bluuebunny/crossref_metadata_2025 huggingface dataset:
Efficacy of Alphanate® (Human Factor VIII/Von Willebrand Factor Concentrate) in Preventing Excessive Bleeding during Surgery or Invasive Procedures in Patients with Congenital Von Willebrand Disease. A Multicenter Retrospective Study.
Authors: Eyster M. Elaine , Sexauer Charles L. , Brown Simon , Lipton Richard A. , Kessler Craig M. , Aledort Louis M. , Rivard Georges E.
Published: October 2019

Objective: To assess the efficacy of Alphanate® as replacement therapy in subjects with congenital VWD undergoing surgical or invasive procedures.

Methodology: Retrospective data from 5 hospitals and accounting for 8 years of chart review has been collected. The study protocol and the subject’s informed consent were approved by the local Institutional Review Boards. To date, 35 treated events (27 subjects) have been evaluated. Events were classified by local investigators and an independent referee committee as major or minor surgery, and invasive procedures. Treatment efficacy was rated using a 4-point verbal rating scale. Replacement therapy was considered effective if the treatment outcome was rated as excellent or good, and non-effective when the outcome was rated as poor or none.

Results: Efficacy results (number and percentage) obtained by local investigators and the referee committee are presented in Tables 1 and 2.

Conclusions: Since there may be bias in the interpretation of responses made by the participating physicians, it was felt that true responses might better be assessed retrospectively by an adjudication committee. Therefore, both Tables were presented here. Much of the discrepancies between these 2 tables was generated by oral surgery. There was a high level of efficacy agreement between investigators and the referree committee. Therefore, it is concluded that Alphanate® is effective in preventing excessive bleedings during surgeries and invasive procedures in subjects with congenital VWD.

Table 1. Efficacy Results Obtained by Investigators Major surgery (n=9) Minor surgery (n=17) Invasive procedure (n=9) Total (n=35) Excellent 6 (66.7%) 14 (82.4%) 8 (88.9%) 28 (80.0%) Good 3 (33.3%) 1 (5.9%) 1 (11.1%) 5 (14.3%) Poor 0 (0.0%) 1 (5.9%) 0 (0.0%) 1 (2.9%) None 0 (0.0%) 1 (5.9%) 0 (0.0%) 1 (2.9%) Table 2. Efficacy Results Obtained by Referee Committee Major Surgery (n=12) Minor Surgery (n=11) Invasive Procedure (n=12) Total (n=35) Excellent 8 (66.7%) 11 (100%) 11 (91.7%) 30 (85.7%) Good 1 (8.3%) 0 (0.0%) 0 (0.0%) 1 (2.9%) Poor 3 (25.0%) 0 (0.0%) 1 (8.3%) 4 (11.4%) None 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)
Littoral Cell Hemangioma of the Spleen.
Authors: Naik Seema , Chaudhri Farida , Yang Stephen
Published: October 2019

Introduction: Splenic hemangiomas are rare, range from 0.03–14% in autopsy studies. The primary tumors of the spleen are benign and originate from the vascular endothelium and rarely from the lining cells of red pulp sinuses, giving rise to Littoral cell angiomas (LCA), first described by Falk et al in 1991. It usually is an incidental benign tumor presenting as mild to moderate splenic enlargement seen at any age in both sexes. Grossly it usually has multiple distinct nodules are spongy with dark bloody spaces ranging from 0.2 to 9.0 cm in diameter.

Case Report: 65 years old white male patient presented with thrombocytopenia, platelet count 84000/cmm, Hemoglobin 11.8 and WBC 5500. He had no significant past medical history. Review of systems was noncontributory. There were no other physical findings. The patient had normal upper gastrointestinal series. Colonoscopy revealed tubular adenomatous polyp. CT scan chest revealed thoracic vertebral hemangioma. CT scan of abdomen showed enlarged spleen measuring 15cm axially with multiple low attenuation areas throughout the spleen. FNA of spleen showed spindle cells positive for factor VIII and CD31. The patient had normal bone marrow biopsy as well as cytogenetics. The patient underwent splenectomy which showed littoral cell angioma with heterogeneous population of lymphocytes, histiocytes, eosinophila, neutrophils, platelets, and large polylobated cells. The patient had marked clinical improvement with normallization of platelet count post splenectomy.

Discussion: Littoral cell angiomas are seen as hypo echoic areas seen on ultrasonography and CT scan of abdomen. The natural history is benign and do not recur post splenectomy. Spontaneous rupture can occur in 25% of patients. On MRI, siderosis is seen due to hemophagocytosis by littoral cells. The lesions are of variable size and solitary or multinodular located in the red-pulp of the spleen. They are composed of anastomosing vascular channels with irregular lumina featuring cyst-like spaces. The LCA cells have a dual-endothelial/histiocytic characteristics, that react with F VIII Ag and are positive for CD68 antigen. Angiostatin inhibits angiogenesis and metastatic tumor growth. The mildly atypical cells, but not frankly malignant with low Ki 67 staining and diploid DNA histogram are in accordance with a low-grade malignancy. LCA has also been associated with synchronous malignancies such as lymphoma, colonic cancer, renal cancer, ovarian cancer, pancreatic cancer, seminoma and gastric leiomyosarcoma, a long-term follow-up for these patients is recommended.
Ex Vivo Expanded Erythroid Progenitor Cells Augment Therapeutic Angiogenesis by Extensive Cytokine Production.
Authors: Muta Koichiro , Sasaki Shuzi , Zhang Min , Inoguchi Toyoshi , Abe Yasunobu
Published: October 2019

