A liposome based platelet substitute, the plateletsome, with hemostatic efficacy

The complexity of platelet mediated hemostasis has hindered development of a platelet substitute for transfusion therapy. In the current study, the hemostatic efficacy of a liposome based modality, the plateletsome, is demonstrated. A deoxycholate extract of a platelet membrane fraction, with a minimum of 15 proteins including GPIb, GPIIb-IIIa and GPIV/III, was incorporated into sphingomyelin: phosphatidylcholine: monosialylganglioside or egg phosphatide small unilamellar vesicles by reverse-phase/sonication and French press extrusion. These plateletsomes decreased bleeding by 67% in the tail bleeding time in rats made thrombocytopenic (platelets < 30,000/microliters) with external irradiation (7-9Gy) by Cesium source. Efficacy was also demonstrated in the thrombocytopathic, Fawn-Hooded rat, but to a lesser extent than in the thrombocytopenic animals. Direct plateletsome infusion to the tail wound was more effective than systemic administration for all effective preparations. On post-mortem examination, no pathologic thrombi were detected by gross and histopathologic examination of the lungs, livers, kidneys, or spleens of thrombocytopenic or normal animals after plateletsome infusion. No evidence of intravascular coagulation, monitored by levels of circulating fibrinogen and platelet counts, was observed when plateletsomes were administered intravenously to rabbits. No deleterious effect, either inhibition or hyperaggregability, on platelet aggregation studies in vitro was observed. While further refinements are clearly required, this study indicates that liposomes bearing specific platelet proteins may provide a basis for a clinically applicable platelet substitute.

Human neutrophil azurocidin synergizes with leukocyte elastase and cathepsin G in the killing of Capnocytophaga sputigena

Azurocidin was purified in the presence of phenylmethylsulfonyl fluoride. Electrophoresis revealed at least seven species which exhibited N-terminal sequences consistent with azurocidin. Azurocidin exhibited no bactericidal activity against Capnocytophaga sputigena or other oral bacteria but synergized the bactericidal activity of enzymatically active elastase. Azurocidin also interacted synergistically with cathepsin G.

Biologically modified PHEMA beads for hemoperfusion: preliminary studies

Polyhydroxyethylmethacrylate (PHEMA) beads were prepared by phase separation polymerization. Hydroxyl groups on PHEMA beads were activated with CNBr at alkaline pH. Adsorption of heparin, blood proteins (i.e. albumin, fibrinogen and gamma-globulin), protein A, HIgG and DNA on these beads were studied. Preparation and activation procedures are given here. The preliminary results of these studies are also reported.

In vivo and in vitro complexes of activated protein C with two inhibitors in baboons

In vivo complex formation of activated protein C with protein C inhibitor (APC-PCI) and with alpha 1-antitrypsin (APC-alpha 1AT) following infusion of 0.25 or 1.0 mg APC/kg in 1 hour into baboons was studied using immunoblotting and sandwich enzyme-linked immunosorbent assay (ELISA)s. Before APC infusion, detectable plasma levels (about 30 ng/mL) of APC-alpha 1AT complex were found in the baboon plasma. At the lower APC dose, APC-PCI and APC-alpha 1AT complex levels were 1.4 +/- 0.3 (mean +/- SD) and 0.8 +/- 0.1 microgram/mL after 1 hour of infusion. At the higher APC dose, the APC-PCI level was similar to the APC-alpha 1AT level during the first 30 minutes, but after 1 hour of infusion the APC-alpha 1AT level was higher than the APC-PCI level, reaching 4.1 +/- 1.2 and 2.9 +/- 1.2 microgram/mL, respectively. After 24 hours, complex levels had returned to basal conditions. During infusion of protein C (1.0 mg/kg in 1 hour), both complexes were detected in low concentrations. Following bolus injection of APC, half-lives (t1/2) for APC and APC-PCI and APC-alpha 1AT complexes of 10, 40, and 140 minutes, respectively, were observed. After 1-hour incubation with 2.5 micrograms/mL APC, baboon plasma contained 1.0 +/- 0.2 and 0.8 +/- 0.1 microgram/mL of APC-PCI and APC-alpha 1AT, respectively. Addition of 10 micrograms/mL APC to baboon plasma yielded 2.5 and 2.4 micrograms/mL APC-PCI and APC-alpha 1AT after 1 hour, respectively. Immunoblotting analysis also showed in vivo formation of complexes of APC with an auxilliary inhibitor but not in vitro in citrated plasma. These data show that both PCI and alpha 1AT are physiologic inhibitors of APC and suggest that when PCI is depleted by a high dose of APC, alpha 1AT becomes the major inhibitor of APC.

