Evaluation of a rapid von Willebrand factor activity latex immuno assay for monitoring of patients with von Willebrand disease (VWD) receiving DDAVP or VWF replacement therapy.

Haemostatic management of surgery in patients with von Willebrand disease (VWD) includes DDAVP or von Willebrand factor (VWF)-containing concentrates. Although the recommendations are for monitoring by VWF activity assays, it is quite common for clinicians to use factor VIII due usually to longer turnaround times required for VWF ristocetin cofactor assay (VWF:RCo) measurements. The aim of this study was to evaluate use of the rapid HaemosIL VWF activity (VWF:Act) latex immuno assay (LIA) on an automated coagulometer (ACL TOP(™) 700; Instrumentation Laboratory, Bedford, MA, USA) compared to platelet-based VWF:RCo assays in this setting. One hundred and sixty-seven plasma samples from 42 patients [Type 1 (n = 22), Type 2A (n = 2), Type 2B (n = 3), Type 2M (n = 10), Type 3 (n = 3)] and acquired von Willebrand syndrome (n = 2) with VWD treated with DDAVP or VWF-containing concentrates were included in the study. Method comparison and method bias were evaluated by Bland-Altman analysis (BA) and Passing and Bablok regression modelling respectively. BA of baseline samples (n = 39) showed a mean difference of -3.0 (±1.96 SD -25.2 to +19.4). Post (treatment) samples (n = 120) were separated into two groups. Group 1 contained samples with VWF:RCo levels 10 to ≤175 IU dL(-1) (n = 97) and group 2, samples with VWF:RCo levels >175 IU dL(-1) (n = 23). BA of group 1 postsamples showed a mean difference of +3.4 (±1.96 SD -44.6 to +51.5), and the BA of Group 2 samples was -23.9 (±1.96 SD -136.1 to +88.3). In conclusion, use of HaemosIL VWF:Act LIA test on an automated coagulometer is a reproducible and rapid assay that can be used as an alternative test for monitoring VWF replacement therapy, facilitating dose adjustments on a real-time basis.

Prediction of the mediastinal drainage after coronary artery bypass surgery.

Using multiple correlation and linear regression approaches, we investigated the association between the amount of mediastinal drainage for the first 24 postoperative hours and clinical variables as well as multiple haematological tests performed at three time points: before anaesthesia induction, 10 minutes after protamine administration and just after skin closure, on 46 patients undergoing primary coronary artery bypass grafting. Three models from the three times were then developed to predict mediastinal drainage. The number of internal mammary grafts, the total number of grafts and plasma fibrinogen concentration were useful predictors of mediastinal drainage at all three times. The platelet count taken only after skin closure was found to provide additional predictive information. Each regression model explained approximately 60% of the variation in postoperative mediastinal drainage. The information obtained from these predictive models is useful in defining high-risk populations.

Characterization of activated lymphocyte-tumor cell adhesion.

This study demonstrates the variable expression of ICAM-1 and leukocyte function antigen-3 (LFA-3) on four tumor cell lines (COLO526, K562, Daudi, and HT-29). In addition, phorbol ester (PMA) activation of lymphocytes modulated LFA-1 from a uniform to a clustered surface distribution; whereas after treatment with high levels of Mg2+ ions, the unique epitope for high-affinity LFA-1 was identified using clone Mab24. Using a flow cytometric adhesion assay it was demonstrated that PMA-activated lymphocytes formed conjugates with COLO526 and Daudi, and that these conjugates were inhibited by anti-CD2 with varying inhibition by LFA-1 clones MHM24 and 25.3.1. When lymphocytes were induced to express the high-affinity form of LFA-1, conjugates were identified with COLO526, K562, and Daudi and these conjugates were sensitive to the presence of both CD2 and LFA-1 antibodies. Further studies using confocal microscopy confirmed significant adhesion between peripheral blood lymphocytes pretreated with either PMA or high levels of Mg2+ and the adherent cell line COLO526. In conclusion, this unique study has demonstrated for the first time the important role of the active form of LFA-1 on the lymphocyte cell surface for conjugate formation with an ICAM-1-expressing tumor cell; also, two pathways of cell signaling were identified for conjugate formation to occur.

