bluuebunny/crossref_metadata_2025 huggingface dataset:
Thrombotic Thrombocytopenic Purpura in a Patient with Sickle Cell Crisis.
Authors: Chatiwala Jumana S. , Guron Gunwant , Sidhom Ibrahim
Published: April 2020

Thrombotic thrombocytopenic purpura (TTP) in association with sickle cell crisis is rare. We present a case of sickle cell crisis and TTP. This is 48 years old Nigerian male with history of mild sickle cell anemia since childhood presented with sickle cell crisis and mental state changes. On admission labs are hematocrit of 20 and platelet count of 212,000. He was treated for sickle cell crisis but developed acute dysuria and progressively worsening anemia (Hct-13.7) and thrombocytopenia (Plt-9000) with sickle cell and fragmented RBCs on peripheral smear with LDH of 8772. This picture was consistent with TTP. Patient was immediately started on plasma exchange. Patient received a course of plasma exchange as well as hemodialysis and his condition improved, with return of platelet count to normal (232), LDH to baseline (276). Patient was discharged with mild renal insufficiency (serum creatinine-2.3) off dialysis and plasma exchange.

Conclusion: TTP is a micro vascular occlusive disorder characterized by systemic or intrarenal aggregation of platelets, thrombocytopenia, and mechanical injury to erythrocytes. It is associated with pentard of signs and symptoms: thrombocytopenia, microangiopathic hemolytic anemia (schistocytes on peripheral blood smear), neurological abnormalities, renal failure and fever. In practice thrombocytopenia, microangiopathic hemolytic anemia and elevated lactate dehydrogenase levels are often sufficient for the diagnosis. Our patient with sickle cell crisis was a diagnostic challenge and it is our belief that TTP evolved during inpatient therapy for painful crisis. We believe his hemolysis was due to sickle cell disease and TTP. The syndrome was reversed with prompt and aggressive treatment with plasmapharesis. (1, H. E. Lee, V. J. Marder, L. J. Logan, S. Friedman, B. J. Miller, Life-threatening thrombotic thrombocytopenic purpura (TTP) in a patient with sickle cell-hemoglobin C disease. Ann Hematol. 2003 Nov 82(11): 702–4. 2, Epub 2003 Aug 16. Chehal A, Taher A, Shamseddine A, Sicklemia with multi-organ failure syndrome and thrombotic thrombocytopenic purpura. Hemoglobin. 2002 Nov; 26(4): 345–51. 3, J. Bolanos-Meade, Y. K. Keung, C. Lopez-Arvizu, R. Florendo, E. Cobos, Thrombotic thrombocytopenic purpura in a patient with sickle cell crisis. Ann Hematol. 1999 Dec 78(12): 558–9. 4, Geigel EJ, Francis CW, Reversal of multiorgan system dysfunction in sickle cell disease with plasma exchange. Acta Anaesthesiol Scand. 1997 May; 41(5): 647–50.)
Infectious Mononucleosis Presenting with Severe Thrombocytopenia, Positive Anti-Platelets Antibodies, and Peripheral Blood Blasts.
Authors: Haddad Rami Y. , Komrokji Rami S.
Published: April 2020

Case Report: 18 year old male presents with 2 weeks history of sore throat, fever, and hemoptysis. Physical examination revealed exudative and hemorrhagic tonsillo-pharyngitis, posterior cervical lymphadenopathy, mild splenomegaly, and petechieal rash involving the extremeties and the trunk. On presentation, CBC showed Hgb of 15.5gm/dl, WBCs of 11.8 K/uL, Platelets count of 4 K/uL. Differential count showed lymphocytes of 56%, reactive lymphocytes 1%. Monospot test was positive. CT abdomen confirmed the physical finding of splenomegaly, and showed mild hepatomegaly. Treatment was initiated with pulse methylprednisone 1g/d, and IVIG 1g/kg/day. Both were given for 2 days. One unit of SDP was transfused on days 2, 4, 5. On day 4 platelets count was 6 K/uL. 2–3% blasts were detected on the peripheral smear on days 4 and 5. Bone marrow biopsy and aspiration were done on day 5. They revealed reactive marrow changes with no increase in blasts. Flow cytometry revealed reactive marrow lymphocyte subpopulations and no inrease in immature myeloid cells. Subsequently, EBV serology was reported; EBV capsid IgM and IgG were both positive at >4-fold higher than upper normal limit. In addition, Platelets antibodies were reported positive for IIB/IIIA, IB/IX, and IA/IIA. Platelets count on day 7 was 58 K/uL without platelets transfusion in the previous 24 hours.

Conclusion: Literature review reveals rare cases of Infectious Mononucleosis presenting with severe thrombocytopenia. Most of these cases were treated successfully with steroids and /or IVIG, similarly to ITP. However, no previous association with peripheral blood blasts has been described. Moreover, only two previous reports have described the association between Infectious Mononucleosis and the presence of platelets antibodies but without details of the receptors involved.
Dengue Fever and Thrombocytopenia: A Deadly Duo.
Authors: Lale Ajit , Lale Seema , Bick Rodger , Fareed Jawed
Published: April 2020

