An acquired inhibitor that produced a delay of fibrinopeptide B release in an asymptomatic patient.

An asymptomatic, 29-year-old woman was referred to our hospital before surgery because in the basic study of hemostasis she showed a prolonged thrombin time (TT) and a normal reptilase time (RT). She had not received any anticoagulants so, to account for these abnormal results the presence of an inhibitor or a dysfibrinogenemia was suspected. A 1:1 mixture of the patient's plasma with control plasma did not correct the TT. Dysfibrinogenemia was excluded because the defibrinated plasma retained the inhibitory activity when mixed with normal plasma. When 0.02 mg/ml of Protamine Sulphate (a concentration that neutralizes 1 U/mL of heparin in normal plasma) was added to the patient's plasma, the inhibitory activity did not disappear. IgG from the patient and from normal serum was isolated. The patient's IgG was able to prolong the TT of a normal plasma and of a purified fibrinogen. The patient IgG did not impair the catalytic activity of thrombin, because no difference was observed in the hydrolysis of S-2238 by 1 U NIH human thrombin with normal or patient IgG. The time course of the thrombin-mediated fibrinopeptide-release from normal fibrinogen with the patient's IgG, showed a delay in the fibrinopeptide B (FPB) release without affecting the fibrinopeptide A (FPA) release. This patient has an IgG antibody that delays fibrinopeptide B release of fibrinogen.

Contribution of prothrombin 20210A allele and factor V Leiden mutation to thrombosis risk in thrombophilic families with other hemostatic deficiencies.

BACKGROUND AND OBJECTIVES: The aims of this study were to compare the lifetime probability of developing thrombosis in 722 relatives of 132 thrombophilic families of symptomatic probands with recognized thrombophilic defects and to determine the prevalence of the factor V Leiden (FVL) mutation and the 20210A allele of the prothrombin gene (PT20210A) in these families. DESIGN AND METHODS: The study included 722 members belonging to 132 unrelated families. The propositi were patients who had been referred to our Thrombosis Unit. The families were selected through a symptomatic proband. Once a patient with a deficiency or mutation was identified, family members were screened for the same defect. RESULTS: The prevalence of FVL and PT20210A in families with other thrombophilic defects was higher than expected. Compared with non-deficient individuals, the risk of venous thrombosis was increased in subjects with antithrombin (AT), protein S (PS) and protein C (PC) deficiencies, and in carriers of FVL and PT20210A mutations. The risk of thrombosis was significantly increased for individuals with combined genetic defects (PC-FVL, PS-FVL, PS-PT20210A and FVL-PT20210A). The ages at the time of 50% thrombosis-free survival were as follows: 34 years for AT deficiency, (19 years with FVL, 21 years with PT20210A), 62 years for PC deficiency (33 years with FVL, 44 years with PT20210A), 37 years for PS deficiency (24 years with FVL, 36 years with PT20210A), 50 years for the FVL mutation (52 years with PT20210A), and 65 years for the PT20210A mutation. As for clinical characteristics, no differences were observed except for the higher frequency of oral contraceptive-related thrombosis in women who were carriers of PT20210A or FVL. INTERPRETATION AND CONCLUSIONS: Based on these results, screening for FVL and PT20210A mutation is recommended in patients with other thrombophilic defects. To the best of our knowledge, this is the first family study, including the PT20210A mutation, that compares genetic risk factors for thrombosis and the lifelong probability of developing thrombosis.

Topical heparin for the treatment of acute superficial phlebitis secondary to indwelling intravenous catheter. A double-blind, randomized, placebo-controlled trial.

OBJECTIVE: To assess the clinical efficacy of a topical gel containing 1000 IU x g(-1) of heparin, applied three times daily for a maximal period of 7 days to patients with acute superficial phlebitis secondary to indwelling intravenous catheter. METHODS: A Double-blind, randomized, placebo-controlled study was conducted in one of the internal medicine wards of a tertiary General Hospital in Barcelona, Spain. Inpatients of both genders over 18 years of age that developed superficial phlebitis and gave informed consent were included in the study. The sample size estimation was 132 patients. Sixty-six patients were allocated to each group. There were five protocol deviations and 24 withdrawals in the intervention group, and one protocol deviation and 25 withdrawals in the control group. Consequently, 37 patients in the intervention group and 40 in the control group completed the trial. The main outcome measure was the disappearance of the symptoms and signs of superficial phlebitis. Clinical course, investigator's global impression and adverse events were also recorded. RESULTS: According to the intention-to-treat analysis, after treatment for 7 days superficial phlebitis healed in 27 of the 61 patients (44.3%) who received topical heparin, and in 17 of the 65 patients (26.1%) receiving placebo, giving a relative risk [95% confidence interval (CI)] of 1.69 (1.03-2.78). This indicates that six patients (95% CI, 3-72) have to be treated in order to induce one additional healing. The clinical course and the overall clinical impression were similar in both groups. One patient treated with topical heparin developed mild urticaria. CONCLUSION: Topical heparin is safe and effective for the treatment of superficial phlebitis secondary to indwelling intravenous catheter.

Low levels of tissue factor pathway inhibitor (TFPI) in two out of three members of a family with thrombophilia.

We describe a family with severe thrombosis of early onset in two siblings and in their father. Low levels of TFPI were detected in the two siblings (50% and 45% respectively) but their parents have normal TFPI levels. All other hemostatic proteins associated with thrombophilia, as well as blood lipids were within the normal range. The release of TFPI, after heparin administration, was proportionally reduced in the two siblings as compared with controls. The study of this family does not permit to conclude that low levels of TFPI are responsible for their thrombophilia. In the future the study of more families with similar characteristics may allow to know the inheritance of TFPI and whether there is a causal relationship between low levels of TFPI and thrombosis.

