Clinical features in 36 patients homozygous for the ARG 506-->GLN factor V mutation

We analyzed the clinical features of 36 patients homozygous for the Arg 506 to Gln factor V mutation and found a circumstantial event at risk for thrombosis in 29 of the 31 patients with thrombosis. The most frequent predisposing factors were the post-partum period and the use of oral contraceptives in women, and surgery in both sexes. Venous thrombosis recurred in 48% of the patients. One patient had a myocardial infarction at age 33 years, and also had an antiphospholipid syndrome. Homozygous Gln 506 mutation leads to far less severe thrombotic complications than homozygous protein C and protein S deficiencies and does not seem to predispose patients to arterial thrombosis.

Liver transplantation without the use of fresh frozen plasma

In orthotopic liver transplantations (OLT), fresh frozen plasma (FFP) is classically used to normalize coagulation factor concentrations. In this study, 28 OLT were performed without the use of FFP. According to their preoperative factor V (FV) levels, two groups of patients were defined: Group 1 (13 patients, FV > 10% and < 60%) and Group 2 (15 patients, FV > 60%). Spontaneous evolution of coagulation factors, concentration, and bleeding were observed during OLT and up to 48 h after surgery. Total intraoperative bleeding was similar in both groups (3460 +/- 2700 mL and 3470 +/- 2110 mL in Groups 1 and 2, respectively). Levels of clotting factors were not different between groups after the anhepatic stage. The lowest values were noted after reperfusion. Thirty-six hours after surgery, all levels of clotting factors in both groups were more than 50%, with FV level increasing the most rapidly. Hematocrit from the subhepatic drainage liquid was 1.8% and less than 1% at 24 and 48 h, respectively, after surgery. No reintervention for bleeding was necessary. These results suggest that, in OLT, correct hemostasis can be assumed without FFP use when hyperfibrinolysis, platelet count, fibrinogen rate, and hemodynamic status are controlled.

[Pulmonary embolism disclosing activated protein C resistance]

Resistance to the activation of protein C is a recently discovered constitutional anomaly of coagulation which is responsible for thromboembolic events in young subjects. We report a case in a 26 year old man who presented with pulmonary embolus. Laboratory data was characterised by an absence of any lengthening of the activated cephaline time after adding purified activated exogenous Protein C. The confirmation of this anomaly is provided by the evidence of a mutation Arg 506 to Gln of Factor 5. The outcome is favourable with treatment by Heparin then by anti-Vitamin K.

Homozygous variant of antithrombin with lack of affinity for heparin: management of severe thrombotic complications associated with intrauterine fetal demise

Patients with homozygous heparin-binding-site (HBS) qualitative antithrombin deficiencies are at significant risk of venous and arterial thrombosis. We report on the eighth case of homozygous HBS deficiency, and the fourth case concerning the Arg 47-Cys mutation. The proposita is a 25 year old, without known thrombotic antecedent, despite an oral contraceptive therapy for 7 years. After 25 weeks of a first pregnancy, she presented an intrauterine fetal demise complicated with deep vein thrombosis and pulmonary embolism. Heparin therapy was inefficient (no clinical nor angiographic improvement, no biological hypocoagulability). Heparin cofactor activity was < 10%, antigen concentration was normal. The crossed immunoelectrophoresis of patient's plasma, with and without heparin, showed a typical profile of qualitative HBS antithrombin deficiency. The molecular analysis revealed an homozygous Arg 4-Cys mutation. Antithrombotic therapy was achieved with continuous infusion of antithrombin concentrates (80 IU/kg/day) and unfractionated heparin (500 IU/kg/day) during 12 days, leading to clinical improvement, and followed by treatment with vitamin K antagonists. This observation emphasizes the risk of intrauterine fetal demise and the inefficiency of heparin therapy without antithrombin infusion in type II HBS homozygous deficiency. The management of a future pregnancy will probably require repeated infusions of antithrombin.