Dengue fever (DF) is one of the most ill understood diseases of Asian Pacific countries which is associated with reversible vascular complications. These complications are part of severe manifestations of Dengue Haemorregic Fever (DHF) and Dengue Shock Syndrome (DSS) which can be prevented with early detection and appropriate interventions. Increased hematocrit, elevated liver enzymes, altered coagulation profile and decreased platelet count are some of the parameters which predicts severity of this disease. Thrombocytopenia is always considered a predictive parameter for the inpatient management of dengue fever as well as recovery parameter in DHF and DSS. We examined 28 reviews and original articles out of 175 listed in “Pub med” on Dengue Fever and thrombocytopenia to find any possible relevance with the pathophysiology of thrombocytopenia and clinical bleeding in dengue across the spectrum of disease. Correlation between platelet counts and development of clinical bleeding was also studied as well as diagnostic markers for early detection. Finally, we summarize recent reports on treatment of thrombocytopenia, including evidence for conservative use of platelet transfusions and briefly complications of platelet transfusions. Thrombocytopenia is the most common laboratory finding in dengue patients, most patients manifesting petechiae, epistaxis, and mild mucosal bleeding. Severe hemorrhage is catastrophic and associated high mortality. Close monitoring of the patient for hemorrhagic manifestations and marked thrombocytopenia is strongly recommended. Other modalities include transfusion therapy with supportive therapy.
Inverse Correlation of Serum Leptin Levels and Platelet Counts in Patients with Menstruation-Associated Cyclic Thrombocytopenia.
Authors: Kameoka Junichi , Yamada Minami , Kadowaki Ikuko , Kaku Mitsuo , Sasaki Takeshi
Published: April 2020

The platelet counts of patients with cyclic thrombocytopenia (CT) are occasionally associated with menstruation, yet its mechanism is unknown. Leptin has been shown to stimulate the production of Th1 cytokines (Nature1998;27:897), which dominate in idiopathic thrombocytopenic purpura (ITP) (Blood2004;103:2645), and a recent study showed that the serum levels of leptin, whose secretion is menstruation-related, are high in ITP (Eur J Haemataol2004;72:348). Here we examined the serial serum levels of leptin in 3 patients with CT by radioimmunoassay. Case 1 is a 29-year-old woman with ITP who had repeated spontaneous abortion at an early phase of pregnancy accompanied by transient severe thrombocytopenia. Case 2 is a 37-year-old woman diagnosed as having ITP and autoimmune neutropenia during her second pregnancy, whose platelet counts became cyclic after delivery. Case 3 is a 28-year-old woman, who developed CT after splenectomy performed for refractory ITP two years before. The serum leptin levels were inversely correlated with the platelet counts in case 1 (r = −0.573, P =0.047, n=13) and case 3 ( r = −0.771, P =0.029, n=9), and a similar inverse correlation was observed in case 2, although the correlation was statistically not significant (r = −0.524, P=0.116, n=10). These findings suggest that leptin might play an important role in the pathogenesis of menstruation-associated CT. Further interventional studies to give leptin and its antagonists to the patients with CT, as well as to ITP model mice, will be warranted.
Association between Platelet Autoantibody Specificity and Response to Intravenous Immunoglobulin G in the Treatment of Patients with Immune Thrombocytopenia.
Authors: Johnston Kaye L. , Go Ronald S.
Published: April 2020

Background: Recent studies in murine model of immune thrombocytopenia (ITP) suggest that autoantibodies against GPIba may cause thrombocytopenia through Fc-independent pathway and ITP mediated by anti-GPIb may be less responsive to intravenous immunoglobulin G (IVIG) treatment (Nieswandt B, et al. Blood 2000; Webster ML, et al. Blood 2006). The objective of this study was to investigate the potential association between platelet autoantibody specificity and response to intravenous immunoglobulin G (IVIG) treatment in patients with ITP.

Methods: We retrospectively reviewed the clinical history of ITP patients who had platelet autoantibody test and received IVIG for treatment of thrombocytopenia. ITP was diagnosed by usual clinical criteria. All platelet autoantibody tests were performed by the Blood Center of Wisconsin (Milwaukee, WI) using ELISA, which detects antibodies reactive with platelet GPIIb/IIIa, GPIb/IX, and GPIa/IIa. A response was defined as a platelet count of > 50 x 109/L with a minimum increment of 30 x 109/L.

Results: We found 17 patients who received IVIG and had platelet autoantibody test performed. The median age was 58 years (range, 20–83) and 10 (59%) were males. ITP was considered idiopathic in 12 patients. In the remaining 5 patients, the following hematologic conditions were present: chronic lymphocytic leukemia (2), Hodgkin lymphoma (1), myelodysplastic syndrome (1), and non-Hodgkin lymphoma (1). Antibodies reactive with GPIIb/IIIa, GPIb/IX, and GPIa/IIa were detected in 13, 10, and 8 patients, respectively. In 3 patients, none of these antibodies were detected. Among the 14 patients with antibodies, 9 (64%) had antibodies against more than 1 glycoprotein. The median pre-treatment platelet count was 9 x 109/L (range, 1–68). Overall, 10 (59%) patients responded to IVIG. A response occurred in 7 of 7 patients without anti-GPIb/IX but in only 3 of 10 patients with anti-GPIb/IX. The difference in the response rates between the 2 groups was statistically significant (P= .0098).

Conclusions: Our clinical results support the murine model findings that ITP mediated by anti-GPIb may be less responsive to IVIG treatment. However, because of the small number of patients investigated and the retrospective nature of the study, our findings must be confirmed by other groups in a larger patient population.
Thrombotic Thrombocytopenic Purpura: Is Plasma Exchange Enough? A Fifteen Year Australian Experience at the Royal Melbourne Hospital.
Authors: Ng Ashley P. , Frawley Natasha , Hogan Chris , Grigg Andrew , Cohney Solomon , Nicholls Kathy , Becker Gavin
Published: April 2020

Introduction Thrombotic Thrombocytopenic Purpura (TTP) is a cause of microangiopathic-haemolytic anaemia and thrombocytopenia, associated with renal and neurological dysfunction with thrombotic complications causing significant morbidity and mortality.

Methods A restrospective single-institution analysis of patients with TTP treated between 1990–2005. Renal or bone marrow transplantation patients were excluded.

