Considerations in the laboratory assessment of haemostasis.

SUMMARY: This review outlines a number of key issues when performing laboratory testing of homeostasis. The effect pre-analytical variables have on the reliability and consistency of screening tests is often forgotten due to a lack of understanding and awareness. This can be improved through educating healthcare professionals who are involved in taking blood for assessment. Recent advances in coagulation testing have not enabled laboratories to replace the Prothrombin Time (PT) and Activated Partial Thromboplastin Time (APTT) screening tests with more advanced assays and they continue to play an important role with the advantage of being easily automated. However, there are many analysers on the market, each with varying sensitivity to coagulation defects and it is important to keep this in mind when interpreting results.

Achieving and maintaining quality in the laboratory.

In order to ensure the delivery of a service of the highest possible quality, it is an essential requirement that laboratories undertake strict internal quality control (QC) measures as well as participate in external quality assessment (EQA) schemes. For any given test, a critical part of the internal QC process involves the establishment of reference intervals using samples taken from normal individuals, and then calculating limits representing the 95% range. This forms the basis for assessment of abnormal test results, which will in turn impact on laboratory performance in proficiency testing exercises in EQA programmes. Whereas for plasma-based assay systems, variability in performance in EQA exercises is usually determined by measurement of a coefficient of variation (CV), results of genetic testing is usually measured in absolute terms. Despite this, results of genetic EQA programmes confirm that errors in testing do occur, as much because of inadvertent sample switching and transcription errors as to analytical mistakes. EQA programmes involving identification of mutations by DNA sequencing, such as haemophilia, is made difficult by the high information content of sequence data. Nevertheless, results show that errors are usually made in the naming of the mutations, indicating that this is an evolving and poorly standardized area. Developing countries face particular challenges in the encouragement of laboratories to participate in local EQA programmes, as well as in relation to the logistical issues of sample provision, distribution and result collation in an effective and affordable manner.

Essential issues of laboratory investigation for patients with haemophilia and bleeding disorders.

Apart from history-taking and physical examination, laboratory investigation is one of the essential issues for the definite diagnosis of haemophilia and bleeding disorders. The limited resources of medical personnel, equipment and reagents should be shared among several departments in the hospital, especially for serving patients with common genetic diseases such as thalassemia and haemoglobinopathies. Medical personnel require appropriate training to expand their skills in laboratory techniques. Laboratory procedures can be created, modified and simplified using locally produced and shared equipment. Molecular genetic studies can also be set up at different levels of hospital service using simple, rapid and low-cost methods. Finally, a system of periodic external quality control will guarantee the accuracy of laboratory results.

Analysis of intron 22 inversions of the factor VIII gene in severe hemophilia A: implications for genetic counseling.

Intrachromosomal recombinations involving F8A, in intron 22 of the factor VIII gene, and one of two homologous regions 500 kb 5' of the factor VIII gene result in large inversions of DNA at the tip of the X chromosome. The gene is disrupted, causing severe hemophilia A. Two inversions are possible, distal and proximal, depending on which homologous region is involved in the recombination event. A simple Southern blotting technique was used to identify patients and carriers of these inversions. In a group of 85 severe hemophilia A patients, 47% had an inversion, of which 80% were of the distal type. There was no association with restriction fragment length polymorphism (RFLP) haplotypes. The technique has identified a definitive genetic marker in families previously uninformative on RFLP analysis and provided valuable information for genetic counselling information may now be provided for carriers without the need to study intervening family members and the diagnosis of severe hemophilia A made in families with only a nonspecific history of bleeding. Analysis of intron 22 inversion should now be the first-line test for carrier diagnosis and genetic counselling for severe hemophilia A and may be particularly useful when there is no affected male family member or when intervening family members are unavailable for testing.

Value of DNA analysis with multiple DNA probes for the detection of hemophilia A carriers.

Detection of hemophilia carriers is an important issue and should be addressed with great care. The allelic frequencies of three intragenic probes (Bcl I for probe p114.12, Xba I for probe p482.6, and Bgl I for probe C) and one linked probe (Bgl II for probe DX 13) are reported, together with their diagnostic yield singly and in combination. In this series, 725 individuals (405 females) in 156 families were analyzed for restriction fragment-length polymorphisms. A total of 255 females (63%) were found to be informative for their carrier state with one or more probes. The most informative intragenic probe was p482.6 (useful in 49% of informative females). The most informative probe was DX 13 (useful in 59% of informative females), but this is a linked probe that carries a 5% risk of cross-over. By the use of probes p114.12, p482.6, and DX 13, almost 98% of all the informative females could be detected. In about 71% of families with a family history and a known carrier, prenatal diagnosis was feasible.