The Effect of Preoperative Aspirin and/or Heparin Therapy on Coagulation and Postoperative Blood Loss after Coronary Artery Bypass Surgery.

OBJECTIVE: To assess the effects of preoperative aspirin and/or intravenous heparin therapy on perioperative coagulation tests and postoperative blood loss for 24-hour after coronary artery bypass surgery. METHODS: Multiple conventional coagulation tests, activated clotting time, thrombelastograph, skin bleeding time and platelet aggregation were performed before induction of anaesthesia, following protamine administration and after skin closure in 45 patients. RESULTS: There was no significant difference in either coagulation tests or postoperative blood loss (median of 860 mL with a range of 275 to 2800 mL, versus 833 ml with a range of 500-1380 mL) between the aspirin and no-aspirin patients. Preoperative heparin therapy affected most coagulation tests (e.g. international normalised ratio, activated partial thromboplastin time, thrombin clotting time, prothrombin time, activated clotting time and coagulation time of thrombelastography) before anaesthesia. The effects disappeared following protamine administration and after skin closure. Post operative blood loss was not significantly increased for the heparin group compared with the no-heparin group (median of 850 mL with a range of 700-1400 mL, versus 856 mL with a range of 275-2800 mL, respectively). Similar results were seen in patients receiving preoperative co-administration of aspirin and heparin compared with patients receiving aspirin alone. There was no suppression of platelet activity in patients receiving preoperative heparin or co-administration of aspirin and heparin. However, such suppression was found in patients receiving aspirin only. CONCLUSION: This study suggests that preoperative aspirin ingestion and intravenous heparin therapy should be administered as indicated and that concerns about the risk of postoperative bleeding should not lead to modification or cessation of such therapy.

Antithyroid and antiadrenal autoantibodies in antiglomerular basement membrane disease, thin basement membrane disease and Alport syndrome.

The basement membranes of the glomerulus, thyroid and adrenal all contain the Goodpasture antigen, the target of autoantibodies in antiglomerular basement membrane (GBM) disease. Antithyroid antibodies can be associated with antiGBM disease, and there have been occasional reports of antithyroid antibodies in Alport syndrome, an inherited kidney disease where the GBM lacks the Goodpasture antigen. The aim of this study was to determine how often antithyroid and antiadrenal autoantibodies occurred in antiGBM disease, Alport syndrome and a related condition, thin basement membrane disease (TBMD). Sera from patients with antiGBM disease (n = 19), Alport syndrome (n = 5) or TBMD (n = 13) were tested for antithyroglobulin, antithyroid microsomal and antiadrenal antibodies. Five of the patients with antiGBM disease (5/19, 26%, P NS) had antimicrosomal, and one had antithyroglobulin, antibodies (1/19, 5%, P NS). No patient with Alport syndrome had antithyroid antibodies. One with TBMD (1/13, 8%, P NS) had antithyroglobulin and antimicrosomal antibodies at titres of 1/400 and 1/25,600, respectively. Both patients with antithyroglobulin antibodies had previously been diagnosed with hypothyroidism. No one with antiGBM disease, Alport syndrome or TBMD had antiadrenal antibodies. Antithyroid microsomal antibodies do not occur significantly more often in patients with antiGBM disease than in normals, and antithyroid and antiadrenal antibodies are not associated with Alport syndrome or TBMD.

Characterization of platelet aggregation induced by the human carcinosarcoma Colo 526: role of platelet activation, tumor cell cytoskeleton and tumor cell plasma membrane.

Tumor cell-platelet interactions have been shown to be involved in the process of metastasis. This study characterizes the aggregation of washed platelets induced by the human uterine carcinosarcoma Colo 526. Ultrastructural studies revealed a two-stage process in which the earliest events were the adhesion and degranulation of individual platelets in contact with the tumor cell membrane. The second stage consisted of a wave of aggregation involving all residual platelets. We found that the first stage was initiated by a factor integral to the tumor cell plasma membrane which acted independently of the tumor cell cytoskeleton or metabolic processes. This factor was found to be a glycoprotein or glycolipid with functionally important sialic acid and N-linked carbohydrate residues. The initial stage was not dependent on platelet activation as neither aspirin nor prostacyclin prevented adhesion or degranulation. The second stage was found to be dependent on platelet activation. These results suggest that platelet aggregation induced by Colo 526 involves a distinctive primary stage which is initiated by a factor on the tumor cell plasma membrane resulting in the degranulation and lysis of individual platelets. This process can occur independently of platelet activation or aggregation and thus may have some relevance to the clinical use of platelet antagonists as antimetastatic agents.