Prevalence and clinical significance of antiphospholipid antibodies in heart valve disease: a case-control study

The purposes of this study were (1) to assess the prevalence of antiphospholipid (aPL) antibodies in patients with non-specific heart valve disease referred for valve replacement and (2) to determine whether the presence of aPL antibodies carries a risk for thrombotic events during a postoperative follow-up in a prospective cohort. The sera of 89 consecutive patients and 80 matched control subjects were tested for antibodies to cardiolipin (immunoglobulin G and immunoglobulin M) and for lupus anticoagulant. The prevalence of aPL antibodies was significantly higher in patients (19 [21%] of 89) than in control subjects (7 [9%] of 80) (p < 0.05). Patients were divided into two subgroups according to the presence (subgroup A) or the absence (subgroup B) of aPL antibodies. No significant difference in age or sex ratio was observed between the two subgroups. A history of arterial thrombosis was more frequent in subgroup A (8 [42%] of 19) than in subgroup B (8 [11%] of 70) (p < 0.01). No significant difference with respect to the occurrence of thrombotic events was observed during a median follow-up period of 8.7 months. Thus a high prevalence of aPL antibodies was found in patients referred for heart valve replacement compared with matched control subjects. No increased risk has been demonstrated in the patients with aPL antibodies.

First case of sporadic protein S deficiency due to a novel candidate mutation, Ala 484-->Pro, in the protein S active gene (PROS1)

In a series of 16 propositi with symptomatic protein S deficiency and a protein S gene mutation, we identified a sporadic case of a novel mutation that probably affects gene expression. The mutation, a G to C transversion leading to the substitution of Ala 484 by Pro, was not found in the protein S gene of the patient's parents. Transmission of the paternal and maternal protein S alleles was apparently normal, on the basis of the frequent polymorphism in exon XV. We also checked the transmission of chromosomal material by analysing protein C gene polymorphisms, beta-globin gene frameworks and four variable number of tandem repeats (VNTRs). By combining the results of these analyses, we were able to rule out nonpaternity and to confirm the de novo nature of the mutation.

Incidence of activated protein C resistance caused by the ARG 506 GLN mutation in factor V in 113 unrelated symptomatic protein C-deficient patients. The French Network on the behalf of INSERM

Because multiple risk factors in one patient may increase the clinical expression of thrombophilia, we assessed the presence in protein C-deficient patients of the factor V Arg 506 Gln mutation responsible for activated protein C resistance. Using a strategy allowing rapid screening of factor V exon 10, we studied 113 patients with protein C deficiency and 104 healthy volunteers. We detected the Arg 506 Gln mutation in 15 patients (14%) and in one healthy subject (1%). We identified a previously unpublished sequence variation leading to an Arg 485 Lys substitution in three normal subjects and seven protein C-deficient patients. A significant difference in the allelic frequency of the Arg 506 Gln factor V mutation was found between protein C-deficient patients heterozygous for an identified protein C mutation (n = 84; allelic frequency, 4.8%) and protein C-deficient patients with no identified mutation in the protein C gene coding regions (n = 25; allelic frequency, 14%). The results demonstrate that a significant subset of thrombophilic patients has multiple genetic risk factors although additional secondary genetic risk factors remain to be identified for the majority of symptomatic protein C-deficient patients.

Detection of monocyte tissue factor after endotoxin stimulation: comparison of one functional and three immunological methods

Monocyte procoagulant activity is mainly due to tissue factor (TF) expression, but functional assays may not be sufficiently accurate in clinical use, making useful a determination of TF antigen level. The aim of this study was to compare the results of one functional and three immunological TF assays (ELISA, immunocytochemical staining on slides and flow immuno cytometric analysis), in normal monocytes, after standardized stimulation by endotoxin. TF expression was determined in blood mononuclear cells isolated by gradient centrifugation and cultured, with or without various concentrations of endotoxin. On lysed cells, TF activity was determined by amidolytic assay and TF antigen level was determined, after triton extraction, by ELISA (Imubind, American Diagnostica). Mouse monoclonal antibody against TF (4508, American Diagnostica) was used for 1) immunocytochemical (ICC) staining on cytocentrifuge slides (Avidine-Biotine-peroxidase-Complex revelation) and 2) flow cytometric analysis using indirect labeling (Fab'2 Fluoresceine Isothyocyanate revelation). The determination of TF activity and TF antigen by ELISA method were equally sensitive to low concentration of endotoxin (0.005 EU/ml) and well correlated in the presence of higher concentrations of endotoxin. ICC led to a qualitative detection with a similar sensitivity to endotoxin stimulation. Flow cytometric analysis was poorly sensitive to increasing stimulation of monocytes. Of note, the functional, ELISA and immunocytochemical assays for monocyte TF expression were sensitive to endotoxin concentrations as low as 0.005 EU/ml.