[Effect of a new 10% hydroxyethyl starch solution HES/270/0.5 on blood coagulation, blood loss and hemodynamics in comparison with 3.5% PPL]

20 patients scheduled for total hip replacement were given 1,000 ml of a new preparation of 10% hydroxyethylstarch (HES) (MW 270,000: 0.5) preoperatively. They were compared to a group of 20 patients who received 1,000 ml of 3.5% plasma protein solution (PPS). HES caused a more pronounced hemodilution than PPS. With HES, central venous pressure (CVP) rose significantly higher than with PPS. PTT was significantly prolonged in the HES but not in the PPS group. TT was significantly reduced by HES in comparison to PPS. PT (Quick-value %) and fibrinogen levels showed no difference in both groups. Blood loss and transfusion volume were comparable to HES and PPS until 24 h after the operation. One patient showed generalised flush after HES. This HES preparation is a colloid with volume-expanding properties and appears to be without clinically apparent effects on coagulation (up to a volume of 11).

Suppression of late phase enhanced vascular permeability in rats by selective depletion of neutrophils with a monoclonal antibody

We investigated the role of neutrophils in increased vascular permeability by a selective reduction of neutrophils using a monoclonal antibody, RP-3. An intraperitoneal injection of RP-3 not only selectively depleted peripheral blood neutrophils, but prevented the neutrophil infiltration to the tissues. Proteose peptone, zymosan, and BCG induced three different types of inflammatory edema, showing the early phase only, early plus late phase, and the late phase only, respectively. Only the late phase response of zymosan and BCG was inhibited by a depletion of neutrophils by RP-3, though the early phase response induced by proteose peptone and zymosan was not affected. Reconstitution of neutrophil-depleted rats by in situ injection of these cells restored the inflammatory edema induced by BCG, depending upon the number of neutrophils injected.

[Acute experimental uveitis caused by a single administration of heterologous blood protein to the vitreous body of rabbits]

The initial allergic reaction of an uveitis character was evoked by a single application of horse's serum into the rabbit vitreous. The dynamics of the development of the inflammation was observed macro and microscopically. It was stated that there exists a close correlation of the intensification of the inflammatory reaction in the macroscopic and microscopic evaluation; the microscopic changes in the eye tissues preceded the macroscopic changes and they persisted longer.

Radionuclide methodology for the assessment of the microcirculation in island pedicle flaps in a sheep model

Island pedicle flaps with a proximal well-perfused part and a distal poorly-perfused part were raised in eight anaesthetized sheep. Autologous red blood cells were labelled in vitro with 99TcmO4 and plasma with 111In chloride. The labelled cells and plasma were injected intraarterially and both dynamic and static images of the time-course of radioactivity were obtained with a gamma camera. Time activity curves were generated for selected regions of interest of the flap. For both plasma and red cells there was a substantial decline in the amount of tracer reaching the distal part of the flap; the time to maximum counts increased and the time activity curves indicated a minor uptake and almost no clearance pattern. In general there were marked local differences in the flow of plasma and red cells. The flow of plasma was more rapid than that of the red cells in five of the eight sheep. The model provides a standardized pedicle flap having a proximal part with adequate circulation and a distal part with inadequate circulation. It is concluded that this sheep model is suitable for radionuclide studies examining those factors that influence the distribution of blood flow within this tissue.

Fluid requirements of patients with burns and inhalation injuries in an intensive care unit

We have studied 9 patients with burns (20%-75%) who had inhalation injuries and compared their actual fluid requirements with their requirements calculated from the Muir and Barclay formula. All patients were resuscitated with plasma protein fraction at a rate sufficient to keep their physiological variables within the following range: heart rate less than 120/min, central venous pressure 8-12 cm H2O, urine output greater than 30-50 ml/h, systolic blood pressure greater than 90 mm Hg and diastolic blood pressure greater than 60 mm Hg. The amount of plasma protein fraction needed was 4.38 +/- 1.26 ml/kg/% burn in the first 24 h and 2.15 +/- 0.97 ml/kg/% burn in the second 24 h. This is an increase of 75% and 110% respectively above values predicted from the formula. We suggest that the observed difference is due to a combination of the presence of an inhalation injury which increases fluid requirements by approximately 30% in the first 24 h and the use of plasma protein fraction rather than the dried plasma used in the original Muir and Barclay formula.