Alternative therapies for clinical limb ischemia have become very important for patients with peripheral ischemic disease (PAD), who cannot undergo surgical or percutaneous revascularization. Delivery of angiogenic growth factors, such as vascular endothelial growth factor (VEGF), fibroblast growth factor-2 (FGF-2), hepatocyte growth factor (HGF), stromal cell-derived factor-1α (SDF-1α), and placental growth factor (PlGF), using recombinant proteins or gene transfer have been considered for alternative treatment of PAD and their efficacies have been demonstrated. Recent reports have demonstrated that erythroid progenitor cells contain and secrete various angiogenic cytokines. Although this suggest an important role for erythroid progenitor cells in angiogenesis, no studies have reported in vivo evidence of angiogenesis induction by erythroid progenitor cells. Here, the impact of purified human erythroid colony-forming cell (ECFC) implantation on therapeutic angiogenesis was investigated in murine models of hindlimb ischemia. ECFCs were purified from human peripheral blood and expanded ex vivo. ECFCs from day 5 to 7, those are considered as erythroid progenitors of colony-forming unit erythroid(CFU-E) level of maturation, showed the highest vascular endothelial growth factor (VEGF) productivity. THerefore, day-6 ECFCs were used for the following experiments. Day-6 ECFCs contained larger amounts of VEGF and fibroblast growth factor-2 (FGF-2) than peripheral blood mononuclear cells (PBMNCs). In tubule formation assays with human umbilical vein endothelial cells, ECFCs stimulated 1.5-fold more capillary growth than PBMNCs, and this effect was suppressed by antibodies against VEGF and FGF-2. Using an immunodeficient hindlimb ischemia model and laser Doppler imaging, we evaluated the limb salvage rate and blood perfusion after intramuscular implantation of ECFCs. ECFC implantation increased both the salvage rate (38% vs. 0%, P<0.05) and the blood perfusion (82.8% vs. 65.6%, P<0.01). The capillary density was 1.6-fold higher in the ECFC group than in the control group. Implantation of ECFCs promoted angiogenesis in ischemic limbs by supplying angiogenic cytokines (VEGF and FGF-2), suggesting a possible novel strategy for therapeutic angiogenesis for the patients with PDA.
Rituximab Produces Long-Term Responses in Immune Thrombocytopenic Purpura (ITP).
Authors: Case Delvyn C. , Hedlund Jacquelyn A. , Ebrahim Kurt S. , Boyd Marjorie A.
Published: October 2019

ITP in adults is an autoimmune disease characterized by antibody-mediated thrombocytopenia. A significant number of patients relapse after initial therapy with prednisone and splenectomy when necessary, and require other therapy for continuing thrombocytopenia. Rituximab, an anti-CD20 chimeric monoclonal antibody has been utilized in ITP refractory to other modes of treatment (Feurestein, M., et al. The use of Rituximab in 28 patients with immune thrombocytopenic purpura (ITP). Proc. Am. Soc. Clin. Onc.22:187, 2003). We report on the long-term responses possible in ITP treated with Rituximab. Twenty-two patients with ITP refractory to initial conventional therapies with platelet counts <30,000/ul were treated with Rituximab 375 mg/m2 IV weekly x4. Responses were characterized as partial response (PR; platelets >50,000/ul but <150,000/ul) and complete response (platelets >150,000/ul). Patient characteristics included 5 males and 17 females with ages 24–83 years (median 58). Twenty had undergone splenectomy. Thirteen patients (59%) responded to Rituximab. Six responses were PR with durations lasting 2, 2, 3, 3, 4, and 6 months. Continuing Rituximab monthly after initial therapy of 4 weeks did not produce improved platelet counts in patients who failed Rituximab or who achieved PR. Seven responses were CR with durations of 12, 20+, 25+, 29+, 38+, 40+, and 48+ months. The one patient who relapsed at 12 months was retreated with Rituximab but did not respond. There was no correlation between response and age, sex, or duration of ITP. Neither of the patients who declined prior splenectomy responded. There were no serious complications of Rituximab infusions. Twenty-five percent of patients had mild first infusion reactions. Rituximab can produce long-term CR in 27% of patients with ITP refractory to initial therapy.
Sucessful Outcome in Poor-Prognosis Acute Thrombotic Thrombocitopenic Purpura Treated with Plasma Exchange and Rituximab.
Authors: Neto Cesar Almeida , Mendonça Mirianceli C. , Braga Marcelo C. , Ghaname Fabiana S. , Gobette Fernanda , Silva Luis F.F. , Ghaname Jorge N. , Gamne Anis
Published: October 2019

Background: Thrombotic thrombocytopenic purpura (TTP) is a rare and severe disease that must be diagnosed and treated promptly for a successful outcome.

Case Report: In February 2005, a 44-year-old woman was admitted with severe microangiopathic hemolytic anaemia, jaundice, fever, seizures followed by coma and hypovolemic shock. She had joint pain 20 days before admission (anti-nuclear factor positive; 1/160) and had short-term episodes of bizarre behavior 1 week before admission. Her LDH was 2,860 IU/L; platelet count 37,000/mm3; hemoglobin 5.1 g/dl; blood smears contained schistocytes; AST 240 U/L; ALT 166 U/L; HIV and hepatitis seronegative, and CT normal at admission. TTP was diagnosed and pulse methylprednisolene initiated (1 g iv for 3 days) with single-volume daily plasma exchange using fresh frozen plasma. After two sessions, there was marginal neurological improvement, platelet count increased to 95,000/mm3 and LDH decreased to 2,199 IU/L. After six plasma exchanges, neurological status worsened, LDH increased sharply (7,139 IU/L) as did ALT (1,700 U/L), AST (3,000 U/L) and platelet count was 72,000/mm3. Rituximab (four, weekly 375 mg/m2 doses) and plasma exchange with cryosupernatant substitution fluid were initiated. The first plasma exchange was postponed until 24 hours after the first dose of rituximab and 48 hours after subsequent doses. Within two days, there was neurological improvement, stable platelet levels and decreased LDH. Complete remission was achieved after 23 plasma exchanges and four doses of Rituximab. Plasma exchange was tapered and the patient remained in sustained remission until now. There were episodes of hives related to plasma exchange, but no toxicity related to rituximab.