Evaluation of the effect of cicletanine on genetic atherosclerosis in the rabbit.

This study was designed to evaluate the hypolipidaemic and anti-atherosclerotic potential of cicletanine in a genetic hypercholesterolaemic rabbit model. In a pilot study the effect of 8 weeks oral administration of 2 treatment levels of cicletanine (10, 30 mg.kg-1.day-1) was compared with vehicle alone. In the main study, 8 weeks oral administration of 2 treatment levels of cicletanine (5, 30 mg.kg-1.day-1) was compared with parallel treatment with probucol (15 mg.kg-1.day-1) and with nifedipine (10 mg.kg-1.day-1). At the start of each study and at scheduled points throughout, blood samples were collected for routine biochemical and lipid/lipoprotein analyses. At the end of each test period all animals were examined at post mortem. Aortae were dissected and examined for the presence ans degree of atheroma. Hearts were examined for the presence of lesions. Sections of aortae were stained for lipid, examined histologically and scored for extent of atheroma using an atherosclerotic index. In the pilot study cicletanine had no effect on blood lipid levels. Gross pathology indicated a reduction in the extent of aortic atheroma in cicletanine-treated animals. Histopathological examination of thoracic and abdominal regions of the aortae confirmed these gross findings. The atherosclerotic index was significantly reduced (p less than 0.06) in all drug treated animals. In the main study similar data were achieved. None of the test drug affected plasma lipid/lipoprotein levels. Gross pathology indicated a reduction in the extent of aortic atheroma in all cicletanine-treated animals and also in the nifedipine-treated group. This was confirmed by histopathological examination of thoracic and abdominal regions of the aortae.(ABSTRACT TRUNCATED AT 250 WORDS)

Inheritance and bleeding in factor XI deficiency.

A study of 20 Jewish and four non-Jewish kindreds transmitting factor XI deficiency (164 individuals) confirmed inheritance to be autosomal with severe deficiency in homozygotes (mean factor XI level 3.8 u/dl, SD 2.91) and partial deficiency in heterozygotes (mean factor XI level 57 u/dl, SD 10.42; normal mean factor XI level 96 u/dl, SD 11.6). The probability of an individual being heterozygous can be predicted from the factor XI level using a graph derived from this data. The accuracy is increased by including the prior probability derived from the pedigree. A high frequency of heterozygote to heterozygote mating was observed in the Jewish families consistent with an estimated gene frequency of 13.4% in this racial group. The relationship between factor XI level and bleeding tendency is poor; a third of heterozygotes had bled excessively after surgery, including six with factor XI levels above 50 u/dl, showing this condition to have clear signs of expression in heterozygotes. The lower limit of the normal range (2 SDs from the mean) was found to be 72 u/dl.

Effect of etofylline clofibrate on experimental thrombus formation and prostacyclin activation.

1-(7-Theophyllinyl)-2-ethyl-[2-(p-chlorophenoxy)-isobutyrate] (etofylline clofibrate, theofibrate, Duolip) was shown to possess substantial thrombus disaggregating activity in the microcirculation of the hamster cheek pouch following minor vascular damage by electrical stimulation. At 12 mg/kg p.o. the moderate effect of a single dose (12% reduction in disaggregation time) increased to a maximum reduction of 31 and 43% following 5 and 7 consecutive daily applications, respectively. Etofylline clofibrate was more active than other drugs already tested in this test system, but less than the prostaglandins PGE1 and PGI2. The antithrombotic efficacy found in both in vivo tests, thrombus formation and disaggregation, suggests as mode of action of etofylline clofibrate an agonistic interaction with intimal PGI2. This could be by enhancement of its production or by a synergistic interaction with this prostanoid, rather than inhibition of thromboxane A2 synthetase.

The effect of prostaglandin E1 incorporated in lipid microspheres on thrombus formation and thrombus disaggregation and its potential to target to the site of vascular lesions.