Results Forty patients were identified. Aetiology was idiopathic 75% (n=30), connective tissue disease-related 12.5% (n=5), malignancy-related 5% (n=2) and pregnancy-related 7.5% (n=3). Presenting features: neurological 62.5% (n=25), renal impairment (creatinine>0.11 mmol/L) 76% (n=28), microangiopathic-haemolytic anaemia 97.5% (n=39) and thrombocytopenia 100% (mean platelet-count 42x10^9/L). Mean Hb 93 g/L and mean Lactose dehydrogenase (LD) 2517 U/L (<420). 38 patients received up-front single plasma-volume plasma-exchange using fresh-frozen plasma (median 11 exchanges). All received steroids. Complete-response (CR) (normalisation of platelet count, LD, neurological examination and rising Hb), was achieved in 79% (n=30) following plasma-exchange of whom 43% (n=13) relapsed (median 14.5 days from therapy-cessation): eleven achieved CR2 with further therapy and two died from TTP-related complications. Partial-response (PR) was obtained in 7.9% (n=3) with up-front plasma-exchange: one remained in PR with prostate-cancer treatment and two relapsed: one achieved CR and one sustained-PR with further therapy. 13% (n=5) were refractory to plasma-exchange: four died from TTP-related complications and one achieved CR with treatment intensification. Therapeutic intensification included steroids (n=34), vincristine (n=7), intravenous immunoglobulin (n=6), Rituximab (n=3) and splenectomy (n=6).

Conclusion TTP is associated with a significant relapse-rate (43%) and TTP-related mortality (16%) despite plasma-exchange. Delineation of patients at high risk of relapse following CR will potentially allow targetted treatment intensification. Treatment intensification is also clearly required for patients with refractory TTP and consideration may be given to other immunosuppressive agents, such the chimeric monoclonal anti-CD20 antibody, Rituximab, as a steroid-sparing agent and to potentially avoid splenectomy. We propose a central TTP registry is developed within Australia such that therapeutic strategies can be systematically evaluated in a multicentre setting.
Autologous Human Thrombin: Production from Whole Blood.
Authors: Kumar Vijay , Chapman John R.
Published: April 2020

Introduction: Thrombin is routinely combined in surgical practice with a fibrinogen source to prepare fibrin sealant to promote hemostasis or with platelet concentrates to prepare platelet gels to enhance wound healing and reduce infections. Currently, thrombin is derived either from bovine tissue or “pooled” human plasma. The purpose of this study was to evaluate the robustness and reproducibility of a new sterile handheld disposable TPD™ (Thrombin Processing Device) to generate autologous human thrombin in the intra-operative setting, using whole blood as the starting source material. By using whole blood instead of plasma as the starting material, it is possible to eliminate the plasma separation step from whole blood and reduce the thrombin production time and increase its availability to the surgical team intra-operatively. The performance of the disposable set was evaluated at the low and high end of operating room temperatures.

Materials and Methods: Active thrombin was prepared by combining 4 ml of thrombin reagent (a mixture of calcium chloride and ethanol) to 11 ml of blood in a reaction chamber containing negatively charged particles. The whole blood, reagent and particle mixture was incubated for 25 minutes at either 18°C or 24°C (n=25/group) to assess stability of the thrombin activity.

Results: The average activity of the thrombin produced at 18°C and 24°C was 52 ± 14 IU/ml (n=25) and 61 ± 12.2 IU/ml (n=25), respectively. The average volume of thrombin harvested from each aliquot of blood was 9 ± 0.6 ml in both groups. The thrombin concentration generated was demonstrated to rapidly (<5 seconds) coagulate fibrinogen concentrate and retained clotting activity for 1 hr at room temperature (18 - 26 oC) and up to 4 hours when stored on ice.

Conclusions: The results demonstrate that the TPD is able to consistently generate high thrombin activity from human whole blood. The device offers a robust and rapid approach for preparing active thrombin from whole blood. By eliminating the risk for allergic reactions and blood borne pathogen transmission, autologous human thrombin can be considered as a safer alternative to bovine or “pooled” plasma sourced thrombin.
Association between the Plasminogen Activator Inhibitor-1 4G/5G Gene Polymorphism and Ischemic Stroke; a Meta-Analysis.
Authors: Nikolopoulos Georgios K. , Tsantes Argirios E. , Bagos Pantelis G. , Tsiara Chrissa G. , Mantzios Georgios P. , Kapsimali Violetta , Pappa Vassiliki , Travlou Anthi S.
Published: April 2020

The relationship between the insertion/deletion (4G/5G) polymorphism of the plasminogen activator inhibitor type-1 (PAI-1) gene and ischemic stroke (IS), remains unclear. This association has received less attention compared with the relation with coronary heart disease. Since stroke is the third commonest cause of death in the developed world, we performed a meta-analysis of published data regarding this issue. A comprehensive electronic search was carried out up until January 2006 and the analysis was performed using random effects models and meta-regression.

A total of 15 eligible case-control studies were considered. The analysis included 3104 cases and 4870 controls regarding the contrast of 4G/4G vs. the rest genotypes. The 4G pooled allele frequency in cases and controls was 54.21% and 54.75% respectively. Overall, the per-allele Odds Ratio (OR) of the 4G allele was 0.98 with a 95% Confidence Interval (CI) 0.858 to 1.121. As concerns genotypes, we derived non-significant ORs in all contrasts. Our findings do not support a significant association between the 4G/5G polymorphism and cerebrovascular disease under basal conditions. However, the influence of this genotype on the risk of IS in acute disorders might require further investigation, since PAI-1 seems to act as an acute-phase reactant.
The Genetics of Hemostasis: Heritability of Clotting Factor Concentrations in 224 Pediatric Stroke Families.
Authors: Nowak-Gottl Ulrike , Bergs Sandra , Thedieck Sabine , Stoll Monika
Published: April 2020

Background and objectives: Earlier studies found a strong support for a genetic basis for regulation of coagulation factor levels. The present study was conducted to estimate the variation within coagulation factors levels, and how much of this variation could be attributed to heritability and household effect in pediatric stroke families.

