Impact of biomarkers for endothelial dysfunction and procoagulant state on 10-year cardiovascular risk in Type 2 diabetes.

AIMS: To estimate the coronary heart disease and cardiovascular disease risk associated with novel biomarkers in Type 2 diabetes mellitus. METHODS: We measured baseline peripheral blood concentrations of soluble E-selectin, factor XIIa, thrombin-antithrombin III complex and plasminogen activator inhibitor-1 in 86 patients with Type 2 diabetes free of known coronary heart disease. We used Cox proportional hazard models to estimate multivariable-adjusted hazard ratios associated with biomarker levels for 10-year coronary heart disease risk (n = 33 events) or total cardiovascular disease risk (n = 45 events). RESULTS: At baseline, mean (sd) age was 62 years (7 years); 62 were men; and 43 had microalbuminuria. Soluble E-selectin demonstrated cross-sectional relationships with glucose and factor XIIa was related to plasminogen activator inhibitor-1 and triglycerides (all P < 0.05). Baseline log soluble E-selectin was significantly related to incident coronary heart disease and cardiovascular disease. Hazard ratios (95% CIs) associated with a 1-unit increase in log soluble E-selectin in age- and sex-adjusted models were: coronary heart disease : 4.6 (95% CI 1.9-11.3), P = 0.001; cardiovascular disease: 3.6 (95% CI 1.7-7.4, P = 0.001); and in multivariable-adjusted models were: coronary heart disease: 2.9 (95% CI 1.2-7.1, P = 0.02); cardiovascular disease: 2.3 (95% CI 1.1-4.8), P = 0.02. Factor XIIa was significantly related to incident cardiovascular disease. The hazard ratios associated with a 1-unit increase in factor XIIa in age- and sex-adjusted models was 1.5 (95% CI 1.1-1.9, P = 0.003) and in a multivariable-adjusted model was 1.3 (95% CI 1.0-1.6, P = 0.047). Plasminogen activator inhibitor-1 and thrombin-antithrombin III complex were not related to cardiovascular disease events. CONCLUSIONS: In our study, soluble E-selectin and factor XIIa were significantly related to 10-year incident macrovascular events in patients with Type 2 diabetes. These preliminary findings call for replication in larger studies.

Localized reactive angioendotheliomatosis.

We present a unique case of a woman with multiple painful dermal lesions localized to the left upper quadrant of the body. Histological investigation revealed microvascular thrombosis with capillary-wall proliferation. Further investigation revealed a very high anticardiolipin IgG titre and a left subclavian stenosis, presumably providing the reduced blood flow and relative hypoxia to allow microthromboses to occur in the presence of a thrombophilic tendency. Similar clinical and histological features have been reported in patients with the antiphospholipid syndrome and cases of reactive angioendotheliomatosis (RAE). This case represents a unique variant of RAE.

Clinical risk factors for venous thrombosis associated with air travel.

BACKGROUND: Recent reports have linked air travel with venous thrombo-embolism (VTE). Risk factors and associated features of this link are poorly understood. We have accumulated clinical data from a relatively large cohort of patients with traveler's thrombosis. METHODS: A total of 86 patients who developed venous thromboembolism within 28 d of flying were questioned concerning traveling habits, medical history (including risk factors for VTE) and characteristics of the index flight. RESULTS: Of the patients, 72% had at least one risk factor for VTE (excluding thrombophilia) prior to their flight. Of interest, 87% of VTE cases occurred following either a return trip or after an outward journey involving long trips made up of sequential flights. In only two cases could no identifiable risk factor or earlier journey be found. Duration of flights ranged from 2 to 30 h. Of responders, 38% presented with chest symptoms; 92% with VTE developed symptoms within 96 h of their flight. CONCLUSION: We conclude that the majority of VTE associated with air travel occur in those with identifiable risk factors prior to their flight, and that sequential flights may increase this risk.

Model for assessment of endothelial cell function and viability using the MTT dye test and [3H].