Abnormal polymerization and normal binding of plasminogen and t-PA in three new dysfibrinogenaemias: Barcelona III and IV (gamma Arg 275-->His) and Villajoyosa (gamma Arg 275-->Cys).

Congenital dysfibrinogenaemia was found in three non-related patients. None of them had a haemorrhagic tendency, but one gave a thrombotic history. When their fibrinogens were treated with thrombin, they released fibrinopeptides A and B at normal rates, but the resultant fibrin monomers produced exhibited abnormal polymerization curves. This abnormality was more marked in fibrinogen Villajoyosa than in Barcelonas III and IV. Plasminogen and t-PA binding to fibrin monomers from the three dysfibrinogenaemias was similar to that of normal fibrin monomers. The gamma chain was purified from the three fibrinogens, treated with CNBr and the peptides produced were separated by reversed-phase HPLC. Chromatograms of digested fibrinogens showed an abnormal peak that was not present in the normal gamma chain. Amino acid sequence analysis of abnormal peptides and genomic DNA sequencing revealed that the gamma arginine 275 had been changed in the three fibrinogens; in two cases it was substituted by histidine, and in the third by cysteine. The altered properties observed in fibrin monomers produced from fibrinogen with the gamma Arg 275-->His or gamma Arg 275-->Cys substitution, suggests that this amino acid is important in maintaining the protein structure necessary for normal polymerization, but is not essential for the binding of t-PA or plasminogen to fibrin. It also suggests that the change Arg-->Cys produces more severe alterations in the functions of fibrinogen than the substitution Arg-->His.

Nosocomial pneumonia: comparative multicentre trial between monotherapy with cefotaxime and treatment with antibiotic combinations.

In a multicentre clinical trial involving 32 hospitals, 588 adult patients diagnosed with nosocomial pneumonia and not receiving mechanical ventilation were treated randomly with monotherapy with cefotaxime or the antibiotic combination routinely used in each particular hospital. Both groups of patients were similar regarding demographic data, concurrent diseases, additional therapies and causative organism. Protocol violations were recorded in 40 patients, and these patients were excluded from the evaluation of treatment efficacy. The cure rate was 79% in the cefotaxime group and 71% in the group receiving antibiotic combinations; this difference is statistically significant (p = 0.03, Fisher's two-tailed test). In the patients receiving combinations of cephalosporins having activity predominantly against gram-positive organisms plus aminoglycosides, the cure rate obtained was very low. The frequency of serious adverse reactions was significantly higher in the group treated with antibiotic combinations. It is concluded that monotherapy with cefotaxime is the regimen that offers better results for the empirical treatment of nosocomial pneumonia.

Antibiotic prophylaxis with cefotaxime in gastroduodenal and biliary surgery.

In a multicenter prospective, randomized study, the efficacy of a single preoperative dose of 1 g of cefotaxime for avoiding wound infections was compared with four 2-g doses of cefoxitin. In the study, 1,451 patients with infection risk factors who underwent gastroduodenal or biliary surgery were included, of whom 722 received cefotaxime and 729 cefoxitin. The characteristics of both groups were comparable. The frequency of wound infections in the cefotaxime group was 3.3 percent and in the cefoxitin group, 7.6 percent. The difference was statistically significant. The lowest rate of wound infection (0.63 percent) was achieved when cefotaxime was administered during the last hour before surgery. In both groups, the frequency of infections was directly related to the duration of operation. Hospital stay was, on average, 3 days longer in patients with wound infections. After cost-benefit analysis, we have concluded that cefotaxime treatment results in substantial reduction of costs derived from antibiotic prophylaxis.

Enhanced skin reactivity to platelet-derived permeability factor (PDPF) and exogenous histamine in an acute phase rabbit model.

Rabbits made acute phase by sub-cutaneous trauma with 2% croton oil (in mineral oil) were tested by intradermal (ID) injection with platelet-granule extracts containing platelet-derived permeability factor (PDPF). Compared with controls, skin reactivity to PDPF was enhanced in acute phase animals 3-7 days post-trauma, a period of acute inflammation as reflected by the occurrence in the circulation of C-reactive protein; maximal skin responses were observed 3-4 days post-trauma. Individual skin sites reached maximum intensity 15 min-1 hour post-ID injection of PDPF and were sensitive to chlorpheniramine maleate, suggesting a major role for histamine. Intradermal injection of histamine revealed that acute phase animals yielded an initially more intense skin reaction, and were markedly less capable of recovering from the effects of histamine. These data suggest that in the acute phase, there exists a heightened and prolonged sensitivity to the action of histamine which can be exploited by pro-inflammatory agents such as PDPF.

A three-step purification of human alpha 1-acid glycoprotein.

alpha 1-Acid glycoprotein (AGP) was purified to homogeneity by a 3-step procedure using pseudo-ligand affinity chromatography on immobilized Cibacron blue F3GA, Procion red HE3B, and preparative column isoelectric focusing. The overall yield of the combined techniques was 88%. Analysis of the purified AGP by lectin affinity chromatography on immobilized Con A and immunoaffino-electrophoresis indicated that the most acidic form did not interact with the lectin, while the two more basic fractions possessed different affinities for Con A. In addition, 3 different populations of AGP were clearly separated by Con A affinity chromatography.