Conclusion: Plasma exchange with cryosupernatant substitution fluid and rituximab had an important role in the successful treatment of this patient - a systematic clinical trial setting should be considered in order to confirm these findings.
Familial Thrombotic Thrombocytopenic Purpura in Three Siblings.
Authors: Niewiadomska Edyta , Budde Ulrich , Anna Klukowska
Published: October 2019

Thrombotic thrombocytopenic purpura (TTP) is characterized by microangiopathic hemolytic anemia, systemic platelet aggregation, organ ischemia, thrombocytopenia, and fragmentation of erythrocytes. The disease is caused either by congenital deficiency of von Willebrand factor-cleaving protease (ADAMTS 13) or due to acquired autoantibodies against ADAMTS 13. We have been treating three siblings with recurrent episodes of hemolytic anemia, thrombocytopenia, neurological and renal dysfunctions during last 10 years. The oldest brother presented with thromboangiopathic anemia, thrombocytopenia (platelets account below 30x103/μl), episode of unconsciousness, proteinuria and splenomegaly at the age of 15 years. Splenectomy was done with the improvement in thrombocytopenic purpura. But he has suffered from permanent microangiopathic hemolytic anemia, and developed renal insufficiency. He died due to intestinal bleeding last year. Two younger siblings, a 12 year old girl and an 11 year old boy also presented with recurrent symptoms of microangipathic hemolytic anemia and thrombopcytopenia with or without renal dysfunction since early childhood. The diagnosis of congenital TTP in this family was based on clinical symptoms and tests of ADAMTS 13 and its inhibitor. The activity of ADAMTS 13 in two younger siblings performed according to the method of Gerritsen et al. was unmeasurable (<3%, reference range 30 – 120%). The ADAMTS 13 inhibitor was undetectable. Both patients are treated with fresh frozen plasma (FFP) infusions every 4 weeks. Precise diagnosis is very important for proper treatment. Only regular FFP infusions as ADAMTS 13 supplementation can assure normal health condition of children with familial TTP.
Critical Role of the Blood Coagulation in Malaria: Plasmodium falciparum-Infected Red Blood Cells Induce Tissue Factor Expression by Endothelial Cells and Support the Assembly of Coagulation Complexes.
Authors: Francischetti Ivo M.B. , Seydel Karl B. , Monteiro Robson Q.
Published: October 2019

Malaria is still the world’s most important parasitic disease and is responsible for the death of more people than any other communicable disease except tuberculosis. According to WHO estimates, 300–500 million people are infected with malaria every year. Deaths occur mostly among young children in Africa. Cerebral malaria (CM) is the most severe complication and accounts for up to 80% of fatal cases of Plasmodium falciparum malaria. The mechanisms of malaria and CM pathogenesis remain the subject of continuing debate. It is believed that hemostatic alterations could be of importance in the disease since P. falciparum malaria has been associated with thrombocytopenia and hemostatic alterations (pro-coagulant state), by an unknown mechanism. Here we demonstrate that P. falciparum-infected red blood cells (IRBC) induce Tissue Factor (TF) expression by endothelial cells in culture, in a parasitemia- and time-dependent manner. Tissue Factor was consistently detected by functional (Factor Xa formation), antigen (ELISA), and RT-PCR. Remarkably, only mid-late but not early trophozoites and ring stage parasites were capable of inducing TF expression. These findings are compatible with post-mortem brain biopsies where sequestration is composed mostly by late-stage trophozoites. Our experiments also demonstrate that late-stage IRBC support the assembly of the prothrombinase complex in the presence of FVa, FXa, prothrombin and Ca2+ with thrombin formation. IRBC also support the intrinsic Xnase assembly in the presence of FIXa, FVIIIa, FX and Ca2+ with generation of FXa. It is concluded that IRBC manipulates the hemostatic system by initiating the blood coagulation cascade through induction of TF expression by endothelial cells, leading to FXa production. FXa and other components of the prothrombinase complex assemble in the IRBC allowing the coagulation cascade to propagate, with thrombin formation. Thrombin, FXa and FVIIa may also activate the pro-inflammatory PAR receptors in endothelial cells creating a unique inflammatory environment in the vessels where sequestration has occurred. These finding introduces the concept that malaria is an inflammatory syndrome triggered by expression of TF and activation of the coagulation cascade. Identification of TF as a critical mediator of malaria may allow investigators to test other therapeutic alternatives targeting TF in the treatment of malaria.
Viral Safety of a Novel Von Willebrand Factor and Factor VIII Concentrate (Wilate®): Virus Inactivation Capacities of Optimised Solvent/Detergent and Terminal Dry-Heat Treatment (PermaHeat).
Authors: Biesert Lothar , Suhartono Haryadi , Klengel Rolf , Schmidt Torben , Radomski Kai-Uwe , Schwarz Gerhard , Gruber Gerhard , Stadler Monika , Neisser-Svae Andrea , Roemisch Juergen , Svae Tor-Einar
Published: October 2019

Purpose: The virus inactivation capacities of the optimised solvent/detergent (S/D) and terminal dry-heat (PermaHeat) treatments, as part of the Wilate® manufacturing process, were determined in this study. Wilate® is a novel, human plasma-derived, VWF/FVIII concentrate, which through the clinical trials has been proven safe and effective in the treatment of von Willebrand disease and haemophilia A patients.

