The pre-, peri-, and postsurgical activation of coagulation and the thromboembolic risk for different risk groups

Patients after surgery stand at high risk of developing thromboembolic complications. Nevertheless, there is at present no universal and valid guideline on the duration of heparin prophylaxis. This study aims to assess the thromboembolic risk after the different surgical treatments for different risk groups, based on the activation of the plasmatic coagulation and fibrinolysis system. This is measured by estimating the levels of the fibrin monomers (FM) and fibrin-D-dimers (FD) in plasma during the pre-, peri-, and postsurgical periods in patients from the different clinical risk categories (i. e., posttraumatic or elective hip replacement and osteosynthesis and abdominal surgery: conventional or minimal invasive in malignant and non malignant diseases). During an observation period of 14 days the FM and FD levels were found to be significantly elevated in patients from all risk groups. Underlying malignant diseases lead to an elevation of the procoagulatory risk, whereas age itself does not. Patients who underwent hip surgery seemed to be especially at risk. Even after 14 days or at the date of discharge the FM and FD levels were elevated to maximum showing sustained precoagulatory conditions and increased thromboembolic risk. For these patients the long-term prophylaxis, lasting possibly longer than the average hospitalization period, seems evident. Clinical trials to prove this hypothesis are nevertheless urgently recommended. A corresponding clinical trial that compares long-term against standard heparinization was therefore initiated and is now in progress.

Biocompatibility differences with respect to the dialyzer sterilization method

The impact of the method of sterilization (steam vs. ethylene oxide, ETO) on indices of biocompatibility is investigated using polysulfone membranes. Eight patients were treated with a random choice of the high-flux membranes F60S (steam) and F60 (ETO) and the low-flux membrane F6 (ETO). Blood samples were taken prior to and 5, 15, 30, 60, and 180 min after the start of hemodialysis. White blood cell count, platelet count, and plasma concentrations of polymorphonuclear neutrophil elastase, complements C3a and C5a, and beta2-microglobulin were determined. The dialysis procedure was associated with a significant decrease in white blood cell count and beta2-microglobulin level and a significant increase in polymorphonuclear neutrophil elastase and complement C3a and C5a levels. However, the steam-sterilized F60S membrane had a significantly lower impact on the biocompatibility indices than the ETO-sterilized F60 and F6 membranes (p < 0.05 or p < 0.001 for the individual markers). We conclude that using steam instead of ETO for sterilization may improve the biocompatibility of membranes.

[Metachromatic leukodystrophy simulating schizophrenia-like psychosis]

A case of late onset metachromatic leukodystrophy with a clinical picture of paranoid hallucinatory psychosis and severe dyskinesia is described. The problem of diagnostic recognition is discussed. In the case, diagnostic procedures were initiated after atypical clinical course, and established on the basis of MRI and specific biochemical tests.

[Clinical value of the CA 19-9 tumor marker with special reference to the Lewis phenotype]

BACKGROUND

Because of structure and biosynthesis of CA 19-9, it was postulated that patients with the Lewis phenotype Le(a-b-) are not able to synthesize CA 19-9. But some patients with Le(a-b-) on red blood cells showed elevated levels of this tumor marker.

PATIENTS AND METHOD

In 164 patients suffering from benign or malignant diseases both CA 19-9 and the Lewis phenotype were determined in sera. In addition in 51 patients red blood cells were tested for Lewis substances.

RESULTS

The frequencies of the different Lewis phenotypes on red blood cells were compared with the results found in sera. The prevalence of the phenotype Le(a-b-) on erythrocytes was significantly higher than in sera. In 51 patients both determinations were performed. These results were compared additionally. The phenotype Le(a-b-) found on red blood cells agreed with the results found in sera only in 30% of the cases. A loss of Lewis substances on erythrocytes could be seen both in malignant and benign diseases. Only in patients with Lewis substances found in sera elevated levels of CA 19-9 could be seen.

CONCLUSION

Considering only the Lewis phenotype in sera, it could be confirmed that patients with the genotype Le(a-b-)are not able to express elevated concentrations of CA 19-9.