Identification of 15 different candidate causal point mutations and three polymorphisms in 19 patients with protein S deficiency using a scanning method for the analysis of the protein S active gene

To screen for point mutations causing protein S deficiency, we used a sequence of techniques specifically for the study of the protein S active gene, PS alpha. This strategy comprises amplification of exons and intron/exon junctions by means of the polymerase chain reaction (PCR) and electrophoresis of the amplified fragments in polyacrylamide gel containing a gradient of denaturing agents (denaturing gradient gel electrophoresis). Only fragments with altered melting behavior are sequenced after asymmetric PCR. Beside the frequent polymorphism already described on Pro 626, we detected 18 different sequence variations by studying exons II, IV, V, VIII, X, and XV in 19 of 100 consecutive patients with protein S deficiency. Fifteen were candidate causal mutations, 4 of which were associated with a qualitative deficiency (type IIa or IIb). The remaining three sequence variations were probably polymorphisms.

First de novo mutations in the protein C gene of two patients with type I deficiency: a missense mutation and a splice site deletion

In a series of 40 patients with symptomatic protein C deficiency, we identified two sporadic cases with novel mutations that probably affect gene expression. The mutations, a 5-bp deletion of the donor splice site of intron f (nucleotides 3455 to 3459) and a mutation of nucleotide 8523 in exon IX leading to the substitution of Ser 270 by Pro, were not found in the protein C gene of the patients' parents. Transmission of the paternal and maternal protein C alleles was apparently normal on the basis of frequent polymorphisms in exons I, VI, and VIII. We also checked the transmission of the chromosomal material by analyzing the beta-globin gene frameworks and three variable number of tandem repeats (VNTRs). By combining the results of intragenic polymorphism, VNTR and beta-globin gene framework analyses, we were able to exclude nonpaternity and confirm the de novo origin of the mutation.

Evidence for time-dependent activation of monocytes in the systemic circulation in unstable angina but not in acute myocardial infarction or in stable angina

BACKGROUND

Platelet activation plays a pivotal role in the pathogenesis of acute coronary disease. Monocytes are involved in the progression of atherosclerosis and are potent activators of blood coagulation through their ability to synthesize tissue factor (TF). The aim of this study was to compare markers of monocyte and coagulation activation in the systemic blood of patients with unstable angina, acute myocardial infarction, or stable angina.

METHODS AND RESULTS

We studied 26 patients with unstable angina (10 +/- 5 hours after the onset of the last episode of pain), 18 patients with acute myocardial infarction (5 +/- 4 hours after the onset of pain), and 34 patients with stable angina. We measured levels of TF expression in peripheral blood mononuclear cells (isolated by gradient centrifugation and incubated for 16 hours, with or without endotoxin stimulation), levels of plasma prothrombin fragment 1 + 2 (F1 + 2), and levels of fibrinogen in peripheral blood. In patients with unstable angina, both stimulated and unstimulated cells exhibited higher levels of TF expression than in patients with stable angina (P = .0001). In patients with acute myocardial infarction, monocyte TF activity did not differ from that in patients with stable angina. Mean levels of F1 + 2 and of fibrinogen did not differ significantly between groups. Only in the unstable angina group, a modest correlation was found between fibrinogen (r = .72, P = .005) and F1 + 2 levels (r = .54, P = .001) levels and the degree of monocyte TF expression. In patients with unstable angina, monocyte TF expression (both stimulated and unstimulated, assessed by biological activity and by antigen techniques) and fibrinogen levels were correlated with the time elapsed from the beginning of the most recent episode of pain (.61 < r < .72, .02 < P < .0001). By contrast, there was no correlation between these variables and the time from onset of pain in patients with acute myocardial infarction.

CONCLUSIONS

A time-dependent activation of systemic monocytes and a time-dependent increase in fibrinogen levels occurs in unstable angina but not in myocardial infarction. These findings provide further evidence that a specific inflammatory process occurs in unstable angina. Further studies are required to determine whether monocyte activation is a cause or a consequence of plaque instability in patients with unstable angina and to clarify the interrelations between platelet and monocyte activation in these circumstances.

