemophilic patient with inhibitors to Factor VIII. The treatment was performed after substitution therapy with Factor VIII-concentrate, supported by local and systemic antifibrinolytic treatment with tranexamic acid. No complications developed postoperatively, and after 9 months, the patient did not show recurrence of periodontal disease. Although the present case shows, that even severe periodontitis can be treated surgically in haemophilic patients with inhibitors to Factor VIII, this should not be done unless it is absolutely necessary. The treatment of periodontal disease in such patients should be instituted as early as possible in order to prevent the need for extensive surgery or dental extractions.

Applications of immunoperoxidase techniques in specificity testing of monoclonal antibodies (Mabs) against von Willebrand factor (vWf).

The present communication describes the production of a new series of murine Mabs against von Willebrand factor (vWf) in which specificity was tested using immunoperoxidase techniques. Seven Mabs showed specific reactivity with native and disaggregated vWf, whereas no binding was found to material from patients with severe homozygous (or doubly heterozygous) von Willebrand's disease (vWd) or factor VIII coagulant antigen (VIII:Ag). These Mabs are thought to carry separate specificities as only slight or no competitive activity was detected. Four Mabs partially inhibited the ristocetin-induced platelet agglutination and three interacted with vWf-binding to type I collagen. All antibodies bound to the complete range of vWf multimers of normal plasma. Excellent binding and detection properties of Mabs were found in asymmetrical two-site enzyme linked immunosorbent assays (ELISA) for quantitation of vWf antigen (vWf:Ag). One particular antibody (Mab vWf-33) discriminated vWf material from a number of subtype II vWd plasmas tested.

Continuous high-dose factor VIII for the induction of immune tolerance in haemophilia A patients with high responder state: a description of eleven patients treated.

Eleven severely affected haemophilia A patients (aged 6-42 y) with F VIII:C inhibitor (high responders) were treated with high-dose F VIII in order to eliminate the inhibitors. The patients comprise Danish high responder patients treated during the period 1977-1985. In all patients the inhibitors decreased significantly. In six, the inhibitor apparently disappeared (detection limit 0.4 Bethesda Units per ml) (BU/ml), in four patients a low level inhibitor of 0.4-1.4 BU/ml persisted. One patient is still on high-dose schedule. The duration of high-dose treatments ranged from less than one month up to 18 months. In all patients the tendency to spontaneous bleedings vanished when a measurable VIII:C level appeared in the post-infusion sample. The inhibitor suppression has allowed for extensive physical training and rehabilitation orthopaedic surgery. The patients are now able to conduct a normal haemophilic life on self-administered prophylactic doses of F VIII.

A case of Bernard-Soulier syndrome: study of platelet glycoprotein Ib in a kindred.

The Bernard-Soulier syndrome is characterized by low platelet counts, abnormally large (giant) platelets, and impaired or absent platelet aggregation by the inducer antibiotic ristocetin. The recent discovery of the inherited biochemical defect and the deficient synthesis of platelet glycoprotein Ib (GP-Ib), has contributed greatly to the understanding of the disease. We report a case of the Bernard-Soulier syndrome presenting with bleeding from the pharynx after adenotomy. The patient and nearest family members were studied by a novel immunoperoxidase method for quantification of platelet glycoprotein Ib using a specific monoclonal antibody (AN51).

Fibrinogen Aarhus and factor XIII induced polymerization and gel formation.

Fibrinogen Aarhus is an abnormal fibrinogen for which the clotting time with thrombin is greatly prolonged both in plasma and in the isolated fibrinogen. The whole blood clotting time is only slightly prolonged. The patient with this fibrinogen has no bleeding tendency. In this report we have investigated fibrinogen Aarhus in two alternative, thrombin independent polymerization and gelation pathways. These pathways are the factor XIII dependent oligomerization and gelation of fibrinogen, and heteropolymer (fibrinogen-fibronectin) formation which also is catalysed by factor XIII. Both of these reactions are qualitatively the same in fibrinogen Aarhus as in normal fibrinogen, but the rate of oligomerization is somewhat slower in fibrinogen Aarhus. This may depend on impaired association between factor XIII and fibrinogen Aarhus.

Characteristics of the von Willebrand factor in virus inactivated F VIII concentrates: the impact of heat treatment.

The known transmission of viral diseases, particularly AIDS (HIV, LAV, HTLV-III), has led to the mandatory use of virus-inactivated coagulation factor concentrates for treatment of bleeding disorders due to deficient or abnormal synthesis of the factor VIII/von Willebrand factor complex. The present investigation was undertaken to study the influence of heat-treatment on the von Willebrand factor (vWf). Using normal plasma as reference material, we studied the influence of low-purification steps in a simple cryo-plasma and a unrefined freeze-dried cryoprecipitate. For comparison, non-heated and heat-inactivated concentrates of different manufacture representing varying heat-treatment protocols were studied using quantitation of von Willebrand factor antigen (vWf:Ag) by electroimmunoassay and ELISA, and investigation of vWf multimeric composition. A locally produced factor VIII concentrate was studied before and after exposure to 68 degrees C for 72 hours (dry state). Whenever possible, commercial preparations manufactured prior to the heat-treatment era were compared with the present product. The locally produced high purity concentrate elicited only minor changes in oligomeric satellite pattern, which did not change after dry heat exposure. In principle, no major differences were found between non-heated and pasteurized commercial concentrates of same manufactural origin.

Effect of local antifibrinolytic treatment with tranexamic acid in hemophiliacs undergoing oral surgery.