Diagnostic value of CA 19-9 in patients with pancreatic cancer and nonspecific gastrointestinal symptoms

Serum expression of the tumor marker CA 19-9 was studied in 2119 patients. The discriminating capacity between benign and malignant disease was high for CA 19-9, especially in patients with pancreatic cancer (n = 347). The sensitivity of CA 19-9 was 85%. In patients who were Lewis blood type positive, the sensitivity increased to 92%. CA 19-9 levels were significantly lower in patients with resectable tumors (n = 126) than in those with unresectable tumors (n = 221, P < 0.0001; sensitivity 74% vs. 90%). CA 19-9 levels dropped sharply after resection but normalized in only 29%, 13%, and 10% of patients with stage I, II, and III tumors, respectively. In unresectable tumors no significant decrease in CA 19-9 levels after laparotomy or bypass surgery was found. Among patients with the same tumor stage, the median survival time in those whose CA 19-9 levels returned to normal after resection was significantly longer than in those who had postoperative CA 19-9 levels that decreased but did not return to normal (stage I, 33 months vs. 11.3 months; stage II, 41 months vs. 8.6 months; and stage III, 28 months vs. 10.8 months). In patients with recurrent disease, 88% had an obvious increase in CA 19-9 levels. CA 19-9 measurement is a simple test that can be used for diagnosis, for evaluation of resectability, and for prediction of survival after surgery and recurrences.

[Paradoxic occurrence of symptoms of rheumatic fever after thrombolytic therapy with streptokinase--a case of delayed hypersensitivity?]

We report the case of a 51-year-old patient with a Paget von Schrötter-Syndrome of the right arm who underwent a successful lysis therapy with 9 x 10(6) IU streptokinase (Streptase) i.v. over 3 days. 36 h after ending the lysis therapy he developed a generalized eczema, which was interpreted as a drug-induced allergic reaction of the arthus type (Coombs III). He received methylprednisolone p.o. with an initial dose of 40 mg, tapered to 0 over 5 days. One day after the efflorent rash the patient developed fever for 12 h (with 38.8 degrees C maximum) and a gonarthritis of the left knee, and 24 h later of both knees. An echocardiogram showed a small pericardial effusion without hemodynamic influence. On the following 2 days a minimal proteinuria of 0.28 and 0.22 g/l was found. Subsequently and after a follow-up of 2 years, the patient was totally free of pathologic clinical and laboratory findings. We interpret this unusual case as a delayed hypersensitivity reaction to streptokinase with a paradoxical occurrence of clinical symptoms formally fulfilling the diagnostic criteria of "rheumatic fever".

Modulation of lectin-triggered superoxide release from neutrophils of tumor patients with and without chemotherapy

Superoxide production by neutrophils is believed to contribute to the efficiency of the host defence system. This activity is stimulated by the mannose-specific lectin concanavalin A, the N-acetylglucosamine/neuraminic acid-specific wheat germ agglutinin and the galactoside-specific lectins from Viscum album and human placenta. To assess whether this aspect of immune function is affected in cancer patients without or with treatment, neutrophil preparations from 69 patients were examined. Reductions in O2.(-)-production were observed for bronchial carcinoma patients after incubation with concanavalin A and the human lectin, while samples from breast cancer patients without or with treatment exhibited no significantly altered activity in the presence of each of the four agglutinins. Chemotherapy of lung and colorectal carcinoma patients reduced the neutrophilic response to concanavalin A and Viscum album agglutinin. As similarly shown for 9 specimens from other carcinoma types and from hemopoietic malignancies, there is no general impairment of responsiveness. In addition to the property of the lectin, the large extent of interindividual variation should be taken into account when it is attempted to enhance this factor of the host defence system against infections and malignant cells.

Increased risk of acute myelogenous leukemia (AML) and chronic myelogenous leukemia (CML) in a county of Hesse, Germany

The incidence of acute and chronic myelogenous leukemia has been compared for the two neighbouring regions of Marburg and Giessen in Hesse (Germany). The investigation was based on the incident cases of the years 1983-1989 which have been diagnosed in the hematological departments of the universities of the two regions. The epidemiological evaluation of the data has been carried out in terms of a historical follow-up study, and shows an increased relative risk for the region around Marburg with a particular elevation for one community within this region. Potential determinants are discussed and focus on trinitrotoluene (TNT) and decomposition products which are known to contaminate the soil of this community, in some places severely, due to insufficient removal of remnants of the TNT production in large underground plants during World War II.