Compound heterozygosity in a family with protein C deficiency illustrating the complexity of the underlying molecular mechanism

The association of two missense mutations, a Leu 223 to Phe and an Ile 403 to Met, is described in a family presenting with various protein C deficiency phenotypes. In this family, two subjects were compound heterozygotes with protein C levels of about 25%, the other members being heterozygous for only one of the mutations. The Leu 223 to Phe mutation was also found in 9 members of 3 other families and, in all cases but one, resulted in protein C levels below 60% associated with a high incidence of thrombotic complications. The other mutation, an Ile 403 to Met, was identified in those of the family' members who presented with borderline protein C concentrations. In such a family, the genomic DNA analysis represents the only way to differentiate between the genetic status of each family member. The results highlight the importance of the genotype determination and the poor discriminative power of the plasma assays currently used.

Percutaneous transluminal venous angioplasty in occlusive iliac vein thrombosis resistant to thrombolysis

Systemic thrombolysis is less than optimal in total occlusions of the iliac vein in which patency is 20% or less. We describe an interventional therapeutic procedure that may be effective in such cases. We selected 18 patients (average age, 29.5 years; range, 16 to 71 years) with complete iliac vein occlusion that persisted after 24 to 48 hours of systemic thrombolysis (streptokinase 100,000 U/hr). The ipsilateral femoral vein was punctured, and a guide wire was gently advanced through the thrombus into the inferior vena cava. Multiple inflations were performed with a balloon catheter that was advanced on the wire. A temporary vena cava filter was placed as a protection against possible embolic migration. Systemic thrombolysis was administered for 24 to 48 hours. Control venography and pulmonary angiography were performed. Venography showed good recanalization in seven cases, incomplete recanalization in five cases, and failure in six cases. Patency was maintained for a long time (15.6 months). In conclusion, (1) percutaneous transluminal venous angioplasty is a valuable adjunct to systemic thrombolysis when the latter alone fails; (2) segmental flow and mechanical obstruction were the critical factors, since the pharmaceutical factors were held constant, and (3) a more aggressive incremental interventional strategy warrants consideration.

[Incidence and clinical expressions of microvascular complications in patients receiving kidney graft and treated with cyclosporine]

Reported cases of HUS/TTP (hemolytic uremic syndrome/thrombotic thrombopenic purpura) with cyclosporin (CsA) are more and more frequent, which led us to evaluate the incidence of microangiopathic process in kidney graft patients. In our first retrospective study we noted 9.4 percent of HUS/TTP among 117 patients. We tried to detect infraclinical hemolytic events prospectively in 40 new patients by systematic measurement of haptoglobin levels after introduction of CsA. The incidence of falls in haptoglobin levels was 25 percent. The immunological context was always noted: rejection crisis in 5 cases, cytomegalovirus infection in 3 cases, isolated markers of lymphocyte-activity in 2 cases. We never found a clinical or infraclinical form of microangiopathic process without a symptomatic or asymptomatic immunological complication. Monitoring haptoglobin levels make it possible to detect early endothelial injuries which could be linked to the future arteriolopathy described with CsA therapy.

Myocardial infarction after FEIBA therapy in a hemophilia-B patient with a factor IX inhibitor

A case of myocardial infarction (MI) in a hemophilia B patient with a factor IX (FIX) inhibitor (6 BU) is described. MI occurred after two infusions of FEIBA concentrate. Unexpectedly, these infusions resulted in a neutralization of the inhibitor and a consistent plasma FIX activity which may have increased the thrombotic risks. Four days later, a psoas hematoma was suspected. At that time the inhibitor remained undetectable, allowing a therapy with purified FIX concentrates. No recurrence of thrombotic complication was observed. This is an additional illustration of the thrombotic risks associated with the use of activated prothrombin complex concentrates, especially in patients having pre-existing risk factors for thrombosis. The management of bleeding episodes in hemophilia B patients with inhibitor represents an especially difficult challenge.

Protein C and S deficiency in severe infectious purpura of children: a collaborative study of 40 cases

We studied, in 40 children (mean age: 52 months) with severe infectious purpura, the relationships between protein C (PC) and protein S (PS) levels, and shock, disseminated intravascular coagulation (DIC) and outcome. We determined, on admission, PC antigen (ELISA) and activity (chromogenic test), and total PS (ELISA). Results were expressed as % of normal adult values. Statistical analysis was performed with SAS. Thirty children were in shock, 20 had DIC. All children with DIC, and 10 without DIC were in shock. Of 20 children who were in shock and had DIC, 7 died and 3 had an amputation. PC antigen was significantly decreased in shock children (p less than 0.05), in children with DIC (p less than 0.0005), and in non-survivors (p less than 0.05). PC activity was significantly decreased in shock children (p less than 0.05), in children with DIC (p less than 0.0005), and in non-survivors (p less than 0.005). Total PS was not decreased in shock children, but was significantly decreased in children with DIC (p less than 0.005), and in non-survivors (p less than 0.005). We conclude that PC and PS levels were decreased in our children, and that PC levels were significantly decreased in the presence of shock, DIC, and fatal outcome. PC and antithrombin III (AT III) supplementation, should be evaluated in children with severe infectious purpura with shock and DIC.