OBJECTIVES: To establish a reproducible in vitro model for evaluating endothelial cell function in clinical disease states. DESIGN: A prospective study of human umbilical vein endothelial cells (HUVEC) isolated and cultured. SETTING: Department of Haematology, University of Yaounde I, Cameroon and Department of Medicine University of Newcastle-upon-Tyne, England. RESULTS: The optimum initial cell seeding concentration, for maximal conversion of the formazan dye was 40 x 10(3) cells/well, after 24 hours incubation. At concentrations above 40 x 103 cells/well some inhibition of dye conversion occurred. The conversion of formazan dye was directly proportional to cell numbers for the first 48 hours only, at all cell concentrations. Thereafter, cell metabolism appeared to be inhibited. Third passage endothelial cells (ECs) were exposed to a range of lipopolysaccharide (LPS) concentrations for one and 24 hours, prior to performing the MTT dye test. Dye conversion was observed after one hour at even the lowest concentration of LPS (0.1 microgram/ml), to 49.9% +/- 5.6% of unperturbed control EC, with 10 x 10(3) initial seeding numbers. After 24 hours perturbation a small but statistically significant further inhibition was observed. [3H] thymidine incorporation studies indicated that the lowest LPS concentration tested (0.1 microgram/ml) had a stimulatory effect on DNA synthesis at the higher cell concentration (20 x 10(3) cells/well). In the range of 1 to 100 micrograms/ml of the LPS tested, there was increased DNA synthesis at all cell numbers. CONCLUSION: The model may be used to monitor the effects of other agents which are known to, or could be associated with, alterations in endothelial cell function and will serve in mimicking clinical situations including hyper coagulable states.

Association of polymorphisms in the cytochrome P450 CYP2C9 with warfarin dose requirement and risk of bleeding complications.

BACKGROUND: The cytochrome P450 CYP2C9 is responsible for the metabolism of S-warfarin. Two known allelic variants CYP2C9*2 and CYP2C9*3 differ from the wild type CYP2C9*1 by a single aminoacid substitution in each case. The allelic variants are associated with impaired hydroxylation of S-warfarin in in-vitro expression systems. We have studied the effect of CYP2C9 polymorphism on the in-vivo warfarin dose requirement. METHODS: Patients with a daily warfarin dose requirement of 1.5 mg or less (low-dose group, n=36), randomly selected patients with a wide range of dose requirements from an anticoagulant clinic in north-east England (clinic control group, n=52), and 100 healthy controls from the community in the same region were studied. Genotyping for the CYP2C9*2 and CYP2C9*3 alleles was done by PCR analysis. Case notes were reviewed to assess the difficulties encountered during the induction of warfarin therapy and bleeding complications in the low-dose and clinic control groups. FINDINGS: The odds ratio for individuals with a low warfarin dose requirement having one or more CYP2C9 variant alleles compared with the normal population was 6.21 (95% CI 2.48-15.6). Patients in the low-dose group were more likely to have difficulties at the time of induction of warfarin therapy (5.97 [2.26-15.82]) and have increased risk of major bleeding complications (rate ratio 3.68 [1.43-9.50]) when compared with randomly selected clinic controls. INTERPRETATION: We have shown that there is a strong association between CYP2C9 variant alleles and low warfarin dose requirement. CYP2C9 genotyping may identify a subgroup of patients who have difficulty at induction of warfarin therapy and are potentially at a higher risk of bleeding complications.

Rescue thrombolysis: alteplase as adjuvant treatment after streptokinase in acute myocardial infarction.