Protein S degradation in vitro by neutrophil elastase

Human protein S is degraded by neutrophil elastase. The characteristics of cleavage are compared in a purified protein S preparation, a concentrate of vitamin K-dependent proteins (PPSB) and in normal plasma as well as in alpha-proteinase inhibitor (alpha PI)- deficient plasma. Elastase incubation of purified human protein S (molar enzyme-to-substrate-ratio 1:5500-1:55) reduces the molar mass of the native protein S (81-83 kDa) to about 79 kDa by cleavage of a small peptide. Incubation with very high elastase concentrations (molar enzyme-to-substrate-ratio 1:5.5) completely degrades protein S into small fragments. The elastase incubated protein S has a higher isoelectric point than the native form (Ip 5.9 vs. 5.3). Protein S in a PPSB coagulation factor concentrate is degraded in the same way as isolated protein S. By immunoblotting also smaller split products of molar masses between 34 and 70 kDa are demonstrated. In normal plasma protein S is not degraded by elastase concentrations up to 14 mumol l-1. In plasma of a patient with alpha 1-proteinase inhibitor deficiency protein S can be degraded by elastase. The native 82 kDa protein is degraded to a 72 kDa protein. PEG precipitation of the protein S- C4b- binding protein-complex shows that elastase predominantly splits the free protein S.

Granulocyte-monocyte colony-stimulating factor levels during hemodialysis-induced leukopenia

Hemodialysis (HD), especially with cellulosic membranes, leads regularly to a transient but marked drop of peripheral neutrophils. Such neutropenia during the initial 10-30 min of HD is followed by a reincrease in granulocyte count up to a mild leukocytosis. Although this phenomenon accounts for the best documented side effect of HD, little is known about the underlying regulatory mechanisms. Therefore in this study the blood levels of granulocyte-macrophage colony-stimulating factor (GM-CSF) were measured during HD. Previous investigations have demonstrated that GM-CSF plays the central role in controlling the homeoiostasis of leukocytes by up- and downregulation of proliferation and efflux of cells out of the maturation compartment within the bone marrow. Three patients with chronic renal failure underwent HD with cuprophane membranes. In all cases a significant drop of peripheral granulocytes occurred, but GM-CSF levels remained unchanged and were found in the normal range during the whole period of the treatment. It is therefore concluded that GM-CSF may not be significantly involved in the regulation of peripheral leukocytes during HD.

Hemophan versus hemophan--a philippic against the suggestion of constant membrane quality

All statements referring to biocompatibility of dialyzers depend on the suggestion of a constant and reproducible structure of the investigated membrane material. The data presented here strike this concepts in case of hemophane. Two commercially available hemophane dialyzers, the GF MC 120 (Gambro) and the MO 450 (SMAD) membranes, were compared. Significant differences could be seen in the induction of leukopenia and leukocyte sequestration reaction within patients lungs, but also in capacity to influence granulocyte oxidative metabolism and release of granular enzymes. According to these data it seems questionable whether hemophane is a membrane material with constant structure and quality normally expected for products bearing trade names. Excluding other differences (like surface-area or sterilization method) variable amounts of DEAE substituents and/or an inconstant distribution of the DEAE groups within the membranes may be the most possible reason responsible for the differences found. The study underlines the urgent need of an exact physico-chemical characterization of dialyzer membranes and is therefore a challenge for free publication of such basic data by the producers.

Felty's syndrome: favorable response to granulocyte-macrophage colony-stimulating factor in the acute phase

We report a case of Felty's syndrome in which infectious complications due to severe neutropenia could be overcome by short-term treatment with recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF, 7 micrograms/kg/day s.c.). Leukocyte counts rose from 1,050/mm3 at presentation to 4,470/mm3 after 15 days of treatment. A flare-up of arthritis was not noted. Defects in granulocyte function and clinical improvement prior to leukocyte rise suggest that the beneficial effect of GM-CSF is mainly due to an improvement of granulocyte function.

Protein C degradation in vitro by neutrophil elastase

Purified protein C is completely degraded into small peptides by in vitro incubation with purified elastase. Protein C is a rather sensitive substrate as degradation is already accomplished by low elastase concentrations (molar enzyme-to-substrate ratio 1:510) and short incubation periods (5 min-60 min). Protein C in a PPSB coagulation factor concentrate is equally degraded and similar split products are detected by blotting techniques. The protein C activity (measured by a chromogenic substrate) is faster reduced by elastase than the protein C concentration (measured by an ELISA). Incubation of normal plasma with high elastase concentrations (5.7 nmol/ml plasma) results in reduction of the protein C band while no split products are detectable. The pathophysiologic significance of the effects of elastase on protein C remains to be elucidated.