Methods: S/D virus inactivation studies were performed in down-scaled settings using 1% Octoxynol/0.3% TNBP for 4 hours at +23–28°C. PermaHeat was performed at +100°C for 120 min at 0.6% residual moisture in the lyophilisate (0.7–1.6% during regular manufacturing). Robustness conditions were studied for both steps.

Summary of results: S/D treatment revealed the following inactivation ratios [log10]: HIV-1: ≥7.5, SBV: ≥8.6 and PRV: ≥8.5. All enveloped viruses (EV) were inactivated below the detection limits of the infectivity assays already after 2 minutes. Variation of process parameters did not reduce the efficacy of the S/D treatment. For PermaHeat the following inactivation ratios were found at extreme conditions, i.e. low residual moisture [log10]: EV: HIV-1: ≥5.8, SBV: ≥5.5 and PRV: 4.9 - NEV (non-enveloped viruses): REO-3: ≥6.4, HAV: ≥5.7, PPV: 4.1.

Conclusion: The Wilate® manufacturing process comprises two dedicated, efficient and robust virus inactivation steps, S/D and PermaHeat treatments. The total capacities [log10] for the individual viruses amount to ≥13.3 for HIV-1, ≥14.1 for SBV, ≥13.4 for PRV, ≥6.4 for REO-3, ≥5.7 for HAV, and 4.1 for PPV. Other production steps may contribute to virus reduction as well.
Significance and Study of Fibrinolytic System in Pleural and Ascitic Fluid.
Authors: Lu Xingguo , Mao Mao Jianshan , Liu Jin , Zhang Xiaohong , Zhao Xiaoying , Xu Genbo , Gong Xubo , Yang Zhongguo
Published: October 2019

Objective: To study significance and character of fibrinolytic system in pleural and ascitic fluid with three disease.

Methods: Urokinase plasminogen activator (uPA), urokinase plaminogen activator receptor (uPAR) were measured by ELISA, tissue plaminogen activator (tPA), plaminogen activator inhibitor-1(PAI-1), plasminogen (Plg), plasmin (Pl), and a2 plasmin inhibitor (a2PI) by colorimetric assay.

Result: The levels of uPA and uPAR in pleural and ascitic fluid were marked higher in malignant tumor (2533.42±1369.89 ng/L and 7.32±1.59μg/L) and tuberculosis (2618.05±1542.50 ng/L, 8.75±3.48μg/L)than in cirrrhosis (961.25 ± 692.82ng/L and 2.73±1.59 μg/L, P<0.01). The level of tPA was marked higher in cirrhosis (353.75±142.31 IU/L) and malignant tumor (341.16±136.46 IU/L) than in tuberculosis(266.45±43.70 IU/L, P<0.01). The levels of PAI-1, Plg and Pl were in order of quantity tuberculosis(828.02±217.02 AU/L, 5.17±1.51 IU/ml and 65.52±25.22%), malignant tumor (540.35±217.52 AU/L, 3.90±1.25 IU/ml and 49.52±14.27%), cirrhosis (337.88±162.03 AU/L, 1.88±0.51 IU/ml and 26.04±8.45%). There were significant difference among them (P<0.01). The level of a2PI was marked higher in malignant tumor (82.38±28.68%) and cirrhosis (91.75±24.73%) than in tuberculosis (61.62±27.67%, P<0.05). Among seven targets in malignant tumor group, only the level of uPA was significant difference between positive group in pleural and ascitic fluid with cancer cell (3073.44±1161.93μg/L) and negative group without cancer cell (1453.38±1128.39μg/L, P<0.01).

Conclusions: There were significant difference in fibrinolytic charater in pleural and ascitic fluid with different diseases. To join test with fibrinolysis targets can not only help determine quality of pleural and ascitic fluid, but also can help deeply understand pathologic processes in desease, especially some biologic actions of malignant tumor.
Clinical Diagnosis and Management of Children with Large Splenic Hemangiomas Accompanied with Consumptional Coagulopathy.
Authors: Ci Pan , Jing Chen , Lu Dong , Jingyan Tang , Yaoping Wang
Published: October 2019

Objective To improve the diagnosis and treatment of children with large splenic hemangiomas accompanied with consumptional coagulopathy.

Methods From Dec 2003 to May 2004, 2 children with large splenic hemangiomas and coagulational abnormality were admitted consecutively. Both of them were boys, aged 2.8 and 3.5 years old, respectively. Both of them had splenomegaly, and Patient 2 also had multiple bone hemangiommas(confirmed by biopsy before splenectomy) on addmission. Imaging studies failed to confirm the diagnosis of splenic hemangiomas. Both of them received 24 hours continuous subcutaneous injection of Nadroparin Calcium therapy and the coagulopathies were improved. Then, Patient 1 had splenectomy, and Patient 2 received Nadroparin Calcium therapy plus steroid and interferon therapy for 6 months, then also went to splenectomy.

Results Both of the two patients had normal platelet counts and normal coagulation parameters just after their splenectomies. Histology studies confirmed the diagnoses of splenic cavernous hemangiomas. Before splenectomy, Patient 2 had a stable status for 6 months after he received Nadroparin Calcium therapy plus interferon and steroid therapy. Till March 31th, 2005, Patient 1 had disease free for 13 months, and Patient 2 had normal platlet counts and normal coagulation parameters for 5 month besides his stable multiple bone lessions.