BACKGROUND: In acute myocardial infarction patients who do not reperfuse their infarct arteries shortly after thrombolytic treatment have a high morbidity and mortality. Management of this high risk group remains problematic, especially in centres without access to interventional cardiology. Additional thrombolytic treatment may result in reperfusion and improved left ventricular function. METHODS: Failure of reperfusion was assessed non-invasively as less than 25% reduction of ST elevation in the electrocardiographic lead with maximum ST shift on a pretreatment electrocardiogram. 37 patients with acute myocardial infarction who showed electrocardiographic evidence of failed reperfusion 30 minutes after 1.5 MU streptokinase over 60 minutes were randomly allocated to receive either alteplase (tissue type plasminogen activator (rt-PA) 100 mg over three hours) (19 patients) or placebo (18 patients). 43 patients with electrocardiographic evidence of reperfusion after streptokinase acted as controls. Outcome was assessed from the Selvester Q wave score of a predischarge electrocardiogram and a nuclear gated scan for left ventricular ejection fraction 4-6 weeks after discharge. RESULTS: Among patients in whom ST segment elevation was not reduced after streptokinase, alteplase treatment resulted in a significantly smaller electrocardiographic infarct size (14% (8%) v 20% (9%), P = 0.03) and improved left ventricular ejection fraction (44 (10%) v 34% (16%), P = 0.04) compared with placebo. This benefit was confined to patients who failed fibrinogenolysis after streptokinase (fibrinogen > 1 g/l). In patients in whom ST segment elevation was reduced after streptokinase, infarct size and left ventricular ejection fraction were not significantly different from those in patients treated with additional alteplase. CONCLUSION: Patients without electrocardiographic evidence of reperfusion after streptokinase may benefit from further thrombolysis with alteplase.

Do patients with epistaxis have drug-induced platelet dysfunction?

Aspirin and other non-steroidal anti-inflammatory drugs (NSAID) are being used increasingly. A positive correlation has been shown between epistaxis and the use of NSAID in the over 50s. This prospective study compared the NSAID intake and platelet function in 50 patients with epistaxis and 50 controls. Standard haematological parameters and the platelet response to collagen and arachidonic acid aggregation and adenosine triphosphate release were measured. The patients showed a significant increase in NSAID intake (P < 0.01, 95% confidence for the difference in the medians = 4-36%) and hypertension (for diastolic blood pressure > 100 mmHg, P < 0.01, 95% confidence for the difference in the medians = 5.9-16.1). The patients showed a significant reduction in platelet aggregation to collagen (P = 0.025). Non-steroidal anti-inflammatory drugs produce a significant platelet dysfunction which should be considered in the multifactorial aetiology of epistaxis.

A comparison of five commercial thromboplastins: ISI re-evaluation on an automated coagulometer.

Five commercial rabbit brain thromboplastins were compared with an International Reference Preparation on an ACL coagulometer, using 90 patients stabilized on warfarin and 22 normal individuals. The prothrombin times were converted to INRs using the thromboplastin manufacturers' quoted ISI. The quoted ISIs were reassigned using orthogonal regression analysis and then used to recalculate INRs for patient and commercial INR control plasmas. This showed that the manufacturers' quoted ISIs and the INR control plasma results were inconsistent. With one thromboplastin the manufacturers quoted ISI changed from 1.17 to 1.05 whilst the control plasma results changed from an INR of 4.3 to an INR of 3.7 (manufacturer's INR, 3.3). In most routine laboratories ISI reassignment is not practical. We conclude that the availability of a reliable plasma calibrant is essential for the accurate calculation of INRs at a local level.

Autotransfusion after coronary artery bypass surgery: is there any benefit?

Postoperative salvage autotransfusion of shed mediastinal blood, using the cardiotomy reservoir, is an inexpensive technique whose efficacy and safety are evaluated in this study. We randomized 75 consecutive patients into two groups. The autotransfusion group (n = 42) received autotransfusion after the completion of the coronary artery bypass grafting (CABG) until the drainage was < or = 50 mL per hour for 2 consecutive hours. The control group (n = 33) was treated with standard chest drainage. Both groups received homologous blood transfusion when the hematocrit fell below 30%. Packed red cells were required post-operatively in 84.8% of the control group and 80.9% of the autotransfusion group (p = NS). Postoperative colloid fluid replacement (excluding autotransfusion fluid) did not differ significantly between the groups. The prothrombin time was significantly higher in the autotransfusion group 24 hours postoperatively (p = 0.03). The fibrin degradation products were elevated only in the serum of the autotransfusion patients (p < 0.002). More febrile patients were seen in the autotransfusion group although not significantly more than the controls. The autotransfusion group received more red cells than the control group, but it lost more red cells in the mediastinal drains. In conclusion, the autotransfusion of shed mediastinal blood has not proved beneficial in reducing the postoperative requirements in homologous blood in patients undergoing coronary artery bypass grafting (CABG).