[Preventive treatment of systemic embolic complications of atrial fibrillation]

Non-valvular atrial fibrillation multiplies the risk of presumed embolic events by a factor of four. The hemorrhagic risk of anticoagulant treatment varies considerably and its prophylactic efficacy was not tested in any randomised trial before the end of 1989. The recommendations of experts at that time recognised that data were inadequate. The publication since of four randomised trials involving 3,049 patients has provided a more objective base for management decisions, highly in favour of the anticoagulation of cases of non-isolated atrial fibrillation in the absence of contraindications.

[Arterial thromboses and essential thrombocythemia in young patients]

The authors report two cases of essential thrombocythemia (ET) which occurred in young subjects (25 and 33 years) and revealed by arterial thromboses. The first case was one of myocardial infarction: in the second case, ischemic signs in the left leg led to cutaneous necrosis. Thrombotic signs are commonplace in ET and are generally considered to be attributable to an impaired underlying vascular territory. The cases reported by the authors conflict with these data and it would seem, therefore, that the onset of thrombosis in the absence of any associated cardiovascular risk can be envisaged. With regard to therapy, if thrombotic signs occur, myelosuppressive treatment must be undertaken; in asymptomatic patients, due to the potential and unpredictable risk of thrombosis, this treatment should be initiated if the platelet count rises above 800 x 10(9)/l. Hydroxyurea is generally prescribed (particularly in young patients) since it is generally considered to be devoid of any leukemogenic potential.

[Protein C deficiency and vascular thromboses. Apropos of 2 cases and a review of the literature]

Protein C, a physiological inhibitor of coagulation, acts by inactivating coagulation factors V and VIII. It was identified 20 years ago and purified 10 years later. Its anticoagulant properties have been confirmed by the demonstration of thromboembolic diseases associated with constitutional protein C deficiency. Deficiency is defined as a less than 65 p. 100 level of the protein. There is no correlation between protein C level and clinical severity. Constitutional protein C deficiency is transmitted as an autosomal dominant trait. The protein C level observed in homozygous deficiency is about 50 p. 100, more often quantitative (type I) than qualitative (type II), the other coagulation factors being present at normal levels. Protein C deficiency is responsible for recurrent and familial thromboembolic necrosis and for cutaneous necrosis during treatment with antivitamin K drugs. Protein C assays must now be part of the aetiological evaluation of thromboembolic disease. Physiological variations in protein C levels have been encountered in neonates and pregnant women as well as in some pathological conditions, after surgery or under certain treatments. Familial inquiries are essential to detect asymptomatic protein C deficient subjects. Treatment rests on anticoagulants: antivitamin K drugs after effective heparinization in thromboembolic accidents, prevention of accidents by heparin in protein C deficient subjects and when a risk of thromboembolic disease is present. We report here one case of venous thrombosis and one case of arterial thrombosis, both being characterized by the finding of protein C deficiency during full evaluation of haemostasis factors.

Distinctive features of procoagulant response of monocytes from diabetic patients

The procoagulant activity (PCA) of disrupted monocytes was examined in 32 diabetic patients (26 with insulin-dependent and 6 with non-insulin-dependent diabetes) versus 30 control subjects. Diabetes monocytes exhibited a weak PCA before any incubation, associated in 10 cases with a significant amount of factor VII activity. Incubation led to a significant rise in PCA in diabetes cells, when stimulated with lipopolysaccharide or not, and in control cells only after stimulation. In incubated diabetes cells, PCA was prothrombinase-like when factor VII was associated with the freshly isolated cells, and tissue factor-like (as in the controls) when no factor VII was associated with the cells. The characteristics of PCA were not correlated with clinical features or with the type of diabetes. Our study suggests that diabetes monocytes exhibit a higher level of PCA than control ones, possibly corresponding to an in vivo stimulation, or at least a higher responsiveness to stimuli occurring in vitro.