Extracellular ATP causes of loss of L-selectin from human lymphocytes via occupancy of P2Z purinocepters.

Lymphocytes from normal subjects or patients with chronic lymphocytic leukemia are known to possess receptors for extracellular ATP termed P2Z purinoceptors whose physiological role is undefined. Addition of extracellular ATP (50-500 microM) to both normal and leukemic lymphocytes caused loss of binding of monoclonal antibodies to L-selectin (CD62L) on the cell surface. UTP, ADP, and adenosine (all at 500 microM) had no effect on L-selectin expression. Several features of the ATP-induced loss of L selectin indicate that this effect is mediated by lymphocyte P2Z purinoceptors. First the loss was attenuated in isotonic NaCl medium compared to 150 mM KCl medium. Second the loss of L-selectin was immediately halted by addition of Mg2+ ions in molar excess of ATP. The most potent nucleotide causing L-selectin loss was benzoylbenzoic ATP (> 10 microM) which is also the most potent agonist for the P2Z purinoceptor. Finally preincubation of lymphocytes with oxidized ATP, an irreversible inhibitor of P2Z purinoceptors, also inhibited ATP induced loss of L-selectin. Extracellular ATP is known to open an ion channel associated with the P2Z purinoceptor on B-lymphocytes which allows influx of Ca2+. However, ATP-induced loss of L-selectin did not require extracellular Ca2+. Moreover addition of the calcium ionophore, ionomycin, had minimal effect on L-selectin expression. Staurosporine (500 nM), an inhibitor of protein kinase C, inhibited only 10% of ATP induced loss of L-selectin but completely inhibited the loss of L-selectin caused by 50 nM PMA. Thus extracellular ATP interacts with lymphocyte P2Z purinoceptors which leads to shedding of L-selectin via a pathway which requires neither Ca2+ influx nor activation of protein kinase C. ATP may have a physiological role in the loss of L-selectin which occurs during the interactions of lymphocytes with other cells.

Laboratory studies of the effect of Pall extracorporeal leucocyte filters LG6 and AV6 on patients undergoing coronary bypass grafts.

A total of 14 patients with ischaemic heart disease undergoing coronary artery bypass grafts were studied for the effect of AV6 control filter and LG6 neutrophil filter, used in the extracorporeal circulation, on different laboratory parameters. There was no statistical difference between the effects of AV6 and LG6 filters on total white cells, neutrophils, monocytes, lymphocytes, platelets or haemoglobin. The expression of neutrophil activation antigens identified with a panel of monoclonal antibodies demonstrated that for the LG6 filter the leucocyte tyrosine phosphate CD45Ro fell during the procedure, whilst there were no significant changes in any of the other neutrophil antigens. The AV6 filter did not significantly diminish the expression of any of the neutrophil antigens. An indirect measure of superoxide production using Dihydrorhodamine 123 identified that the more activated cells appeared to be depleted across the LG6 filter which was not evident with the AV6 filter. These studies indicate that the LG6 is not capable of significantly depleting the neutrophil load generated during extracorporeal circulation but may be capable of selectively removing the more activated forms.

Agonists for endothelial P2 purinoceptors trigger a signalling pathway producing Ca2+ responses in lymphocytes adherent to endothelial cells.