Methods: Blood samples were collected from 853 individuals from 224 white pediatric stroke pedigrees (male 51.3%). Heritability (h2r) and household effect (c2) were estimated for plasma concentrations of fibrinogen, factor (F) II, V, VIIIC, vWF, antithrombin, protein C, protein S, protein Z, prothrombin fragment F1.2 and D-dimer using the variance component method in sequential oligo-genetic linkage analysis routines (SOLAR).

Results: When incorporating h2r and c2 in one model, high and significant h2r estimates were found for protein Z (31.7), protein S (27.5), fibrinogen 29.9) and von Willebrand factor (20.4). In addition to the significant h2r estimates c2 showed a significant effect on phenotypic variation for protein Z (26.0), protein S (22.2) and vWF (14.8). A significant household effect without h2r interaction was found for FVIIIC (30.7), FII (25.6), protein C and FV (12.0).

Conclusion: In the cohort investigated we have shown that genetic factors have a major effect on plasma concentrations of coagulation factors. Our research stresses the importance of research into the genetic regulation of proteins involved in hemostasis associated with pediatric stroke.
Prevalence of Cross Reactive Epitopes to Bovine Factor Va Light Chain Fragments in Normal and Patients Plasma.
Authors: Hoppensteadt Debra A. , Bansal Vinod , Cunanan Josephine , Patel Kuldeep , Wahi Rakesh , Fareed Jawed
Published: April 2020

Several reports have described the presence of antibodies to bovine coagulation factors, such as factor V, prothrombin and factor X in plasma samples obtained from patients exposed to topical bovine thrombin. Other reports have also demonstrated the presence of anti-bovine coagulation factors in patients who have not been exposed to bovine thrombins, suggesting that anti-bovine protein antibodies can be generated in normal individuals. It has been suggested that surgical patients treated with topical bovine thrombin develop specific antibodies to bovine factor V which may be responsible for the bleeding and thrombotic complications. However, there is no definitive clinical study demonstrating a relationship between the apparent hemostatic defects and the presence of bovine factor Va antibodies. It was hypothesized that bovine factor Va antibodies are usually present in patients plasma because of the exposure to dietary bovine products. To test this hypothesis plasma samples from patients with end state renal disease (ESRD)(n=80), acute coronary syndrome (ACS)(n=160), burns (n=40) and healthy normal volunteers (n=140) were profiled for the presence of human factor V antigen (HFVA), bovine FVa antigen as measured by using a modified Elisa method and western blotting methods where bovine factor Va light chain fragment is used as a probe. In contrast to the normals (89±12%), the factor V antigen levels were found to be increased in the ESRD (148±30%), ACS (164±41%) and burn (145±27%) patients. Thus, there appears to be an up regulation of factor V antigen in these patients. All of the groups tested for the presence of immunoreactive material to the bovine factor Va light chain exhibited 2–3 ug/ml levels which were not significantly different. However, in the western blotting studies all groups exhibited cross reactivity with the factor Va light epitopes. There were bands present in the molecular weight range of 22, 36, 45 and 97 Kda in both the ESRD and burn patients. In the ACS patients there was an additional band observed at 166 Kda. These observations underscore the notion that bovine antifactor Va antibodies are non-specific and highly prevalent in both the surgical/interventional patients and normal population. A possible explanation for the presence of these antibodies is that most normal individual and patients problem are exposed to bovine proteins. Moreover, the higher prevalence of these antibodies in the ESRD and ACS patients may be due to additional exposure to heparin and aprotonin.
Complete Remission Represents the Major Surrogate Marker of Long Survival in Multiple Myeloma.
Authors: Wang Michael , Delasalle Kay , Thomas Sheeba , Giralt Sergio , Alexanian Raymond
Published: April 2020

The impact of complete remission of myeloma on long term outcome remains controversial. Between January 1987 and May 2006, we evaluated frequencies of partial and complete remission, and survival from onset of therapy, for 721 consecutive, newly diagnosed patients who received a high-dose, dexamethasone-based combination as primary treatment. Only patients <65 for whom intensive therapy was a uniform option were included; 45 patients with nonsecretory myeloma protein or with <50 mg/day of only Bence Jones protein were excluded in order to provide a valid myeloma protein marker in all patients. Criteria for partial response (PR) required reduction of serum myeloma protein level by >50% and of Bence Jones protein by >90%; complete remission (CR) was defined by negative findings on immunofixation. Among 721 previously untreated patients, the initial response rate was 57%, including 8% with CR. Within 12 months, 397 patients received intensive therapy with a high-dose, melphalan-based regimen supported by autologous stem cells. In comparison with non-transplanted patients, intensified patients were younger (median 52 vs 56 yrs), more anemic (median 10.3 vs 11.3 gms/dl), and had more patients with stage 3 disease by ISS criteria (37% vs 25%) (p<.01). Intensive therapy converted PR to CR in 34%, resistant disease (NR) to PR in 51%, and NR to CR in 14% of patients. For 209 patients with persistent resistant disease, the median survival was 2 yrs. Among 384 patients who achieved PR as maximum benefit, median survival times were significantly longer for 164 patients who received only primary treatment (4.3 yrs) and for 67 patients converted from NR to PR by intensive treatment (4.3 yrs) (p<.01); survival was even longer for 153 patients with persistent PR after intensive therapy (5.9 yrs) (p<.01), an outcome attributed to the high frequency of further moderate reduction of responsive myeloma after high-dose therapy even without CR. For 124 patients who achieved CR after only primary therapy or after intensive therapy of PR or NR, the median time to CR was 3 months (range 1–12 months) and median survival times of 10–14 yrs were similar; the median survival of 9 yrs for 32 patients intensified in CR was also similar, suggesting that high-dose therapy provided no further benefit after CR had been achieved with initial therapy. A randomized trial may be useful to clarify this question. Among the patients who died in CR, the cause of death was unrelated to myeloma in 20%, justifying future analyses of disease-related survival for such patients. Prolongation of survival was evident primarily when intensive therapy induced a major reduction of the myeloma and especially to CR. The sensitivity of myeloma to intensive therapy declined progressively for patients treated in NR, PR, or CR.
Clinical Outcomes of Off-Label Use of Recombinant Activated Factor VII (rFVIIa) at Teaching Hospitals Affiliated with a Medical School.
Authors: Cheng Yijun , Baxter Melissa S. , Schroeder Walter S. , Bernstein Zale P.
Published: April 2020