Conclusion Childhood large splenic hemangioma accompanied with consumptional coagulopathy is a rare disease, which can be cured by splenectomy. Before operation, it is necessary to improve the coagulation abnormality, and 24 hours continuous subcutaneous Nadroparin Calcium injection plus coagulation factors transfusion is effective.
Hemostasis with Erythropoietin in Massive, Uncontrollable, Diffuse GI Bleeding.
Authors: Zaharia Veronica C. , Zaharia Daniel R.
Published: October 2019

Purpose: Erythropoietin currently used as a hemopoietic agent, has remarkable hemostatic activity which can be lifesaving in diffuse, uncontrollable bleeding processes. Following is an example case report:

Case presentation: 47 y/o male was admitted with massive GI bleeding and a Hemoglobin (Hg) of 6.7 mg/dl requiring transfusion of 26U Packed Red Blood Cells {PRBC) and 9U of Fresh Frozen Plasma (FFP). The work up revealed a large cell lymphoma infiltrating the mesenteric lymph nodes, the retroperitoneum and the spleen. The small intestine was diffusely infiltrated and bleeding. A portion of the small intestine was resected in an attempt to stop the bleeding; still, the bleeding continued and the Hg could not be raised above 7.8. Erythropoietin 20,000U was administered subcutaneously on day 9 to help correct the anemia. An additional 40,000U were administered on day 14 and 21. Three days after the 2nd dose of Erythropoietin the bowel movement did not appear grossly bloody, the Hg stabilized, and chemotherapy could be administered. After discharge with a follow up of 10 months his Hg stabilized at 12–12.5 mg/dl without any bleeding or transfusion.

Discussion: Erythropoietin has been shown to shorten the bleeding time in chronic renal failure patients on hemodialysis by improving the platelet/subendotelial cell interaction and by raising the platelet count. An enhanced platelet aggregation in response to Ristocetin was noted in Erythropoietin treated uremic patients. This effect was correlated with a rise in platelet Serotonin. Erythropoietin also has been found to have a procoagulant effect in uremic patients by decreasing the protein C, protein S, antithrombin III level. These observations offer an explanation for the clinically observed hemostatic effect of Erythropoietin.

Conclusion: This and other cases have shown that Erythropoietin is a potent hemostatic factor in anemic patients with diffuse uncontrollable bleeding processes, where large amounts of transfused PRBC can barely keep up with the losses and hemostatic procedures can either not be done or failed. As more experience accumulates Erythropoietin may start a second life as a hemostatic factor.

Figure Figure
The Behavior of Anticardiolipin Antibodies Levels in Patients with Venous Thromboembolism.
Authors: Martinez Aline A. , Rodrigues Celso A. , Morelli Vania M. , Noguti Maria Aparecida E. , Andrade Luis Eduardo C. , Lourenco Dayse M.
Published: October 2019

The aim of this study was to investigate anticardiolipin (aCL) (IgG and IgM) levels in patients with objectively confirmed venous thromboembolism (VTE). aCL IgG and IgM were measured using an in-house ELISA assay. When aCL levels were ≥10 U, a second measurement was performed using another sample at least 6 weeks after the first test. Patients tested twice with aCL levels ≥10 U were classified as having positive aCL and those with only one measurement ≥10 U had transitory aCL. aCL was evaluated in 282 outpatients with VTE, with median age of 39 years (range:15–94), 66.7% were women. We found 28 patients (9.9%) with positive aCL (IgG in 5.6%, IgM in 1.8% and IgG + IgM in 2.5%) and 29 (10.3%) with transitory aCL (IgG in 5.3%, IgM in 3.2% and IgG + IgM in 1.8%). The association of systemic disease with VTE had a significant effect on the occurrence of transitory aCL (OR= 3.6; 95%CI: 1.5–8.8), but not on positive aCL (OR= 1.7; 95%CI: 0.6–5.0). There was a significant correlation between the first and second measurements for IgG (rs= 0.58; p < 0.0001) and for IgM (rs= 0.49; p = 0.011). Patients with IgG < 30 GPLU showed a higher risk of having transitory aCL (OR= 4.9; 95%CI: 1.2–19.7; p= 0.027), and this effect was more pronounced in patients with IgM < 30 MPLU (OR=15; 95%CI: 1.2 – 113.6; p= 0.008). In conclusion, prevalence of transitory aCL was as high as positive aCL in patients with VTE, mainly among those with IgG or IgM < 30 U. Higher aCL levels were more frequently associated with repeatedly positive aCL. Transitory aCL was more frequent in the presence of systemic disease associated with VTE, which could reflect an epiphenomenon, whereas repeatedly positive aCL could play a more important role in the genesis of VTE.
Antiphospholipid Antibody Syndrome: Annexin V Competitive Flow Cytometric Assay for Determination of Anti-Platelet Phospholipid Autoantibodies.
Authors: Tomer Aaron , Barlev Shira , Abu-Shakra Mahmoud , Shenkman Boris
Published: October 2019