Recirculation of lymphocytes through the body involves their frequent adhesion to endothelial cells but little is known of the signalling pathways between these two cell types. Lymphocytes from patients with chronic lymphocytic leukaemia were loaded with the Ca(2+)-sensitive indicator, fura 2, and allowed to adhere to either glass or monolayers of human umbilical-vein endothelial cells. Addition of ATP or UTP (1-10 microM) to the superfusate produced a transient rise in cytosolic Ca2+ concentration in the lymphocytes adherent to endothelium (24 of 35 cells). In contrast, ATP or UTP (1-10 microM) had no effect on the cytosolic Ca2+ of lymphocytes attached to glass. As the only lymphocyte receptor for ATP (P2Z class) requires higher ATP concentrations ( > 50 microM) for Ca2+ influx and is unresponsive to UTP, the involvement of a lymphocyte P2Z purinoceptor is unlikely. Various agonists including ATP, UTP, 2-methylthioATP, ADP and histamine all stimulated increases in endothelial cytosolic Ca2+ but only ATP and UTP (both agonists for endothelial P2U purinoceptors) triggered Ca2+ transients in adherent lymphocytes. Removal of extracellular Ca2+ did not abolish the ATP-induced rise in cytosolic Ca2+ concentration in lymphocytes adherent to endothelial cells. These findings show that stimulation of endothelial P2U purinoceptors triggers an endothelial-lymphocyte signalling pathway which releases internal Ca2+ in adherent lymphocytes.

Various cells release a stable small molecule that inhibits endothelium-dependent relaxation.

Previous studies have shown that neutrophils release a stable factor that inhibits endothelium-dependent relaxation. In the present studies, the effects of supernatants derived from various cells on endothelium-dependent relaxation were studied. Cells were obtained from seven sources: human hematopoietic cells including mononuclear leukocytes (MONO), polymorphonuclear leukocytes (PMNs), and chronic lymphocytic leukemia (CLL) cells; cells of the cardiovascular system including human endothelial cell line ECV304, human smooth muscle cells, and rat myocardial cells; and the tumor cell line HPB. These isolated or cultured cells were incubated for 1 h in Krebs solution to release the factor. The results showed that the supernatants from 10(5) cells/ml of all cells except the tumor cell line HPB produced a potent inhibitory effect on endothelium-dependent relaxation of rat aortic rings in response to acetylcholine and Ca2+ ionophores A23187 and ionomycin but not on endothelium-independent relaxation to nitroprusside and glyceryl trinitrate. When the concentration increased to 10(6) cell/ml, the supernatants from the tumor cell line HPB also slightly but significantly inhibited endothelium-dependent relaxation. The potency order was PMNs = MONO = CLL cells > cardiac cells > smooth muscle cells > the endothelial cell line ECV304 > the tumor cell line HPB. It seems that the hematopoietic cells and the cardiac cells are more active in release of the factor. The effect of this factor was rapid in onset and hard to wash out. A cyclooxygenase inhibitor or a thromboxane A2-prostaglandin H2 receptor antagonist partially but significantly reduced the effect of the factor.(ABSTRACT TRUNCATED AT 250 WORDS)

Studies of the effect of Pall leucocyte filters LG6 and AV6 in an in vitro simulated extracorporeal circulatory system.

Neutrophil activation is thought to play a major role in the inflammatory response seen in reperfusion injury and similar clinical situations, i.e. extracorporeal circulation. Impairment of neutrophil function or reduction of total numbers of neutrophils using a leucocyte filter may be beneficial in reducing the adverse clinical effects. In this study we have investigated the effect of the Pall LG6 and control AV6 filters during simulated in vitro cardiopulmonary bypass (CPB). Various parameters were evaluated including neutrophils, total leucocytes, monocytes, lymphocytes and platelets, expression of antigens on neutrophils using a panel of leucocyte-associated monoclonal antibodies CD13, 14, 15, 45Ro, 67, 11a, 11b and L selectin. The effects of leucocyte stimulation with phorbol myristate acetate (PMA) and a leucocyte bolus from a patient with chronic myeloid leukaemia (CML) were also investigated. We have demonstrated that the LG6 significantly reduces leucocytes, in particular neutrophils, with a modest reduction of lymphocytes, platelets and haematocrit, whereas the AV6 had no effect on leukocytes or neutrophils in the test system. In addition the LG6 was associated with a reduction in expression of all leucocyte antigens by approximately 20%; however there was no appreciable alteration of any of the antigens with AV6. Leucocyte stimulation with PMA resulted in a dramatic decrease of all cellular elements and an extra leucocyte load (using CML leucocytes) was not effectively filtered by the LG6 filter. These studies identify the capacity of the LG6 as compared with the AV6 to deplete activated neutrophils in an in vitro simulated cardiopulmonary bypass circuit.