BACKGROUND: Recombinant factor VIIa (rFVIIa), NovoSeven®, is currently licensed in the United States for treatment of bleeding in hemophilia patients with acquired coagulation factor inhibitors. The off-label uses of this medication have expanded dramatically in past few years. Here we report our experience with the off-label use of rFVIIa at University at Buffalo affiliated teaching hospitals which include a level III trauma and major cardiothoracic centers.

PATIENTS AND METHODS: We reviewed the clinical, laboratory, and radiographic data of a consecutive series of 43 patients who received off-label rFVIIa between December 2001 and September 2005.

RESULTS: The indications for off-label rFVIIa use included CNS bleeding (17 patients), cardiothoracic and vascular surgery (9 patients), trauma (7 patients), GI bleeding (4 patients), coagulopathy (2 patients) and prophylaxis for surgery (4 patients). The dosage ranged from 32 to 150 mcg/kg with most patients receiving 90 mcg/kg. While a majority of patients received a single dose of rFVIIa (29 patients), one received a total of 22 doses. Overall 21 patients (49%) were alive at discharge. Those patients who received rFVIIa to stop severe bleeding from trauma or surgery appeared to have the worst outcome. The patient who received 22 doses of rFVIIa appeared to derive some clinical benefit after his initial doses, but became non-responsive to additional therapies. Successful hemostasis with rFVIIa was achieved in 100% of patients with preoperative prophylactic use. There were no thromboembolic events attributed to rFVIIa treatment.

CONCLUSIONS: The outcome of off-label use of rFVIIa appears to correlate with clinical indications, with prophylactic use having greatest benefit and surgical hemorrhage, the worst. Our findings were used to revise guidelines to allow for more efficacious use of off-label rFVIIa.
Heterogeneous Expression of Protein C (PC), Protein S (PS) and Thrombomodulin (TM) in Human Colon Cancer Tissue.
Authors: Wojtukiewicz Marek , Sierko Ewa , Zawadzki Roman J. , Zimnoch Lech , Klsiel Walter
Published: April 2020

Colon cancer is often complicated by thromboembolic episodes. It has been recognized that blood coagulation proteins play a role in malignant tumor progression and metastatic dissemination. An important inhibitory mechanism is provided by protein C (PC) system consisting of protein C, protein S (PS) and thrombomodulin (TM). Thrombin binds to membrane-bound TM and consequently activates PC. Active PC together with its cofactor - PS inactivates coagulation factors Va and VIIIa. Recently novel biological activities have been desribed for protein C system components that do not relate to its hemostatic functions. Active protein C exerts antiapoptotic activity towards endothelial cells (ECs) and activates proteolytic enzymes. It induces proliferation of ECs and angiogenesis. Protein S was documented to inhibit apoptosis as well as inflammatory and immunologic response.

The purpose of the study was to elucidate the solid phase interactions between colon cancer tissue and components of protein C system that may contribute to tumor progression. The tissues from colon cancer were obtained at surgical resection during radical treatment of 66 patients. The patients undergoing surgery have not received any previous anticancer therapy. Tumor fragments were processed acc. to AMeX method and than embedded in paraffin. Immunohistochemical studies (avidin-biotin complex-ABC - technique) were performed using polyclonal antibodies against PC, PS and TM.

Weak expression of PC was observed in cancer cells of two thirds of the examined specimens while in 4/66 cases there was no staining for PC in cancer cell bodies. One third of colon cancer fragments revealed strong expression of PC. Presence of PS was demonstrated in 64 cases of colon cancer, however its expression was irregular: a weak staining was observed in 60 cases and strong one - only in 4 cases. Two cases of colon cancer tissue have not revealed any staining for PS in cancer cells. Weak expression of TM was observed in two thirds of the examined cases, while a strong staining was revealed in one third of colon cancer tissues. However the expression of TM was inconsistent: not all cell bodies were TM-positive. The presence of PC and PS, but not TM was demonstrated in tumor associated macrophages. Furthermore, PS and TM antigens were localized in tumor stroma. Heterogeneous expression of PC system components in colon cancer tissue may indicate that their biological activity, exerted via their interplay with coagulation/fibrinolysis and regardless of their function in hemostasis, may modulate tumor growth.
Dielectric Barrier Discharge Plasma in Coagulation and Sterilization.
Authors: Balasubramanian Manjula , Sebastian Anita , Peddinghaus Marie , Fridman Gregory , Fridman Alexander , Gutsol Alexander , Friedman Gregory , Ari Brooks
Published: April 2020

Rapid loss of blood, in the operating room or trauma, necessitates a need for hastening coagulation Attempts to hasten coagulation include electrocautery based on thermal plasma discharges. Although there have been other effective attempts to prevent further loss of blood via coagulation, tissue damage and dessication can occur as a result of the high temperatures 2. Our group has developed a method to initiate rapid coagulation with dielectric plasma discharge (cold). Initial experiments were performed using fresh blood from volunteers to compare time for coagulation of whole blood exposed to plasma, one minute versus 10 minutes. We tried same experiments on cut cadaver organs such as spleen and placenta which showed evidence of rapid coagulation compared to control without evidence of tissue damage.