A flow cytometric assay was developed for the determination of autoantibodies directed against platelet anionic-phospholipids in antiphospholipid syndrome (APS). The method is based on demonstrable competition between the placental anticoagulant protein I, annexin V, and the patients’ autoantibodies on the platelet anionic-phospholipids (the binding site for the prothrombinase complex; prothrombin, factors Va and Xa). The method is practical and rapid, uses readily available reagents, and standard equipment. Ninety-two plasma samples, 41 from patients with clinical diagnosis of APS, 27 from patients with systemic lupus erythematosus (SLE) and 24 from healthy individuals were analyzed. Thirty-five (85%) of patients with APS (either with or without SLE), 15 (94%) of patients with APS and SLE, and 20 (80%) of APS patients without SLE were positive. Nineteen (70%) out of 27 patients with SLE alone were also positive; of whom 15 (58%) were positive for either anti-cardiolipin antibody (ACL) or lupus anti-coagulant (LAC). Comparison with ACL showed 40 (93%) out of 43 patients positive for ACL were also positive by flow cytometry (FCM). However, 13 (48%) out of 27 patients negative for ACL were found positive by FCM. Seven of these patients have primary APS and 6 have SLE; 7 of whom were positive for LAC. Three (13%) out of the 24 control samples, all negative by FCM, were positive for ACL. Comparison with LAC showed 32 (91%) out of 35 patients positive for LAC also positive by FCM. Of 18 patients negative for LAC, 7 (39%) were negative and 11 (61%) were positive by FCM. Four of the 11 patients have a diagnosis of APS and 7 of SLE; 6 of whom were positive for ACL. None of the controls, all negative by FCM, was positive for LAC. In conclusion, the annexin V competitive flow cytometric assay for the determination of anti-platelet phospholipid autoantibodies maybe useful for the laboratory diagnosis of APS.
Cerebral Sinovenous Thrombosis Post Head Injury - 10 Year Experience in Children.
Authors: Komwilaisak Patcharee , Brandao Leonardo , Blaser Susan , Dirks Peter , deVeber Gabrielle , Williams Suzan , Chan Anthony K.C. , Ahbaya Kulkarni
Published: October 2019

Cerebral sinovenous thrombosis (CSVT) post head injury is infrequently diagnosed in children. We retrospectively reviewed 323 patients with histories of head injury and a computerized tomography scan of the head from June 1996 to June 2005. Twelve patients (3.7%) were diagnosed with CSVT. The mean age was 6 years (range from 2 to 15 years). Male to female ratio was 10:2. The mechanism of injury included motor vehicle accidents in 5 patients, and falls in 7 patients. Nine patients had minor head injuries (GCS> 8) whereas 3 patients had severe head injuries (GCS<8). The most common presenting symptom was vomiting in 5 patients and other less common symptoms including: headache, seizure and irritability. The commonest locations of thrombosis were sigmoid and transverse sinus. Four patients had extensive thrombus involving more than 3 sinuses. Of the 12 patients, 9 (75%) patients had skull fractures and 6 (50%) had epidural hematomas in association with CSVT. Seven patients (58%) received anticoagulant treatment. The duration of anticoagulant therapy was from 2 days to 6 months. Anticoagulation was discontinued in 3 patients (25%) due to extension of CNS bleeding. All patients receiving anticoagulation were therapeutic with an anti-factor Xa level of 0.5–1 units/mL on enoxaparin, 0.35–0.7 units/mL on standard heparin and INR level of 2–3 on Coumadin. There was complete resolution in 6 patients with the imaging done in a mean followup of 78.5 days, partial resolution in 3 patients with the mean followup imaging in 95.6 days, unchanged status in 1 patient 6 days after the diagnosis and no followup imaging in 2 patients. Six patients had thrombophilic work-up and all were normal. Of the 7 patients with full recovery, 3 patients did not receive anticoagulation. Four patients had seizure and headache, left hemiparesis, panhypopituitarism and optic atrophy, and attention deficit disorder, respectively. In conclusion, the prevalence of CSVT post head injury in children was approximately 3.7%. The etiology of CSVT in this situation might be associated with skull fracture and hematoma, which could compress the cerebral sinus. Large prospective studies involving multiple centers are required to ascertain whether prothrombotic investigations are necessary and if anticoagulation improves neurologic outcome in patients with CVST post head injury.
Anti-Haemostatic Properties of Diverse Haematophagous Hirudinea from around the World Could Have New Therapeutic Potentials.
Authors: Wakeman Lisa , Munro Roger , Al-Ismail Saad
Published: October 2019

The purpose of this study was to survey the anti-haemostatic nature of cephalic extracts prepared from phylogenetically diverse rhyncobdellid (proboscis-bearing) and arhynchobdellid (jawed) leeches and to evaluate the significance in the context of their evolutionary development. Cephalic extracts from specimens of each species were prepared by homogenising in tris buffer the anterior one-third region of the bodies containing the salivary glands. In the case of the giant leech Haementeria ghilianii, paired anterior salivary glands were removed by excision through the oesophagus. The posterior musculature served as control material. Homogenates were double-centrifuged and supernatants micro-filtered. Individual extracts (or imidazole buffer as control) were pre-incubated 1:4 with pooled normal citrated plasma for 5 minutes prior to testing for inhibition of coagulation or with platelet rich plasma prior to assessing their effect on platelet aggregation. All extracts were kept on ice and tested within 1 hour of preparation. Coagulation screening tests using Dade-Behring reagents on a Sysmex CA-1500 coagulometer included PT, APTT, thrombin clotting time, atroxin clotting time, euglobulin clot lysis and anti-Xa assay. Collagen (2μg/ml) and ADP (5μM) were used as inducers of platelet aggregation. The species of leeches examined and their country of origin were:

Proboscid Leeches Source Sub-Family Haementeria ghilianii Brazil Haementeriinae Oosthuizobdella garoui South Africa Haementeriinae Placobdella parasitica Canada Glossiphoniinae Jawed Leeches Macrobdella decora N. America Macrobdellinae Hirudinaria manillensis China Hirudinariinae Hirudinaria javanica Indonesia Hirudinariinae Poecilobdella granulosa India Hirudinariinae Myxobdella africana Kenya Praodbellinae