The objectives of the present clinical investigation were to examine the effects in hemophiliacs of local antifibrinolytic treatment with tranexamic acid on the incidence of postoperative bleeding after oral surgery and on the amount of replacement therapy needed to control bleeding. The study compared three groups of patients. The patients in group A received high doses of factor concentrate and systemic antifibrinolytic treatment with tranexamic acid. In group B local antifibrinolytic treatment with tranexamic acid was added to the treatment received by group A. Group C received replacement therapy to raise factor levels to approximately 10% of the normal value perioperatively, combined with systemic and local antifibrinolytic treatment (mouth rinse) with tranexamic acid. The study demonstrated that local antifibrinolytic therapy with tranexamic acid as a supplement to the currently used systemic therapy significantly reduces the incidence of postoperative bleeding. The results of the study further suggest that replacement therapy can be reduced during oral surgery in the hemophilic patient provided that local and systemic inhibition of fibrinolysis is instituted.

Fibrinogen Aarhus--a new case of dysfibrinogenemia.

Fibrinogen Aarhus was found in a woman with slightly prolonged whole blood clotting time. The thrombin induced clotting of plasma and purified fibrinogen was much prolonged. Kinetic analysis of FPA and FPB release revealed larger apparent Km and Vmax values for fibrinogen Aarhus than for normal fibrinogen. No clot formation of fibrinogen Aarhus was demonstrated in the presence of Batroxobin and the release of FPA was slower than normal. Upon addition of the clotting enzyme from Agkistrodon contortrix contortrix clotting did occur but the clotting time was much prolonged in comparison with normal fibrinogen. The turbidity of fibrin gels obtained from fibrinogen Aarhus was similar to normal fibrin gels at low thrombin concentrations. Increasing thrombin concentration resulted in appearance of degradation products in the fibrin gels from fibrinogen Aarhus and at the same time a relative increase in turbidity of the gels was observed. Possibly reasons for the slow release of fibrinopeptides, the delayed gelation, and susceptibility to degradation by thrombin are discussed.

Enzyme linked immunosorbent assay (ELISA) for the measurement of factor VIII coagulant antigen (CAg) using haemophilic antibodies.

A method for the quantitation of factor VIII clotting antigen (VIII:CAg) has been developed based on a micro enzyme linked immunosorbent assay (ELISA) principle employing antibodies from two polytransfused haemophilia A patients. Solid polystyrene support bound IgG fraction of inhibitor plasma extracted VIII:CAg from normal plasma and samples. Bound VIII:CAg was detected by peroxidase labelled F(ab')2 fragment of the IgG used for solid phase. Two assays, each based on its particular inhibitor antibody, were set up. The F VIII clotting antigen in plasma of 30 healthy persons was found identical with the two VIII:CAg assays (r=0.97) and closely correlating with clotting activity (VIII:C) (r=0.84). Serum VIII:CAg was 67% (+/-14.5%) of the corresponding plasma value. In severe haemophilia A, 17 out of 19 had VIII:CAg values less than 1 U/dl. Two patients with cross-reactive material (CRM+) were found. In some milder cases of haemophilia A, higher values of VIII:CAg than VIII:C was recorded. The sensitivity of the method was 0.08 U/dl. Inter assay coefficient of variation at the 100 U/dl level was 9.5% (CV%), at the 2 U/dl level 16.4% (CV%). Mainly due to the great stability of enzyme conjugated antibody compared to the natural decay of radioiodinated material and subsequent loss of detecting material, ELISA was found superior to immunoradiometric assay (IRMA).

Pentoxifylline does not interfere with stable coumarin anticoagulant therapy: a clinical study.

A study was undertaken to investigate the possible interaction between pentoxifylline and coumarin. Ten patients on a previously stable anticoagulant treatment were investigated twice prior to, then 13 and 27 days after initiation of treatment with 1600 mg pentoxifylline daily. Coumarin therapy was continued in unaltered dosage. Parameters recorded were: bleeding time, platelet count, platelet adhesivity, spontaneous and collagen-induced platelet aggregation, activated partial thromboplastin time, prothrombin time, prothrombin-proconvertin activity, plasminogen activator and fibrin(ogen) degradation products. Platelet aggregation studies revealed a slightly higher sensitivity to collagen in 2 patients compared to pre-treatment values and in 1 patient the tendency to spontaneous aggregation was slightly increased after treatment. No other single test result changed significantly from premedication baseline values.

Treatment of necrobiosis lipoidica with low-dose acetylsalicylic acid. A randomized double-blind trial.

16 patients with clinically and histologically verified necrobiosis lipoidica lesions were treated with either 40 mg acetylsalicylic acid or placebo daily for 24 weeks in a double-blind controlled study. The lesions became statistically significantly larger in both groups in spite of inhibition of the aggregation of the platelets in the acetylsalicylic group.

HTLV-III seropositivity in European haemophiliacs exposed to Factor VIII concentrate imported from the USA.

77 Scottish haemophiliacs and 22 Danish haemophiliacs were serologically tested for antibodies to human T-cell leukaemia virus III (HTLV-III). Since 1979 the Scottish patients had been treated largely with factor VIII concentrate produced in Scotland, whereas all but 2 of the Danish patients had received both locally prepared concentrate and commercial concentrate made from US donor material. 15.6% of Scottish and 59.1% of Danish haemophiliacs were antibody positive (p less than 0.001). None of 11 haemophiliacs not treated in the period 1979-84 was seropositive. 2 (6.7%) of 30 subjects who had been treated with locally produced concentrate only were antibody positive, compared with 23 (39.7%) of 58 subjects who had been treated with commercial concentrate. Among 52 users of both commercially and locally produced factor VIII concentrate, seropositivity was directly correlated with the consumption of commercial concentrate (p less than 0.001) but not locally produced material. These data indicate that European haemophiliacs were exposed to HTLV-III via some factor VIII concentrates obtained from the USA.