Prostaglandin E1 incorporated in lipid microspheres (lipo-PGE1) was evaluated following intravenous administration as an inhibitor of ADP-induced thrombus growth rate and as a thrombus disaggregating agent following vascular damage in the microcirculation of the hamster cheek pouch. The drug was shown to be significantly more active and longer acting than PGE1 in the first experiment. Following vascular damage lipo-PGE1 was very efficacious as a thrombus disaggregating agent and was significantly more effective when infused after, rather than before, vascular damage. These data suggested that the drug might be targeted to the site of damage. When incorporated in lipid microspheres, PGE1 appeared to be more stable, longer acting and more efficacious than PGE1 alone.

A two-site, monoclonal antibody-based immunoassay for von Willebrand factor--demonstration that vWF function resides in a conformational epitope.

Two monoclonal antibodies (RFF-VIII:R/1 and RFF-VII:R/2) which recognise the same epitope on von Willebrand factor (vWF) have been used in a simple, two-site, solid-phase immunoradiometric (IRMA) or enzyme-linked assay (ELISA) to analyse vWF in plasma from normal individuals and from patients with von Willebrand's disease (vWD). Results obtained confirm our previous findings (using RFF-VIII:R/2 in a one-site, fluid-phase IRMA) that the MAbs detect the presence of an epitope on the vWF molecule that reflects its function. This epitope is involved in vWF binding to the GPIb protein on platelets. It is reduced in all types of vWD, including type II (or variant) vWD. It is present in normal plasma, in vWF released from normal platelets and from cultured umbilical cord vein endothelial cells. The epitope is, however, found to be reduced in serum. Studies on SDS-treated vWF prove that this GPIb-binding site is dependent on the conformation of the vWF multimers.

Effect of a stable prostacyclin analogue on platelet function and experimentally-induced thrombosis in the microcirculation.

Sodium dl-4-[1R,2R,3aS,8bS)-1,2,3a,8b-tetrahydro- 2-hydroxy-1-[(3S,4RS)-3-hydroxy-4-methyl-oct-6- yne-(E)-1-enyl]-5-cyclopenta[b]benzofuranyl]butyrate (TRK-100) is a stable analogue of prostacyclin (epoprostenol, PGI2). The drug was shown to be a potent inhibitor of platelet aggregation in vitro, induced by adenosine diphosphate (ADP), using platelet-rich plasma (PRP) from human and several animal species. The inhibitory activity of TRK-100 using human platelets was half that of PGI2 and eight times that of PGE1. There was a marked tendency for platelet clumps to disaggregate following secondary aggregation in the presence of TRK-100 at final concentrations higher than 1 ng/ml. This activity was similar to PGI2 and more than 30 times that of PGE1. TRK-100 was shown to induce the disaggregation of a pre-existing thrombus in the microcirculation of the hamster cheek pouch. A dose-dependent response was obtained following oral administration of the drug at levels of 50-200 micrograms/kg. Optimal activity was observed 30-60 min after dosing and activity was sustained throughout the experimental period. TRK-100 was more active than PGE1 in the test system and appeared to be of a similar potency to PGI2. Since this drug is stable, orally active and without the hypotensive activity of PGI2, it is considered to be a potentially useful agent for antithrombotic therapy.

The vascular protection of ditazole and its effect on arachidonic acid metabolism.

Ditazole (4,5-diphenyl-2-bis-(2-hydroxyethyl)-aminoxazol) is a weak anti-inflammatory drug and has been shown to inhibit thrombus formation following electrically stimulated vascular damage in the microcirculation of the hamster cheek pouch. The drug was found to inhibit thromboxane A2 (TXA2) production ex vivo as determined by radioimmunoassay (RIA) and to reversibly antagonise the effect of TXA2 on smooth vascular tissue. However, in contrast to acetylsalicylic acid (ASA), it does not inhibit vessel cyclooxygenase. The apparent vascular protective effect of ditazole could not be ascribed to an enhanced production of vascular prostacyclin (PGI2) since the latter, when estimated ex vivo by RIA, was not enhanced following oral treatment with the drug. It is suggested that the mode-of-action of ditazole may be different from the cyclo-oxygenase/PG synthetase blocking action of most other non-steroidal anti-inflammatory drugs.

Aetiology of rheumatoid arthritis: an attempt to transmit an infective agent from patients with rheumatoid arthritis to baboons.