The effects of hypoproteinemia and volume expansion on lung and soft tissue transvascular fluid filtration

Resuscitation from major trauma or replacement of major operative blood loss frequently results in varying levels of protein depletion and alterations in plasma volume. To assess the importance of these factors on pulmonary and soft tissue transvascular fluid filtration, we compared the effects of hypoproteinemia and plasma volume expansion on the rate of lung and soft tissue transvascular fluid filtration in unanesthetized adult sheep. Ten animals were surgically prepared with chronic lung and soft tissue lymph fistulas. Lung (QL) and soft tissue (Qs) lymph flow rates were used to determine changes in transvascular fluid filtration. Initially, lactated Ringer's solution (LR) was infused to elevate pulmonary arterial wedge pressure of normoproteinemic animals (Norm/LR) 5 mm Hg for 2 1/2 hours. After a plasmapheresis-induced protein depletion of 30% to 35%, similar volume expansions with LR (Hypo/LR) and fresh frozen plasma (Hypo/Plas) were performed. Plasma, lung lymph, and soft tissue lymph oncotic pressures were determined, and transvascular oncotic gradients were calculated. Plasma volume expansion during Hypo/Plas conditions limited (p less than or equal to 0.05, 3 hours after infusion) Qs elevations compared with Hypo/LR expansion. However, there appeared to be no significant advantage with fresh frozen plasma over LR infusion in limiting QL. During fresh frozen plasma infusion, a distinct 10- to 12-hour lag in protein transport into the interstitium was observed in the soft tissue but not the lung microcirculation. The resultant differences in fluid filtration properties were in part the result of significant widening of the oncotic gradient in soft tissue. Plasma protein infusion appeared not to be beneficial over LR in limiting lung transvascular fluid filtration during hypoproteinemic states but significantly decreased soft tissue transvascular fluid flux.

Biochemical reaction of alpha 1 antitrypsin during the substitution therapy of patients with homozygote PI-ZZ deficit

The homozygote deficit of alpha 1 antitrypsin (alpha 1 PI-ZZ) in patients frequently results in a premature development of emphysema in the lung due to incomplete protection against proteases. An active inhibitor substitution appears to be useful. The presented study proves the biological effect of alpha 1 antitrypsin infused into 8 patients. The results were an activity increase of leukocyte elastase and trypsin inhibition in serum as well as doubling of alpha 1 antitrypsin in sputum. This therapeutical conception (with a dose of 60 mg/kg body weight/week) results in an efficient protection. Inhibitors specific for mucosa are not influenced. An improvement of lung function during 6 weeks of intravenous therapy was not achieved. The progressive destruction of lung parenchyma can be probably prevented, however.

Biological activity of partially purified digitalis-like substance and Na-K-ATPase inhibitor in rats

In order to study the biological activity of endogenous digitalis-like substance (DLS) and Na-K-ATPase inhibitor (ATPI), human urine was partially purified and administered to rats, and its effects on the urinary volume, urinary Na excretion and blood pressure (BP) were determined. In addition, the effect on myocardial Na-K-ATPase activity was also measured. After the extraction of 40L of urine with a reversed phase cartridge column (S-fraction), 20 ml of chloroform was added and extraction was repeated. The chloroform layer was applied to an open silica gel column, and at a fraction with ethylacetate: methanol (60: 40, T-1 fraction), DLS and ATPI were eluted at the highest concentration. The water layer was treated with charcoal (D-1 fraction). The acute administration of K-1, T-1 fraction to rats in vivo caused significant rises in urinary volume, urinary Na excretion and BP. In chronic administration of K-1 fraction, urinary Na excretion was significantly elevated and myocardial Na-K-ATPase activity was also significantly suppressed. These results suggest that DLS and ATPI cause increase in the urinary volume and urinary Na excretion and also possess a hypertensive action; and moreover, these substance may affect the heart like cardiotonic steroids and regulate BP by increasing cardiac contractility.