Our research team has developed a novel method using non-thermal dielectric barrier discharge plasma (DBD plasma) to coagulate blood and sterilize tissues without causing thermal damage. This treatment would be safe to patients because no exposed electrodes are involved and high frequency current (under 10 KHz) is kept below mili-ampere. Our experiments have shown that such plasma treatment hastens blood coagulation and causes simultaneous wound sterilization via a large concentration of chemically active species in plasma that are ions, radicals (O, OH, N) and electronically-excited atoms and molecules.

A kinetic model of blood coagulation under influence of DBD plasma was constructed. The model assumes contact flux of positive ions from DBD plasma into the surface of the blood being treated. Once at the surface, these ions recombine, leading to formation of aqueous Hydrogen ions which catalyze the release of Calcium ions into the blood. The addition of Calcium ions to blood speeds up the coagulation process proportionally to the amount of ions added. The model demonstrates thrombin formation in the presence of DBD plasma peaking and occurring within significantly less time compared to thrombin formation without DBD plasma3. Such medically relevant demonstrations and mathematical explanations have allowed us to develop a portable device that may prove useful in situations where control of bleeding is crucial. In addition, because of the potential for simultaneous sterilization, this device may also help to decrease infections. This pioneering technology will find applicability in many clinical situations: sterilization of human tissue surfaces prior to surgery and sterilization of catheters, a well-known cause of morbidity in hospitals.
Major Obstetric Haemorrhage in Late Termination of Pregnancy in Eight Women.
Authors: Sekhar Mallika , Narat Santosh , Le Dieu Rifca , Luqmani Asad , Hollamby Suzie , AlObaidi Magda , Hughes George
Published: April 2020

Eight patients were referred from a private clinic between August 2003 and May 2004 for management of severe uncontrolled bleeding after late second trimester termination of pregnancy (TOP). TOP was perfomed at a mean gestation period of 21.4 weeks (median 21 weeks, 21–23 weeks) and was performed in 2 stages. Stage 1 comprised cervical dilatation, rupture of membrane, severing the cord and insertion of laminara. 24 hours later a dilatation and evacuation procedure was carried out. Mean age was 24.25 years (range 17–35). None of the women had any previous bleeding problems. Mean pre-operative Haemoglobin was 10.5 gm/dl (8.7 to 12.2 gm/dl). 1 patient had a preoperative clotting screen and this was normal. The pattern of bleeding was as follows: PV bleed 8/8, generalised bleed 2/8, haemodynamic failure 5/8. Median time to onset of bleeding after the second stage was 1.5 hours and median time to control bleeding was 9.5 hours. Details of coagulation screen and transfusion support are provided in tables 1 and 2. Factor VIIa was not approved for use in the hospital at that time.

table 1 coagulation parameters UPN nadir fibrinogen (1.8–4.5 g/l) hours to nadir from TOP hours to normal fibrinogen PT (9.6–11.6 secs) APTT (24–32 secs) platelets (150–400 × 109/l) 1 0.44 8 18 16.7 37.2 203 2 0.19 2 7 22.6 54.8 108 3 0.67 7 13 16.8 38 44 4 0.21 5 11 23.4 34.2 145 5 0.35 5 6 21.5 78 47 6 0.5 6 12 31 37.2 141 7 0.57 3 5 15.6 42.7 88 8 0.94 5 12.8 37.7 144 table 2 blood product support UPN cryoppt (units) FFP(units) RBC(units) platelets(units) 1 12 2 2 2 20 4 14 1 3 15 4 9 4 40 4 12 5 20 5 17 2 6 10 3 8 7 18 4 6 1 8 2 2

Obstetric interventions included hysterectomy (1), balloon occlusion (2) ERPC (1), hysterotomy (1), cervical tear repair (2) and vaginal pack (2). Obstetric cause of haemorrhage was identified to be uterine atony (4), retained products (2), uterine injury (2) and no identifiable cause (2). All women recovered fully.

Results: The profound coagulopathy in these women was characterised by a reduction in fibrinogen that was out of proportion to the anomalies in other clotting parameters and platelet counts. Treatment with cryoprecipitate reversed this reduction and controlled the haemorrhage although 5/8 patients required significant surgical intervention.

Conclusions:The coagulation anomalies in these women are indicative of a defibrination syndrome that differs from DIC in the disproportionate reduction in fibrinogen level and the relatively rapid and complete resolution with blood product replacement and treating uterine pathology.Two stage TOPs in late second trimester is associated with significant morbidity.
Rituximab Use in Four Patients with Acquired vonWillebrand’s Syndrome.
Authors: Singh Priya C. , Siegel Jamie E. , Caro Jaime , Besa Emmanuel C.
Published: April 2020