Acquired protein S deficiency in a patient with systemic lupus erythematosus causing central retinal vein thrombosis.

A 16 year old girl with systemic lupus erythematosus (SLE) developed the rare complication of central retinal vein occlusion. Although classically a disease of older patients, it has been recognised in association with SLE but only in the presence of the lupus anticoagulant or antiphospholipid antibodies. The thrombosis occurred when free protein S concentrations were transiently reduced and there was no family history or other known causes of reduced protein S concentrations. No other prothrombotic risk factors were present.

Changes in platelet function and reactivity induced by quinine in relation to quinine (drug) induced immune thrombocytopenia.

Quinine, a drug known to induce immune mediated thrombocytopenia, has been postulated to mediate binding of drug dependent antibodies to a range of platelet membrane glycoproteins. Quinine may not act solely as a hapten however, as we have shown that it inhibits platelet aggregation (ex vivo and in vitro) and release and modifies the ability of activated platelets to bind the adhesive proteins fibrinogen and fibronectin in a dose dependent fashion. Studies on the effect of quinine on the binding of monoclonal antibodies HuPlml (GpIIIa) FMC25 (GpIX) and AN51 (GpIb) to platelets shows a selective reduction in AN51 binding. In addition quinine induced platelet antibodies from thrombocytopenic patients, in the presence of quinine, have been shown to inhibit binding of these monoclonal antibodies to platelets to varying degrees. These observations suggest that quinine causes widespread but specific conformational changes in platelet membrane antigens which may expose neoantigens resulting in the production of quinine induced antibodies.

The role of fibronectin in platelet aggregation.

A monoclonal antibody (anti-Fn2) was prepared which was reactive with both plasma fibronectin and fibronectin located within the platelet alpha granule. Immunoblotting analysis, on thermolysin digestion fragments of fibronectin, identified two immunoreactive fragments of Mr 145 kDa and 155 kDa which are known to contain a cell and DNA binding region. Anti-Fn2 was found to inhibit binding of fibronectin to platelets and DNA. Functional platelet studies, measuring platelet aggregation and 14C-serotonin release in washed platelet systems, demonstrated the ability of anti-Fn2 to totally inhibit low dose thrombin and low-dose collagen induced platelet aggregation and serotonin release. Anti-Fn2 partially inhibited platelet aggregation induced by ADP (10 microM) and arachidonic acid, but had no effect on platelet aggregation induced by high-dose thrombin or by the calcium ionophore A23187. These studies indicate that fibronectin participates in platelet aggregation and release induced by a range of agonists and suggest that it has a more important involvement in platelet function than previously described.

Bleeding due to an acquired inhibitor of platelet associated factor V.

Factor V inhibitors are uncommon, bleeding manifestations variable and recommendations for management are unclear. We present a patient with non-Hodgkins lymphoma who developed gastrointestinal bleeding and was found to have a Factor V inhibitor. The inhibitor was active against both plasma Factor V and platelet associated Factor V, and was associated with a five-fold increase in platelet associated IgG. Fresh frozen plasma was ineffective in preventing bleeding. Resolution of bleeding was associated with a fall in the levels of the inhibitor and of platelet associated IgG. The patient had no further bleeding episodes nor evidence of progression of his lymphoma, but six months later died as a result of metastatic adenocarcinoma.

HLA (class I) antigens on platelets are involved in platelet function.

HLA (Class I) antigens are ubiquitous in their cellular distribution and, while their function in major histocompatibility complex (MHC)-restricted phenomena are clear, their function on other cells, such as platelets, is not so obvious. We now report that several anti-HLA monoclonal antibodies (including an anti-beta 2 microglobulin antibody) selectively affect platelet function in that three different anti-HLA monoclonal antibodies caused not only the aggregation of human platelets, but also caused the release of 14C-serotonin. In addition, the anti-HLA antibodies could selectively block the binding of several platelet agonists such as collagen, adrenalin, ADP, but not the binding of others such as thrombin and arachidonic acid. In blocking studies there also appeared to be an association between platelet glycoprotein IIb-IIIa and HLA Class I antigens. We propose that both heavy and light chains of Class I HLA antigens on platelets may be involved in platelet aggregation and release and suggest an additional role for HLA antigens on platelets.