Thirty baboons were injected intravenously and intra-articularly with material from the joints of 19 patients with active rheumatoid arthritis or with control material. Fifteen of the 30 animals received synovial fluid cells or synovial membrane cells from 3 patients with seronegative arthritis. Ten animals received pooled cells from a total of 16 cases of seropositive arthritis. Five animals were given nonrheumatoid cells. No signs of arthritis were recognised in the 27 surviving animals during 3 years of observation. No significant biochemical, haematological, or serological changes occurred during this period, and no gross or microscopic evidence of synovial or systemic disease was found post mortem.

Evidence for functional endothelial cell damage in early diabetic retinopathy.

Two aspects of endothelial cell function were examined in two matched groups of male insulin-dependent diabetics, six with background retinopathy and seven without retinopathy. Leakage of fluorescein from the retinal capillaries was estimated by vitreous fluorophotometry. In addition, factors VIII/von Willebrand (vWF) and VIII-related antigen (VIII-RAG), which are synthesized by the endothelial cells, were measured, together with VIII-antihaemophilic factor (VIII-AHF). The patients without retinopathy had normal leakage of fluorescein in the macula (mean +/- SEM: 1.10 +/- 0.10 g X 10(-8)/ml) and the posterior vitreous (0.45 +/- 0.11 g X 10(-8)/ml), and normal circulating levels of vWF (123% of a normal reference plasma +/- 18%), VIII-RAG (137 +/- 14%) and VIII-AHF (112 +/- 18%). In contrast, the patients with background retinopathy showed higher leakage of fluorescein in the macula (6.34 +/- 1.74 g X 10(-8)/ml; p less than 0.01), and the posterior vitreous (3.09 +/- 0.94 g X 10(-8)/ml; p less than 0.02), as well as increased levels of vWF (177 +/- 16%; p less than 0.05). There was a trend towards increased VIII-RAG (195 +/- 24%; p less than 0.1), but not VIII-AHF (126 +/- 13%). Alterations of endothelial cell function thus accompany the development of retinopathy. It cannot be said from the present study whether these alterations also precede the appearance of retinopathy.

Effect of etofylline clofibrate on experimental thrombosis and platelet function.

1-(Theophyllin-7yl)-ethyl-2-[2-(p-chlorophenoxy)-2-methylpropionate] (etofylline clofibrate, ML 1024, Duolip) was shown to be a potent inhibitor of experimental thrombus formation in the microvasculature of the hamster cheek pouch and of platelet aggregation and adhesiveness in the cynomolgus monkey. Inhibitory effect on thrombus formation was superior to that obtained with either of the molecule components (clofibric acid and etofylline) or their 1 : 1 mixture and a synergistic effect was apparent. Etofylline clofibrate was more active than a commercial antithrombotic drug combination of acetylsalicylic acid (ASA) and dipyridamole as an inhibitor of thrombus formation in this test system (p less than 0.05) at the proposed therapeutic dose level for each drug. In the cynomolgus monkey, etofylline clofibrate was shown again to be a potent inhibitor of platelet aggregation induced by ADP and collagen and of platelet adesiveness after administration of 12 mg/kg/day for 21 days. A mixture of clofibrate and etofylline (21.25 mg/kg/day and 3.75 mg/kg/day, respectively) had relatively less effect on platelet aggregation and no consistent effect on platelet adhesiveness. The activity found in both test systems indicates a promising antithrombotic potential for etofylline clofibrate and warrants further investigation in humans.

Mechanisms of C. Parvum-induced coagulopathy in mice.

I.v. injection of Corynebacterium parvum (CP) into C57BL and BALB/c mice caused profound coagulation changes, featuring thrombocytopenia, decreased fibrinogen, increased fibrin/fibrinogen degradation products, and a concomitant microangiopathic haemolytic anaemia. These changes were greatest on the 9th day after CP, with recovery by Day 21. I.p. injection caused similar effects but s.c. injection was ineffective. Radiolabelled-platelet kinetics and distribution after i.v. CP indicated disseminated intravascular coagulation with rapid fibrinolysis; EACA treatment exacerbated the thrombosis. The coagulopathy correlated with hepatosplenomegaly, and both were dose dependent. Splenectomy did not effect the coagulopathy, but indomethacin totally abrogated the changes, suggesting that prostaglandin biosynthesis is involved in the pathogenesis.