Treating Acquired von Willebrand’s Syndrome (AVWS) is a challenge requiring multiple therapeutic modalities to achieve success in controlling and preventing bleeding episodes. From review of the literature, clinical use of rituximab, an anti-CD20 monoclonal antibody, in AVWS has not been reported. We present our experience with four patients treated with rituximab for steroid or intravenous immunoglobulin (IVIG) refractory and/or dependent AVWS associated with IgG monoclonal gammopathy of undetermined significance. Rituximab at a dose of 375mg/m2 was administered intravenously weekly for 4 consecutive weeks in the first patient. After 3 cycles of rituximab, we observed a correction of her bleeding time to normal, improvement of her prolonged aPTT, a decrease in her monoclonal IgG and cessation of her bleeding episodes for 29 months. She relapsed and was retreated with rituximab at the same dose for 3 cycles with no improvement in aPTT and bleeding time. She has had no further bleeding episodes after compliance with epsilon aminocaproic acid for one year. The second patient received rituximab intravenously at a dose of 375 mg/m2 weekly for 4 weeks. Prolonged aPTT was unchanged after treatment. He was asymptomatic for 8 months and then received prophylactic IVIG and von Willebrand Factor concentrate (Humate-P) for elective hand surgery. The third patient had a concomitant worsening idiopathic neuropathy and received rituximab 375mg/m2 intravenously daily for 2 consecutive days two weeks apart for his neuropathy. His neuropathy and prolonged aPTT did not improve and he developed gastrointestinal bleeding 1.5 months later. The fourth patient received rituximab 150mg/m2 intravenously weekly for 4 consecutive weeks. Prolonged aPTT was unchanged after treatment. He experienced no bleeding symptoms for 38 months. Factor VIII, Ristocetin Cofactor, von Willebrand Antigen and IgG levels were not significantly affected by rituximab use in cases 2–4. Rituximab seemed to be most effective in the first and fourth cases. The dosing and number of cycles is unclear. Success in the first case with multiple cycles of therapy may be needed for response and warrants further evaluation. Additionally, it appears therapy needs to be reinforced with other agents to prevent or stop bleeding. It was well tolerated with no infectious complications in our patients. Only one patient had an infusion related reaction, which did not require stopping therapy. Further prospective studies are needed to evaluate the efficacy of rituximab and establish the dosing and treatment duration in AVWS.
French Multicenter Study for Post-Marketing Survey of WILFACTIN®: A Von Willebrand Factor Concentrate with a Low FVIII Content.
Authors: Borel-Derlon Annie , Goudemand Jenny , Rothschild Chantal , Chatelanaz Catherine , Bridey Françoise ,   French Post-Marketing Study Group5
Published: April 2020

This non-interventional study is designed to evaluate the safety and efficacy of WILFACTIN® when used for up to 3 years of treatment of bleeding episodes at hospital, for home-self treatment or prevention of surgical bleeding by patients with von Willebrand disease (VWD). The study is set up according to the Note for guidance CPMP/BPWG/220/02. Thirty six French centers enrolled 65 patients. Data from 48 patients (26 females, 22 males) were available for this 19-month interim analysis. Patients ages ranged from 11 months to 83.5 years (median, 38.5 years): 8 had type 1, 25 type 2, and 15 type 3 VWD. Baseline VWF:RCo and FVIII:C levels were less than 20 IU/dl in 37 and 20 patients respectively. The mean observation period was 155 days. A total of 1094 infusions were administered in 39 patients, 15% for spontaneous or trauma bleeds, 23% for invasive or surgical procedures, 59% for long-term prophylaxis and 3% short-term prophylaxis. The mean infusion dosage (VWF:RCo IU/kg body weight) ranged from 35.5 to 77.7 for 10 major bleeds, 23.9 to 53.2 for 25 surgeries and 27.2 to 58.2 for 8 patients with long-term prophylaxis treatment. The majority of subjects for long-term prophylaxis had type 3 VWD (6/8) and all were more than 12 years old. Indications for prophylaxis have included mucosal bleeds for 5 patients and joint bleeds for 3 patients. The number of prophylactic infusions ranged between 1 to 3 per week and these regimens, guided by the bleeding pattern of each patient, yielded favorable results in the prevention of bleeding episodes. Only 7 bleeds occurred less than 72 hours following infusion (7/642 infusions). To date (April 2006), one patient experienced 2 non serious possibly drug-related adverse events: moderate blood pressure increase with chest pain. No cases of thrombosis were reported following treatment. No cases of VWF inhibitor development. The results of this interim analysis of post-marketing survey confirm the safety and efficacy of WILFACTIN® for treatment of VWD, particularly for home self-treatment including long-term prophylaxis, and validate the results documented in previously reported clinical trials.
Rituximab as a Treatment Option for Acquired Inhibitors.
Authors: de Souza Jonas A. , Escobar Miguel A.
Published: April 2020

The incidence of acquired Factor VIII (FVIII) inhibitors is 0.2–1.0 case/million/year with a mortality range of 7.9 to 22%. Management consists of treating the bleeding episode and eradicating the autoantibody. First line therapy for the latter includes immunosuppressive agents with all of their potentially serious side effects. On this study, we add 5 patients to the scant published literature of individuals treated with Rituximab, a monoclonal antibody against CD20+ B cells. The patients had bleeding episodes from moderate to severe and presented with a prolonged partial thromboplastin time (PTT) that did not correct with a 1:1 mix with normal plasma. Inhibitors were confirmed by a low FVIII level and the Bethesda assay. Summarized clinical and laboratory data are shown in the table below. All the patients received Rituximab 375 mg/m2 once weekly × 4 doses. Patients 2–5 received Rituximab exclusively and patient 1 received two initial weeks of prednisone and cyclophosphamide followed by Rituximab. There were no adverse reactions to Rituximab. Complete remission was defined as clinical improvement associated with disappearance of the FVIII antibody and normalization of the factor VIII level. All the patients are currently in complete remission with no relapse, and with a post Rituximab time of more than 36 months for patients 1 and 5, and 12 months for patients 2–4. Rituximab appears to be a safe and well tolerated alternative to cytotoxic agents and it should be studied more thoroughly in prospective randomized studies.