Inhibition of neutrophil chemotaxis by elastase-generated IgG fragments

IgG1 is cleaved in vitro by granulocyte elastase into Fc and Fab fragments. The elastase-specific Fc fragment has been previously detected in vivo. Biological activity of the fragments has been described in modulating neutrophil oxidative metabolism and enzyme release. To investigate further effects granulocyte chemotaxis (CT) was tested. The CT was assayed in Boyden chambers and the chemotactic index (CI) was calculated which represents the mean distance travelled by the activated cells. Stimulation of leucocyte CT by casein, activated serum and FMLP gives maximal values of delta CI = 46.7, 26.4 and 7.2 microns, respectively. Native IgG1 and the elastase-produced IgG fragments do not stimulate leucocyte CT. FMLP-stimulated CT is specifically inhibited by the elastase-produced Fc fragments. Addition of 7 nmol Fc to stimulus concentrations of 16 to 125 nM FMLP results in total inhibition of chemotaxis demonstrated by CI values which are lower than those for unstimulated cells. The inhibition of CT is concentration dependent in the range of 2 to 7 nmol Fc/10(6) PMN. Number and affinity of FMLP receptors are not influenced by Fc fragments, so Fc binds neither to FMLP nor the FMLP receptor. CT stimulated by casein shows a large portion of chemokinesis. Only at suboptimal casein concentrations do Fc and IgG have an inhibitory effect on CT (0.63 mg casein/ml, 10 nmol peptide/10(6) PMN). C5a-stimulated CT is not influenced by IgG or IgG fragments which indicates that the samples are not cytotoxic. So the FMLP and casein-stimulated CT is specifically inhibited by the elastase-produced Fc fragments in a low concentration range.

Polymorphonuclear neutrophil chemiluminescence in periodontal disease

The oxidative metabolism of polymorphonuclear leukocytes (PMNs) in rapidly progressive periodontitis (RPP, n = 19), localized juvenile periodontitis (LJP, n = 10), adults periodontitis (AP, n = 10) and healthy control subjects (HS, n = 39) was compared using the luminol chemiluminescence (CL) method. Possible influences of the isolation procedure on CL were circumvented by replacing starch with Haemaccell 35 as the sedimentation agent. In all groups, CL was significantly higher with autologous serum than with normal pooled serum (NPS) and there was a significant linear relationship between the two values. Comparisons of both pooled and autologous serum between patient groups and their matched controls were not statistically significant. There was a suggestion of serum-induced defects in 2 patients and 1 control. The range of individual values within each group was very heterogeneous, probably because of the many factors that are able to influence both the production of CL and the basal levels of CL observed.

Hemodialysis and blood coagulation: the effect of hemodialysis on coagulation factor XIII and thrombin-antithrombin III complex

Blood membrane interaction during hemodialysis (HD) regularly leads to stimulation of leukocyte function and related release of granular enzymes. The present study aimed to investigate the possible influence of an HD-induced release of granulocyte elastase on blood coagulation. Therefore a highly sensitive substrate of polymorphonuclear elastase, the plasma coagulation factor XIII and its subunits A and S were determined in the course of HD. Consumption of both subunit A and S have been previously shown to be due to proteolysis by elastase, whereas a decrease in subunit A will be typical for thrombin activation. Furthermore, the thrombin-antithrombin III complex (TAT) acting as a predisposition parameter for thrombotic events was measured during HD treatment. Apart from a virtual fall in factor XIII total activity simulated by heparin, no significant HD-induced consumption of factor XIII could be observed. There was also no indication of an elastase- or thrombin-related change in subunit concentrations. Predialysis values of the TAT complex were generally elevated in HD patients, but only patients with acute renal failure showed a constant increase of TAT during HD. These findings suggest that HD patients are exposed to a latent activation of coagulation resulting in an elevated thrombogenetic risk mainly due to the underlying disease. An additional coagulatory stimulation by the HD procedure seems to be restricted to cases of acute renal failure.

Gingival crevicular fluid elastase-inhibitor complex: correlation with clinical indices and subgingival flora