Sea blue histiocytosis: a common abnormality of the bone marrow in myelodysplastic syndromes.

AIMS: To determine whether myelodysplastic syndromes (MDS) are associated with sea blue histiocytosis in the bone marrow. METHODS: A retrospective review of bone marrow aspirates from 35 patients presenting consecutively with MDS and from 20 patients with each of the following: normal marrow appearance (routine staging for non-Hodgkin's lymphoma), polycythaemia rubra vera, immune thrombocytopenic purpura (ITP), chronic myeloid leukaemia (CML) in chronic phase. RESULTS: Sea blue histiocytes were present in the marrow in 12 of 35 cases of MDS and occurred in large numbers in three of these cases. Sea blue histiocytes varied in the degree of cytoplasmic granularity and some cells were intermediate in appearance between classic sea blue histiocytes and pseudo-Gaucher cells. Sea blue histiocyte granules additionally stained positively with Sudan black and periodic acid schiff. Sea blue histiocytes occurred only in the presence of marrow hypercellularity. Their presence did not correlate with FAB subtype, degree of dyserythropoeisis, or megakaryocyte numbers. No sea blue histiocytes were found in the normal marrow or polycythaemia cases. In ITP sea blue histiocytes were seen in two of 20 cases and in chronic myeloid leukaemia in eight of 20 cases. CONCLUSIONS: Sea blue histiocytes are a common cytological feature in the bone marrow of patients with MDS. As other disorders frequently associated with marrow sea blue histiocytes are relatively rare MDS is probably the most common cause of this phenomenon in a northern European population.

Pleural lymphoma in a patient presenting with malabsorption: an illustration of the clinicopathological behaviour in a case of enteropathy associated T cell lymphoma.

A case of enteropathy associated T cell lymphoma (EATCL) is described, which was diagnosed by biopsy of a lymphomatous pleural mass. Retrospective radiological review showed that this lesion had been present when an initial diagnosis of coeliac disease had been made 12 months previously and a detailed description of the natural history of the lymphoma during this period was thus available. The findings show that EATCL may behave in an indolent fashion and masquerade as coeliac disease, delaying the correct diagnosis. The relation of this disorder with coeliac disease and lymphocytic gastritis is discussed with reference to recent published works.

Disseminated zygomycosis and systemic lupus erythematosus.

A young woman with long-standing systemic lupus erythematosus and rheumatic fever presented with deteriorating renal function. She had severe gastritis treated with cimetidine and received methylprednisolone when her blood cultures were repeatedly negative. She developed spontaneous bruising and bleeding from venepuncture sites, leading to clotting studies and a diagnosis of thrombotic thrombocytopenic purpura. At post-mortem, extensive evidence of disseminated zygomycosis was found. The likely portal of entry was the gastric route.

Acute thrombocytopenia after De-Nol.

We describe a case of severe acute thrombocytopenia in a 72 year old man treated with De-Nol for erosive biliary gastritis.

Protamine sulphate and heparin rebound following open-heart surgery.

The efficacy of heparin reversal was investigated in 35 patients undergoing open-heart surgery. A total protamine sulphate dose of 3.0 mgs/kg was administered in divided doses and given as a continuous infusion. On this regime complete heparin neutralisation was observed 10 min after decannulation, but heparin levels were again detectable in 29% of cases 2 hours later. This phenomenon was found to correlate with the total circulating load of heparin to be neutralised. All cases with detectable postoperative heparin levels had in-vivo protamine sulphate: heparin ratios of less than 1.6. These data suggest that in-vitro assays of protamine sulphate neutralisation of heparin may seriously underestimate the required dose of protamine sulphate following open-heart surgery.