Our findings indicate that cephalic extracts from all the species examined contain anti-thrombin properties. However, only the giant leech H. ghilianii appears to possess fibrin(ogen)olytic activity. No evidence of a plasminogen activator was detected in any of the extracts. Platelet aggregation responses induced by both agonists were completely inhibited in the presence of all cephalic extracts. No such inhibition was detectable in the posterior musculature control material. Anti-Factor Xa activity was present in extracts from H. ghilianii. Our findings suggest that anti-haemostatic properties in Hirudinea appear to have evolved in response to biological adaptations rather than in keeping with phylogenetic affinities but further work is required to define the precise nature of such mechanisms in related species The different anti-haemostatic properties in these extracts may offer new therapeutic potentials.
Carotid and Vertebral Artery Dissection Syndromes.
Authors: Grand Beatriz , Solimano Jorge , Ventura Adriana , Micheo Ernesto Quiroga , Riveros Dardo
Published: October 2019

Objetives: To describe the clinical presentation, diagnosis and treatment of patients with carotid and vertebral artery dissection (CAD, VAD).

Design: Retrospective, observational

Patients and methods: Clinical recording were evaluated from 1996 to 2005; 6 patients (3 women, 3 men, mean age 37 years) with CAD (3) and VAD (3) were referred to our hematology unit.

Clinical presentation: progressing stroke 4/6 and transient ischemic attack (TIA) 2/6; warning sings and symptoms preceding the onset of stroke in 80%. Vascular risk factors included smoking and hypertension; associated features were headache, visual symptoms and Horner’s syndrome; Predisposing factors as physical exercise and trauma were found in 4/6. One patient was at 20 weeks of pregnancy.

Diagnosis: Diagnostic tests included: Doppler ultrasound, magnetic resonance imaging (MRI) and angiography (MRA). On admission angiographic studies showed occlusion or stenoses of dissected arteries.

Treatment: Anticoagulation with heparin or low molecular weight heparin followed by oral anticoagulants.

Outcome: No hemorrhagic complication, no recurrence, complete recovery in 5 patients and mild dysarthria in one.

Conclusion: TIA and progressing stroke in young patients are presenting features of CAD and VAD. The diagnosis is based on clinical signs and confirming angiographic investigation. Our experience shows that anticoagulation is the treatment of choice, although controlled studies to show their effectiveness are lacking.
Pharmaco-Economic Impact of Transfusion and Erythropoietin (EPO) Administration for Patients Having Myelodysplastic Syndromes (MDS) in an Hematology Department.
Authors: Rossi Jean-Francois , Lopez Ernesto , Kanouni Tarik , Navarro Robert , Borghero Marc , Latry Pascal
Published: October 2019

The University Hospital of Montpellier is the major university hospital in Languedoc-Roussillon, a region with 2.4 milions of inhabitants including 23–26% of the population having more than 65 years. This hospital includes 1015 beds and places in medicine, and 809 in surgery. Total cost of the products for transfusion concerning the hospital is 7 7606 121$. For the hematology department (56 beds, with 130–150 transplantations per year), the cost of the transfusion products represents 39.53% of the whole budget. 21.26% of the total expenditure of red blood cell (RBC) transfusion and 70.17% of the total expenditure of platelet transfusion are from this hematology department. The outpatient clinic of the department (12 beds) is the major localization for transfusing patients with MDS, representing around 20% of the activity in this part of the department. The total fee of transfusion products for this outpatient clinic is 798 739 $ with 351 464$ for RBC transfusion, representing 44%, while RBC transfusion represents 28% of the activity for the whole department, with 19.7% of increase between 2003 and 2004. The activity of hematology is linked to 2 other sites for outpatient and hospitalization in the region of Languedoc-Roussillon (including 35+10 additional beds). Similar increase of the transfusion was observed. New system of price list concerning medical activity in hospitals has been established in France, with a transfusion price fixed at 873$. By using this new accounting, transfusion appears to be slightly in deficit for an outpatient clinic in a university hospital such ours, considering the other medical activities, particularly transplantation and ambulatory chemotherapy. In addition, the number of patients with MDS is increasing in the region, according to the increase of elderness and number of treated cancers. From 01/02 to 04/05, we treat new patients having MDS, excluding AREB-t, by EPO, subcutaneously, from 12 000 to 60 000 UI per week. 85 patients entered this study. The response rate was based on an increase of hemoglobin level superior or equal to 1.5g%, or a reduction superior or equal to 30% of the transfusion consumption observed for more than 6 months. 22% of the patients reached one of these criteria, with 35% of the patients having refractory anemia (RA), sideroblastic RA or 5q- RA and only 12% of the patients having AREB. Only 5% of the patients transfused had a benefit of EPO. In some patients, we observed a dose effect of EPO between 10 000 and 40 000 UI, but at a lesser extend between 40 to 60 000 UI per week, and lasting less than 3 months. Mean duration of the effect was 1.6 year, depending the transformation risk. Benefit of EPO was not correlated with the hemoglobin level at the inclusion but to the status of MDS. Whole data concerning the indirect and direct costs will be presented for this cohort.
A Novel Method for Efficient Production of Multipotential Hematopoietic Progenitors from Human Embryonic Stem Cells by Co-Culture with Murine Fetal Liver-Derived Stromal Cells.
Authors: Ma Feng , Wang Dan , Hanada Sachiyo , Kawasaki Hirohide , Zaike Yuji , Heike Toshio , Kitamura Toshio , Nakahata Tatsutoshi , Tsuji Kohichiro
Published: October 2019