Age/Sex/Race FVIII:C FVIII inhibitor (BU) Underlying Disorders Bleeding Treatment BU= Bethesda Units; HTN=Hypertension; CHF= Congestive Heart Failure; SLE= Systemic Lupus Erythematous; DM= Diabetes Mellitus; CRF= Chronic Renal Failure; rFVIIa=Recombinant activated factor VII. 1 80/M/Cauc < 1% 33 HTN, CHF rFVIIa 2 37/M/Hisp < 1% 68.4 None rFVIIa 3 45/F/Cauc < 1% 58.4 SLE None 4 70/M/Hisp < 1% 17 DM, CRF rFVIIa 5 83/M/AA 1% 6.8 HTN, DM rFVIIa
Efficacy of Peri- and Postoperative Treatment in 95 Patients with Von Willebrand’s Disease.
Authors: von Auer Charis , Lotter Kathrin , Heinsdorf Sandra , Scharrer Inge
Published: April 2020

Von Willebrand’s disease (VWD) is the most common inherited bleeding disorder in humans, exhibiting quantitative and qualitative defects in the von Willebrand factor. To investigate the quality of treatment during the peri- and postoperative course of patients with VWD, we conducted a retrospective data analysis. We analyzed data of 95 patients with VWD who went for 173 surgical interventions in our center between 1981 and 2003. Peri- and postoperative courses with regard of bleeding complications were reviewd. 59 Patients had type1 VWD (two severe, three moderate, 54 mild). 16 patients had type 2 VWD (14 2A, one 2B, one 2N) and 11 patients type 3 VWD. Nine patients with type1 VWD had an additional factor deficiency (five FXII-, two FVII- and two FV-deficiencies). We analyzed the course of 54 orthopedic surgeries, 41 abdominal surgeries, 15 angiographies, 12 endoscopic surgeries, 10 ear-nose-throat interventions, 11 mamma surgeries, 10 neurological surgeries, 8 soft tissue surgeries, 7 thorax surgeries, 3 thyroid gland surgeries and 2 biopsies. Most patients (108/173) were treated with Humate P, 33 patients with DDAVP (33/173) and 9 patients received both products during the pre- peri- and postoperative period. Three patients received other plasmatic FVIII- concentrates, 20 patients had no therapy for their coagulation disorder. 16 patients (9, 2%) had peri- or postoperative bleeding complications. Most of them were seen in patients with VWD type 2B and 3 and in patients who underwent major surgery and who received only DDAVP. Humate P was used for 9 interventions (9/108 = 8, 3%) and DDAVP for four interventions (4/33 = 12, 1%) with bleeding complications, three patients had no therapy. Most of these complications were reported in thoracic surgery (2/7 = 28%), gynecological (3/11 = 27%) and otolaryngological surgery (2/10 = 20%). Retrospectively 15 bleeding complications could be explained by surgical technique, thromboprophylaxis, inefficient substitution therapy or additional thrombocytopenia. In conclusion our findings show a low frequency of bleeding complications in VWS patients with surgical interventions. Our evaluation reveals the necessity of special hemostaseologic care and laboratory controls for these patients. Substitution therapy should depend on type of VWD and type of surgical intervention. Especially during thoracic surgery, gynecological and otolaryngological surgery a careful peri- and postoperative hemostaseologic management as well as careful hemostyptic techniques of the surgeon are required.
Pharmacokinetic Evaluation of Von Willebrand Factor/Factor VIII Concentrate (Humate-P®) Prior to Elective Surgery in Patients with Von Willebrand Disease.
Authors: Di Paola Jorge , Gill Joan , Bernstein Jonathan , Leissinger Cindy , Ragni Margaret , Shopnik Rinah , Valentino Leonard , Friedman Carl , Knaub Sigurd
Published: April 2020

The VWF/FVIII concentrate Humate-Pâ (ZLB Behring) was studied in a prospective, uncontrolled, open-label clinical trial in adult and pediatric von Willebrand disease (VWD) patients undergoing elective surgery. During an initial PK phase, a detailed profile of FVIII: C, VWF: RCo, and VWF: Ag levels was obtained for each patient after an infusion of 60 IU/kg VWF: RCo/kg body weight as Humate-P, to guide loading dosing intra- and postoperatively. Forty-one subjects were evaluated for the pharmacokinetic assessment: the median age was 31 years (range 16 to 47 years); 66.7% of subjects were female; 17 had Type 1 VWD, 2 had Type 2A, 4 had Type 2B, 6 had Type 2M, and 13 had Type 3. In the 34 subjects who underwent surgery, the primary endpoint of effective hemostasis (investigator-rated assessment as excellent or good) was achieved in 100% (34/34) of subjects 24 hours after the last infusion. The VWF: RCo PK revealed a median incremental in vivo recovery (IVR) of 2.4% per IU/kg over baseline (range, 1.1% – 4.2%), and an overall median IVR response of 86.7% over baseline (range, 37% – 169%). Median value of Cmax was 159 IU/dL (range 84–334). Median terminal half-life of VWF: RCo was 11.2 hours (range 3.5 to 74.9), median clearance 3.1 ml/kg/h (range, 1.0 to 16.6). The FVIII: C PK revealed a median incremental of 2.7% per IU/kg. A median response of 95.5% (range, 44% – 176%) was achieved 15 minutes after the PK infusion, with values remaining >90% until 4 hours post infusion. At 48 hours post infusion, median levels had decreased to 68% over baseline (range, 17% – 122%). An analysis of the relationship between IVR and dose administered demonstrated the dose linearity of the VWF concentrate within a wide dose range (10–135 IU VWF: RCo/kg b. w.). Using the log-transformed IVR in a repeated measures ANCOVA model, the slope (of log10 IVR vs. dose) was −0.0025 (95% confidence interval: −0.0053 to 0.0004).

Conclusion: The PK results are comparable to PK data from other clinical studies with Humate-Pâ as well as PK data from other VWF-containing products. Dose linearity has been shown over a wide range of dosages. The inter-individual variability observed underlines the importance of performing PK assessments, to guide dosing, prior to surgical interventions.

IVR of all VWF-RCo doses (kg/dL), linear regression with 95% CI of mean IVR of all VWF-RCo doses (kg/dL), linear regression with 95% CI of mean