Lupus anticoagulant: a clinical and laboratory study of 100 cases

The clinical and laboratory features of 100 patients with lupus anticoagulant (LA) are reviewed. Subjects were divided into three groups according to their age (1-5, 15-35, 45-89 years). Female prevalence was observed in each group and overall F/M ratio was 3/1. An underlying autoimmune disease (principally lupus erythematosus) was found in 47 cases (10% of the children, 80% of the 15-35-year-old patients and 37% of the elderly patients). Biological criteria for the LA diagnosis were prolonged activated partial thromboplastin time and diluted thromboplastin time (1.3 x control), not corrected after addition of control to patient's plasma. Thromboplastin time was normal in 77 patients. Other types of coagulation inhibitors were eliminated by specific factor assays (with a 10-fold increase of cephalin concentration when necessary). Twenty-three thrombotic episodes were observed. No significant difference was found in the incidence of thrombosis between the autoimmune and non-autoimmune disease group, but the age when first thrombosis occurred was clearly lower in the former. Fourteen obstetrical accidents were noted in eight women but 13 pregnancies terminated without accident. Four patients experienced haemorrhagic complications; they all presented with a severe thrombocytopenia associated with the LA. In our experience, LA is a frequent coagulation abnormality, associated in about half of the cases with a clearly defined autoimmune disease. Clinical presentation appears as notably different according to the patient's age; it is particularly noteworthy that in nine out of 10 children, LA disappeared spontaneously within 6 months.

Acquired type II von Willebrand's disease: demonstration of a complexed inhibitor of the von Willebrand factor-platelet interaction and response to treatment

An acquired von Willebrand's disease developed in two patients in association with a monoclonal gammopathy plus a Sjögren's syndrome and a chronic lymphocytic leukaemia (CLL). In both cases a plasma inhibitor to von Willebrand factor (vWf) was suspected and characterized after plasma gel filtration. The inhibitor was shown to be entirely complexed with vWf and was only demonstrated after complex dissociation by heating. The inhibitor was able to inhibit the binding of 125I-vWf to platelets in the presence of ristocetin in both cases and to thrombin-stimulated platelets in one case. In the two patients, the highest molecular weight multimers (HMWM) of vWf were absent when assessed by sodium dodecyl-sulphate agarose plasma electrophoresis. Intravenous infusion of 1-deamino-(8-D-arginine) vasopressin (DDAVP) resulted in the appearance of the HMWM in both cases and of the satellite bands of each multimer subunit which were lacking prior to the infusion in one patient. After transfusion of a VIII/vWf concentrate containing a significant amount of HMWM, there was a rapid plasma clearance of the vWf-related activities and of the HMWM when compared to that seen in a patient with type III constitutional vWD. We conclude that in the two patients studied the coagulation defect was related to the presence of a circulating inhibitor to vWf which could be responsible for the disappearance of the HMWM from plasma.

[Inhibitors of factor VIII in non-hemophilic patients. Biological and therapeutic aspects. Apropos of 3 cases]

A coagulation inhibitor of the anti-factor VIII: C type was detected in three non-haemophilic male patients aged 75, 70 and 52 respectively. In all three patients antibody titres were low (less than 12.5 Bethesda units initially, less than 20 units subsequently), and a low but detectable level of factor VIII: C persisted (7 to 12 p. 100 in two patients who had severe haemorrhages and 2.100 in the third one). The 3 inhibitors inactivated factor VIII: C with a complex, type II kinetics (Biggs et al.). Strong doses of anti-haemophilic A fractions were biologically effective in one patient but could not stop severe bleeding. Activated plasma fractions were used successfully on several occasions. Once, moderate and repeated doses of anti-haemophilic A fractions resulted in satisfactory correction of factor VIII: C level, and a minor surgical operation could be performed. An immunosuppressive treatment was administered for 3 weeks to one patient and for 3 months to the other two patients. In all three cases the inhibitor disappeared after 5 to 8 months. In non-haemophilic patients with factor VII: C inhibitor the treatment of haemorrhagic episodes must take into account the severity of bleeding, then the usually complex kinetics of the inhibitor; thus it cannot be a direct copy of the treatment used in haemophiliacs with type I inhibitors.