This investigation analyzed, in a cross-sectional study, the possible relationship between gingival crevicular fluid (GCF) elastase-like protease (ELP) levels and the periodontal clinical parameters or the presence of specific bacteria in subgingival plaque. A total of 388 periodontal sites from 8 adult periodontitis patients were examined for plaque index (PII), gingival index (GI), pocket depth (PD) and alveolar bone loss (ABL). GCF ELP levels were determined as ELP alpha-1 protease inhibitor (ELP-alpha 1-PI) complex levels with a commercially available ELISA. Subgingival plaque samples were tested for the presence of Bacteroides gingivalis, B. intermedius and Actinobacillus actinomycetemcomitans by indirect immunofluorescence (IF) microscopy. GCF ELP-alpha 1-PI levels were then correlated with clinical periodontal indices and proportions of IF-positive bacteria per site. Statistically significant positive correlations were found between GCF ELP-alpha 1-PI concentrations and subgingival Bacteroides proportions. When the sites examined were analyzed depending on the level of each clinical parameter, the levels of these correlations changed. A. actinomycetemcomitans correlated highly (r = 0.716) with ABL for sites with low GI score. The correlations between GCF ELP-alpha 1-PI and B. gingivalis (r = 0.642) or B. intermedius (r = 0.774) were the highest for ABL less than or equal to 20% and PD less than or equal to 3 mm, respectively. The strong association between GCF ELP-alpha 1-PI concentrations and subgingival bacteria previously associated with advancing periodontitis indicates that measurement of GCF ELP-alpha 1-PI concentrations may be useful in the evaluation of periodontal sites, especially those with very little or no tissue destruction.

Investigation of the PMN chemotaxis in periodontal disease

The chemotactic responses of peripheral polymorphonuclear leukocytes in 36 patients with rapidly progressive periodontitis (RPP) were compared to responses in 15 patients with localized juvenile periodontitis (LJP) and 10 patients with adult periodontitis (AP). In the RPP group, 13 (36%) patients exhibited reduced chemotactic activity and 7 (19%) exhibited activity. Compared to this, 12 (80%) of the LJP patients displayed reduced chemotactic activity. Among the AP-patients 4 (40%) showed altered chemotactic activity including 1 (10%) with reduced chemotactic activity and 3 (30%) with increased activity. These results suggest that depressed chemotaxis is greatest in LJP, intermediate in RPP and least in AP.

The role of membrane contact in hemodialysis-induced granulocyte activation

Besides complement, interleukin-1 and beta 2-microglobulin, activation of granulocyte function has been found out to be the major parameter in the determination of dialyzer biocompatibility. Unfortunately, the term 'granulocyte activation' has been widely used without restriction to distinct functions or definition of the related metabolic pathways. Therefore, the present study aims to elucidate the influence of hemodialysis (HD) pure membrane contact on granulocyte O2- release. The activation of this metabolic pathway which is also known as the so-called oxidative burst has been generally accepted as the initial signal in the granulocyte inflammatory activation cascade. Two membranes which have been previously shown to differ most widely in biocompatibility, cuprophane and polysulfone, have been selected. During HD with cuprophane the stimulatable O2- release was initially decreased, whereas polysulfone HD was effectless on granulocyte oxidative metabolism. The inhibition was due to a prestimulation of the granulocyte by pure interaction of the cell with the surface of the dialyzer membrane which could be proved by evaluating a plasma-free model. Activation of oxidative metabolism was strongly correlated with granulocyte adherence, showing a significantly higher rate of cell adherence in the case of cuprophane. Nevertheless, sheer forces were able to prevent granulocytes becoming adherent directly to the dialyzer membrane, but sheer forces were not able to influence the oxidative burst reaction, suggesting that the membrane-related stimulation of oxidative metabolism occurs immediately after a very short, possibly a single and hasty contact of the cell to the surface of the dialyzer membrane.

Kinetics of pulmonary leukocyte sequestration in man during hemodialysis with different membrane-types

Although it has been suggested that pulmonary sequestration of leukocytes could account for membrane-dependent white blood cell depletion in HD, direct evidence in patients is still lacking. Therefore a study was initiated to test whether and how leukocytes distribute in the lung circulation during HD with different membranes. Thirteen patients suffering from chronic renal failure underwent lung scintigraphy during HD with cuprophane (n = 3), hemophane (n = 8) and polysulfone (n = 2) lowflux capillary dialyzers. Isolated autologous leukocytes were labelled with 99m-Technetium and reinfused before starting HD. Distribution of leukocyte related activity was registered by lung scintigraphy. In comparison to normal lung scintigraphy performed without HD, an impressive redistribution peak was demonstrated 10-20 min after the start of HD with cuprophane and also to a lesser extent with hemophane. When HD was performed with polysulfone the decrease in activity was delayed but no real redistribution was obtained. In accordance with other phenomena, such as peripheral leukopenia and changes in granulocyte oxidative metabolism, pulmonary sequestration of leukocytes takes place in man in the initial phase of HD and appears to be strongly dependent on the type of membrane.