Intravenous administration of alpha-1-proteinase inhibitor in patients of PiZ and PiM phenotype. Preliminary report

Nine patients with moderate pulmonary emphysema, six of PiZ phenotype and three of PiM phenotype, have received a single intravenous infusion of alpha-1-proteinase inhibitor (human) (A1PI), in a dose of 60 mg/kg over a 30-minute period. They also received a tracer dose (300 microCi) of 131I-labeled A1PI. No active or passive immunization against hepatitis was given. No acute toxicity was observed. Compared with baseline data, significant elevations of serum A1PI (measured both antigenically and as anti-elastase activity) occurred, with a serum half-life approximating 110 hours. Bronchoalveolar lavage fluid, obtained 48 hours after infusion, reflected a significant increase in A1PI concentration versus baseline bronchoalveolar lavage fluid values. Serial gamma camera images of the lungs confirmed persistence of enhanced lung radioactivity for several days. Urinary desmosine excretion did not change following A1PI infusion. During the period of follow-up thus far, no patient has had chronic toxicity, results of liver function tests have been stable, and there has been no development of hepatitis B antigen or antibodies to hepatitis B surface or core antigens.

Production and administration to dogs of aerosols of alpha-1-proteinase inhibitor

The feasibility of aerosol administration of alpha-1-proteinase inhibitor (human) (A1PI) was assessed. Of three different methods of aerosolizing A1PI that were evaluated, an ultrasonic nebulizer was found to be best suited to the present purpose, producing particles of a size that allowed them to reach the distal air spaces of the lung and that retained specific A1PI anti-elastase activity. Administration of 20 mg/kg of A1PI and 150 microCi of 131iodine-A1PI to three dogs was accomplished without complications. Gamma camera scans documented a relatively homogenous distribution throughout the lungs. Bronchial lavage fluid that was recovered from the lungs of the dogs six hours after administration contained large amounts of human A1PI and showed a proportional elevation of anti-elastase activity. There was no evidence of acute toxicity.

Purification of alpha-1-proteinase inhibitor. Preparation and properties of a therapeutic concentrate

Alpha-1-proteinase inhibitor (human) (A1PI) has now been prepared as a lyophilized concentrate and has been tested clinically in humans with A1PI deficiency (also called alpha-1-antitrypsin deficiency). The protein was purified from plasma (Cohn fraction IV-1) by precipitation and ion-exchange chromatography. The resulting product behaves almost indentically to the A1PI in plasma, showing that the process is gentle and nondenaturing. In order to lower the risk of transmission of disease, the product has been heat-treated. Although this resulted in some aggregation of protein, no new antigenic sites were created. Biologic, immunologic, and physiologic studies have shown that the protein behaves normally.

Inactivation of viruses in therapeutic products derived from human plasma

Alpha-1-proteinase inhibitor concentrates have been prepared from pooled human plasma for therapeutic applications. Pasteurization (60 degrees C, 10 hours) conditions have been defined to reduce risks of transmission of viral agents without significant loss of biologic activity of the purified product. Human clinical data collected to date support the model virus inactivation studies regarding viral safety.

Pulmonary penetration of alpha 1-proteinase inhibitor administered parenterally to dogs

To study the penetration of alpha 1-proteinase inhibitor (A1Pl) into the lungs of healthy dogs, 83 mg/kg of active A1Pl was administered intravenously over 30 min followed by a bolus of 131I-A1Pl. Animals were lavaged 2 to 72 h after infusion, sequential gamma camera scans were acquired, and urine was analyzed for the excretion of desmosine. After a distribution phase, infused A1Pl left the bloodstream with a half-life of 103 +/- 24 h. Analysis of plasma antiprotease activity demonstrated preservation of function of the infused A1Pl. Lavage fluid A1Pl concentration and activity were significantly increased 24 h after infusion. Gamma camera scans demonstrated that lung, liver, and spleen acquired 131I-A1Pl similarly; radioactivities per gram of tissue of these organs were similar at autopsy. Excretion of desmosine did not decrease from a baseline of 157 +/- 59 nmol/24 h after A1Pl infusion, indicating no effect of A1Pl infusion on background elastolysis. These data suggest that intravenous administration of A1Pl can raise lung antiproteinase levels within 24 h despite the absence of preferential uptake by the lung of the infused protein.