[Successes and failures of the activated partial thromboplastin time in the preoperative evaluation]

In a prospective study assessing haemostatic functions, the activated partial thromboplastin time was prolonged in 134 out of 10,229 patients studied, without an increase in the prothrombin or thrombin times; this abnormality persisted in only 37 of them on a new blood sample. A retrospective analysis was made of 265 patients who had such an isolated prolongation of the activated partial thromboplastin time on two successive blood samples: the causal abnormality remained unexplained in 135 patients; a well defined coagulation disorder without abnormal bleeding tendency was present in 110 patients (1 severe factor XII deficiency, 58 partial factor XI or XII deficiencies and 51 lupus anticoagulants); a bleeding disorder was diagnosed in 20 patients (8 haemophilias, 8 Von Willebrand's diseases, 4 factor VIII inhibitors). The well-iron efficacy of the activated partial thromboplastin time for detecting coagulation abnormalities is counter-balanced by some disadvantages such as the delay for biologic conclusions. In the preoperative assessment of haemostatic functions, rather than taking a routine approach, it would seem better to determine for each patient the need and the extent of biological testing according to the type of planned surgery, the clinical status of the patient and possible bleeding symptoms.

["Lymphoid" blastic transformation in chronic myelogenous leukemia. Report of three cases (author's transl)]

Three cases of chronic myelogenous leukemia (CML) were studied, occurring in 22, 43, and 30-year-old-men. Two observations (nos. 1 and 3) concerned typical CML, treated by discontinuous busulfan; in the last patient (no. 2), also presenting in addition with a constitutional deficiency from Hageman factor, diagnosis (Ph 1 chromosome) was based on a moderate leukocytosis with myelemia, spontaneously regressive for more than one year. Chronic phase duration was 17, 16 and 8 months respectively. During the first blast crisis, abnormal cells were rather of granular type in one case (no 1), undifferentiated in the other two. In the three observations, complete remission was easily obtained with prednisolone - vincristine but revealed very brief; 2, 2 and 4 months. Among the three patients a second blast crisis was preceded, in two cases (nos. 1 et 3), by a new CML phase during 3 and 1 months respectively. Treatment was then purely palliative by 6-mercaptopurine and hydroxyurea.

[Contribution of ABVD chemotherapy in refractory Hodgkin's disease. Study of 21 observations (author's transl)]

On a two years period, 21 patients with advanced Hodgkin's disease who failed usual therapeutic proceedings were treated by a sequential combination chemotherapy with adriamycin, bleomycin, vinblastine and dacarbazine (ABVD, first described by Bonadonna). Initially 16 patients among 21 had a disseminated disease with stage III B (9 obs.) or IV B (7 obs.). Previously all had been submitted, during a four years mean period, to multiple therapeutic trials always involving MOPP plus lymphoid irradiation and/or other combination chemotherapy. In 19 patients among 21, ABVD was decided because of persistent abdominal lymphoid and/or visceral localizations (liver: 6 obs.; lung: 4 9bs; épidural space: 1 obs.). In 12 patients, abdominal localizations were proved after delayed staging laparotomy. Immediate results with ABVD were: CR: 9 obs. (43%); PR: 5 obs. (24%); failure: 7 obs. (33%). With vinblastine interrupted by intermittent ABVD, 4 CR are persisting with a 8 to 23 months' follow up; among 5 patients who relapsed (3 to 24 months), 4 are still alive. After irradiation of résidual lesions, 4 PR among 5 are persisting with a 6 to 12 months' follow up. For the 21 patients, median survival has not been reached at 30 months.

[Therapy of bacterial infections occuring during aplastic phasis of acute leukemias (author's transl)]

On a three years' period, 122 patients with AL (45 children, 76 adults) received 158 treatments of induction, involving a severe medullary aplasia. In 48 cases (30.4%) none infectious complication was recorded. In the other 110 observations, infections syndrome (septicemia due to gram-negative rods above all) was treated by an early and intensive combination antibiotherapy (three successive protocols are employed, after failure of the precedent), in association with a careful medical reanimation and trasfusions of granulocytes in 16 cases. Regression was obtained in 94 cases (59,5%) but infection was lethal in 16 patients (10.1%). More than cytological variety of AL, principal pronostic element is age (15 deaths among 88 infections episodes in adults, one among 22 in children). Granulocytes rate at the time of aplasia (lower than 500 /mm3) also represents a factor of gravity. Among 94 infections episodes, antibiotherapy was successful alone in 81 cases (86.2%), illustrating the fundamental place of this treatment.