Combination therapy of steroids and immunoglobulin in chronic refractory idiopathic thrombocytopenic purpura (ITP) enabling renal stone fragmentation by lithotripsy.

A 27-year-old woman with idiopathic thrombocytopenic purpura (ITP), which had relapsed following splenectomy, was found to be refractory to a wide range of individual immunosuppressive agents. However, a normal platelet count was achieved with high-dose dexamethasone followed by intravenous immunoglobulins (i.v. Ig). Either agent used alone had previously produced clinically inadequate platelet increments. With this regime, successful renal stone fragmentation by lithotripsy was undertaken, which required no blood product support over the peri-operative period. It is suggested that patients with refractory ITP requiring major procedures, who have not responded to i.v. Ig treatment, merit a repeat trial following high-dose steroid.

Significance of the whole blood activated clotting time in cardiopulmonary bypass.

Recent publications have described a poor correlation between whole blood activated clotting time (WBACT) values and plasma heparin levels during cardiopulmonary bypass (CPB). A prospective, controlled study was undertaken to investigate the variables which may influence the WBACT in this situation. Antithrombin III levels over a range of 35-93 u/dl did not influence either the WBACT value or plasma heparin level. However, reduced platelet function following infusion of prostacyclin (10 ng/kg/min prior to CPB and 20 ng/kg/min thereafter); platelet number (range 63-287 X 10(9)/l) and packed cell volume (range 16-30%) were found to correlate with the WBACT. It is concluded that in addition to the circulating plasma heparin level, the wide variations in platelet number, platelet function and packed cell volume which are frequently observed during cardiopulmonary bypass may also influence the WBACT value.

Hypersplenism and splenectomy in lymphoproliferative and myeloproliferative disorders.

Splenic pooling of red cells and an expanded plasma volume are considered to be among the major mechanisms responsible for the anaemia in hypersplenism. In those conditions in which massive splenomegaly is associated with various degrees of marrow failure, diagnosis of the cause of anaemia may be difficult. A simple technique was used to estimate the degree of hypersplenism, from red cell mass data, in 94 patients with unequivocal lymphoproliferative or myeloproliferative disorders. The splenic effect was found to correlate well with both the size of the spleen (r = 0.75-0.90) and the actual red cell mass (0.79), and was abolished by splenectomy. Clinical data is also presented on 43 of these patients who underwent splenectomy. The incidence and type of complications, survival figures, and possible criteria for patient selection are discussed.

Inhibitor to factor VIII in mild haemophilia.

Factor VIII inhibitors in mild haemophilia are uncommon and the management of such patients is controversial. The development of a persistently high responding F VIII inhibitor in a mild haemophiliac is reported and the behaviour of the inhibitor discussed in the context of the various therapeutic regimes employed for symptomatic management. When inhibitor titres were low, endogenous F VIII stimulation, by DDAVP, was less immunogenic than the administration of exogenous F VIII concentrates. This inhibitor displayed characteristics of an autoantibody, and was characterised as an immunoglobulin of IgG subtype.

Rapid quantitation of plasma heparin and antithrombin III levels for cardiopulmonary bypass monitoring, using fluorometric substrate assays.

Plasma heparin and ATIII levels were determined using recently developed fluorometric substrate techniques on serial samples taken from 9 unselected patients undergoing open-heart surgery on cardiopulmonary bypass. The fluorometric assay for ATIII and established clotting and immunological methods showed a highly significant correlation (p less than 0.001). Heparin recovery was reduced in all cases, and plasma levels (fluorometric assay) demonstrated poor correlation to Whole Blood Activated Clotting Time (Hemochron) estimations. ATIII levels were dramatically reduced during bypass, and in 3 cases reached levels below 0.08 iu/ml. Heparin reversal schedules based upon empirical dosage led to excessive protamine administration by a mean factor of 3.3, as assessed by in vitro neutralization of standardized heparin concentrations.