Evidence for a digitalis-like substance in the hypothalamopituitary axis in rats: implications in the central cardiovascular regulation associated with an excess intake of sodium

The origin and the physiological role of an endogenous digitalis-like substance were investigated by measuring both the digoxin-like substance by a digoxin radioimmunoassay (RIA) and the inhibitory activity on the ouabain sensitive Na+,K+-ATPase in rats. The digitalis-like substance was in high concentration in the pituitary, and in decreasing concentration in the hypothalamus, adrenal and the other organs as measured by RIA using an antibody raised from a goat. However, the adrenal showed the highest content of digitalis-like substance as measured by the antibody raised from a rabbit. The plasma level markedly decreased during a 2-week sodium-loading, and the adrenal content decreased markedly on hypophysectomy as measured with the rabbit-antibody. Therefore, the substance measured with the rabbit-antibody must be one of ACTH-dependent adrenal steroids. The inhibitory activity on the Na+,K+-ATPase was high in the pituitary gland, and was decreased in order of the adrenal, hypothalamus and other organs. The 2-week sodium-loading increased both the content in the pituitary gland and the output in the urine, and decreased the hypothalamic content. Immunohistochemical staining of the hypothalamus with the antibody revealed that the immunoreactivity is restricted to the neurons of the paraventricular nucleus, supraoptic nucleus, magnocellular accessory nuclei and extended their fibers reaching to the inner layer of the median eminence. To determine the role of the substance in the brain, the crude extract dissolved in artificial cerebrospinal fluid was injected into the lateral ventricle; vasopressor responses, tachycardia and hyperactivity of the splanchnic nerve lasting for more than 30 min were recorded, which resembled the responses to ouabain injected similarly.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intraoperative infusion therapy. Evaluation of the rate of administration and assessment of the effectiveness of infusion warmers]

A look at the efficiency of infusion warmers from the clinician's point of view must be based on the infusion rates usually necessary in the operating room. Therefore a retrospective evaluation of 1,510 anesthesia records was made in order to register the flow rate of every infusion. As a general rule the flow rate did not exceed 1.5 1/h. Our past warming apparatus was found not very effective in this range under the standard conditions of a cold operating room with laminar air flow. A new in-line warmer, fast and easy to handle, proved superior in daily use.

[Tolerance of 3.5 percent plasma protein solution]

In a prospective study we found 112 patients out of 9549 who had been given 3.5% plasma protein solution during the preceding year but no other blood derivatives and who had not received any immunosuppressive treatment. 68 patients agreed to be tested for sensitisation to 3.5% plasma protein solution. An intracutaneous test was performed as screening test. Two patients had a false positive reaction, but one of them had urticaria factitia and therefore a positive reaction to NaCl 0.9%. The other patient showed circumscribed reddening in the early phase only, whereas later readings were negative. Neither the test of total IgE by Paper Radio Immuno Sorbent Test (PRIST) nor the test for specific IgE antibodies by Radio Allergo Sorbent Test (RAST) showed any positive results. According to these findings there was no sensitisation to 3.5% plasma protein solution.

Effects of isovolemic hemodilution on abdominal aortic aneurysmectomy in high risk patients

Intraoperative isovolemic hemodilution might increase blood flow and tissue oxygenation in the periphery but there is concern that acute anemia may have deleterious effects on myocardium in patients with coronary artery disease. This study investigates the effects of intraoperative isovolemic hemodilution on morbidity, mortality and hemodynamics in 32 patients with significant cardiovascular disease undergoing elective abdominal aortic aneurysmectomy. The average hematocrit was lowered intraoperatively from 43% to 31% by withdrawing blood and replacing volumes with 1:3 Ringer's lactate. In ten patients myocardial function was evaluated during aortic cross-clamping and declamping in the face of hemodilution. There were two deaths: one myocardial infarction and one multiple organ failure. Aortic cross clamping did not change heart rate, vascular pressures (VP), vascular resistance (SVR), cardiac output (CO), and left ventricular stroke work (LVSW). Following declamping, VP, CO and LVSW decreased and SVR increased momentarily (p less than 0.05), but the myocardial function did not change. Isovolemic hemodilution had no apparent adverse effects on morbidity, mortality and cardiovascular performance in these patients.