Human embryonic stem cells provide a unique tool to study early events occurring in the development of human embryonic hematopoiesis, and their totipotent capability indicates a potent clinical application based on the cellular therapy and the evaluation of drug effects on hematopoietic and blood cells. To achieve efficient production of hematopoietic cells from human embryonic stem cells, we attempted to reproduce the circumstance surrounding embryonic hematopoietic cells in vitro. Since fetal liver is the predominant source of hematopoietic and blood cells in mammalian embryogenesis, we established stromal cells from mouse fetal liver at days 14 to 15 of gestation. In the co-culture of human embryonic stem cells with the established stromal cells, a number of hematopoietic progenitors were generated at around day 14 of co-culture, and this hematopoietic activity was highly enriched in the cobble stone-like cells under the stromal layer. Most of the cobble stone-like cells collected expressed CD34 and contained a variety of hematopoietic colony-forming cells, especially multilineage colony-forming cells, at a high frequency. The multipotential hematopoietic progenitors in the cobble stone-like cells produced all types of mature blood cells, including adult type hemoglobin-synthesizing erythrocytes and tryptase and chymase-bouble positive mast cells in the suspension cultiue with a cytokine cocktail. The developed co-culture system of human embryonic stem cells should offer a novel source for hematopoietic and blood cells applicable to cellular therapies and drug screening.
A Gene-Targeted Mouse Model for Bone Marrow Failure Syndrome.
Authors: Kasai Masataka , Fukuda Yuko , Ishida Reiko
Published: October 2019

Bone marrow failure is a disease syndrome characterized by dysfunction of bone marrow to produce mature blood cells. However, molecular mechanisms causing the disease syndromes remain remarkably obscure. We generated mice homozygous for an inactivating mutation of the Translin gene. Most of the aged mutant mice (Translin−/−) were found to exhibit progressive bone marrow dysfunction manifested by a reduction in immature myeloid cells and erythroblasts, and eventually developed marked splenomegaly, with up to 30-fold elevation in weight. Histological examination of enlarged spleens revealed extramedullary hematopoiesis, prominent expansion of the red pulp areas with an increase in the number of mature granulocytes and a marked lack of immature myeloid cells. Furthermore, these mice also featured complete loss of immature myeloid cells and erythroblasts in bone marrow. On the other hand, an increase in the number of reticulocytes (over 10 %) and unusual appearance of metamyelocytes and orthochromatic erythroblasts were seen in peripheral blood. A cascade of the lineage-restricted transcription factors is known to determine developmental decisions regarding hematopoiesis. How levels of transcription factors are translated into a decision to control lineage commitment is an intriguing question in hematopoiesis which remains to be explored. Therefore, we considered the bone marrow failure in aged Translin−/− might be due to decreased expression of the Ets family transcription factor PU.1 that has previously been suggested to be essential for myeloid development. However, quantitative RT-PCR analysis showed PU.1 mRNA to be expressed at equivalent levels in bone marrows of mutant and wild mice. In contrast, our data indicated a sharp reduction of the mRNA levels of the basic helix-loop-helix (bHLH) protein, E2A and its dimerization partner, TAL1, suggesting a contribution of E47/TAL heterodimer having distinctive DNA-binding properties for fine tune control of gene expression during hematopoiesis. In conclusion, the present studies demonstrated that expression levels of Translin are crucial to the bone marrow’s functional ability, and that our findings will shed light on the molecular events involved in bone marrow failure syndromes.
Effects of 5-Androstenediol on Survival, Clonogenicity, and Expression of IL-6 and NFKB in Irradiated Human Osteoblast and Hematopoietic CD34+ Cells.
Authors: Xiao Mang , Inal Cynthia E. , Whitnall Mark H.
Published: October 2019

We previously reported that 5-androstenediol (5-AED) administration enhanced survival in mice exposed to whole-body ionizing-radiation (IR). 5-AED also induced hematopoiesis and hematopoietic growth factor expression in blood-forming tissue. Since osteoblasts comprise an important part of the hematopoietic niche, we evaluated the radioprotective effects of 5-AED in a human fetal osteoblast cell line (hFOB) and primary human hematopoietic CD34+ progenitor cells. 5-AED (1000 ng/ml) increased hFOB cell survival from 39% (vehicle-treated) to 85% 3 days after a radiation dose of 2 Gy, and from 56% to 64% after 4 Gy. In clonogenic assays of CD34+ cells starting with 104 cells/dish, BFU-E colonies in 5-AED (1000 ng/ml)-treated cultures increased from 163±17 (vehicle-treated) to 418±20 24 h after 2 Gy, and from 59±5 to 118±11 after 4 Gy. CFU-GM colonies in 5-AED-treated cultures rose from 89±6 to 177±13 after 2 Gy, and from 27±3 to 51±3 cells after 4 Gy. Furthermore, 5-AED administration to irradiated CD34+ cell cultures led to an elevated frequency of CD11b+ cells (granulocytes, monocytes and NK cells) as determined by flow cytometry 22 days after irradiation. To test our hypothesis that 5-AED acts via initiation of a cytokine cascade in hematopoietic cells, endogenous IL-6 protein expression was evaluated using ELISA. Administration of 5-AED before and after IR elicited a 10-fold increase in IL-6 levels in CD34+ cultures 24 h after IR. In contrast, IL-6 levels were not elevated in 5-AED-treated, unirradiated CD34+ cells. Recent studies showed that nuclear factor kappa B (NFkB) may play an important role in IR induced damage. We assessed NFkB activation in human FOB and CD34+ cells and now report for the first time that NFkB subunit NFkB1 (p50) expression was significantly inhibited by IR in CD34+ cells in a dose-dependent manner. Moreover, 5-AED at least partially blocked the downregulation of NFkB1 expression in irradiated cells. Taken together, our results demonstrate that 5-AED counters the effects of IR in human hematopoietic CD34+ and osteoblast cells, and that these effects may be mediated by modulation of IL-6 and NFkB.