Activation of blood coagulation in Crohn's disease. Increased plasma fibrinopeptide A levels and enhanced generation of monocyte tissue factor activity

We have examined the relationships among activation of blood coagulation, generation of monocyte procoagulant activity, and clinical activity in patients with Crohn's disease. Subclinical activation of blood coagulation was measured using a radioimmunoassay for fibrinopeptide A. Fibrinopeptide A levels were strongly correlated with the level of disease activity as measured by the Crohn's disease activity index. Patients with active disease who were successfully treated either medically or surgically demonstrated a reduction of fibrinopeptide A levels. Failure of fibrinopeptide A to return to the normal range predicted an early relapse. Monocyte tissue factor generation was assessed in both unstimulated and lipopolysaccharide-stimulated mononuclear cell cultures obtained from the peripheral blood of patients with Crohn's disease. A strong correlation (r = 0.89) was observed between plasma fibrinopeptide A levels and monocyte tissue factor generation. These results suggest that monocyte procoagulant generation may contribute to the activation of blood coagulation in this inflammatory bowel disease. Moreover, fibrinopeptide A levels in Crohn's disease may provide a useful quantitative measure of inflammatory activity.

The effect of sodium warfarin on rabbit monocyte tissue factor expression

A rabbit model was developed to examine the effect of sodium warfarin on peripheral blood monocyte tissue factor (MTF) activity. After three days of treatment with sodium warfarin, MTF expression was significantly impaired (p less than 0.003). Vitamin K reversed this inhibition despite continued treatment with warfarin. Animals resistant to warfarin did not become anticoagulated and failed to demonstrate inhibition of MTF expression. Cells grown in plasma from warfarin-treated animals expressed reduced amounts of MTF activity, while cells grown in normal rabbit plasma demonstrated procoagulant activity in assays using both normal and factor VII-deficient substrate plasmas. These studies suggest that normal factor VII binds to monocytes during the culture period. Moreover, a plasma component in warfarin-treated animals, possibly abnormal factor VII, may bind to monocytes and block expression of MTF activity. This may represent another mechanism for warfarin-mediated inhibition of cell-mediated coagulation reactions in vivo.

Synthesis of PGE2, collagenase and tissue factor by fibroblast substrains: substrains are differentially activated for different metabolic products

Metabolic heterogeneity has previously been demonstrated for cloned fibroblast populations. It is unclear whether a "high producer" or "activated" phenotype for one cell product reflects general metabolic activation or whether activated phenotypes for different metabolic markers segregate independently among cloned populations. We examined human foreskin fibroblast substrains, isolated by limiting dilution cloning, for heterogeneity in biosynthesis of PGE2 and collagenase (stimulated by Interleukin 1-containing mononclear cell supernates), and tissue factor. Synthesis of these products varied 5- to 10-fold among 16 substrains isolated from two parent lines (AT and WB). Metabolic phenotypes (high versus low levels of synthesis) were stable for the substrains over multiple weeks of culture. In neither group of substrains was there a correlation between levels of stimulated PGE synthesis and stimulated collagenase synthesis (r = -0.24 and 0.29 for AT and WB substrains, respectively). Similarly, tissue factor generation did not correlate with either PGE production (r = 0.12 and -0.38 for AT and WB substrains, respectively) or collagenase synthesis (r = 0.17 and 0.21 for AT and WB substrains, respectively). The discordance between high producer phenotypes for the different products was observed even when all three products were measured in the same culture. Activated phenotypes for different metabolic markers thus appear to segregate among cells independently. The process of connective tissue activation by immune cell-derived mediators may depend on the constituent makeup of the responding connective tissue cell population.

Comparison of local versus central tumor measurements in a multicenter cancer trial

Four hundred nineteen solid tumors from 92 patients were measured by a local team consisting of a physician and nurse oncologist or physician's assistant, and centrally by one radiologist. The central radiologist also remeasured 137 tumors on 30 patients to assess intraexaminer agreement. Tumor measurements at specific points in time as well as changes in tumor measurements over time were evaluated. When signed differences were calculated, there was little overall difference between local and central examiners, although three of the eight centers did show a significant difference. However, when absolute differences were calculated, the relative errors of the width times length products ranged from 35 to 55%. Although local and central examiners agreed 75% of the time on change in disease, there was only 42% agreement on the subset of patients who had a remission. In general, the intraexaminer agreement was slightly better than the interexaminer agreement. This study suggests that solid tumor measurements are not particularly reliable, and that survival time remains the most satisfactory endpoint in a cancer clinical trial.

Pulsatile administration of GnRH for the treatment of hypogonadotrophic hypogonadism

Fourteen patients, aged 22-35 years, complaining of infertility and failing to ovulate on clomiphene, were treated with GnRH administered in pulses at 90 min intervals. Four patients received a total of eight courses of GnRH given subcutaneously and 13 were given a total of 20 months of treatment with GnRH given intravenously. Serum concentrations of immunoreactive GnRH were measured in six patients before administration of the drug and at regular intervals for 60 min after subcutaneous and intravenous injections of 5, 10 and 20 micrograms GnRH. Maximum concentrations of GnRH were reached by 5-10 min after subcutaneous injections and within 2 min after intravenous injections. The peak concentrations were 3.6-6.3 times and the sums of increments were 2.0-3.9 times greater following intravenous injections than after subcutaneous injections. Subcutaneous treatments extended for 15-29 days with doses of 5-20 micrograms per pulse. Only one patient ovulated as judged by the luteal phase progesterone and ultrasonic scanning of the follicle. Intravenous treatments were from 12-22 days with doses of 10 micrograms per pulse and 16 treatments out of 20 were ovulatory with four pregnancies. HCG (5000 i.u.) was given when ultrasonic scanning indicated adequate follicular growth, but in eight of the cycles, including three of the pregnancies, the follicle had ruptured before HCG was given. Pulsatile administration of GnRH proved to be an effective treatment for infertility in hypogonadotrophic hypogonadism. Possible reasons for the better results by intravenous rather than subcutaneous injections are discussed.

The effect of serum on monocyte tissue factor generation

Human monocytes generate the procoagulant tissue factor (MTF) following exposure to a variety of immune stimuli in vitro. The generation of MTF is modified by T cells, lymphokines, and immunoregulatory lipoproteins, and recent studies have shown that MTF can be activated in an immune-specific manner following exposure to antigen. We have examined the role of serum factors in the regulation of MTF generation. Low concentrations (less than 1%) of heat-inactivated normal human serum greatly enhanced MTF generation in cultures of normal peripheral blood mononuclear cells. The stimulatory effect was observed in cultures of both unstimulated cells and cells exposed to bacterial lipopolysaccharide. Stimulation was not observed at high serum concentrations (greater than 10%) and could not be explained by endotoxin contamination or activation of the assay system. Stimulatory activity was present in plasma and BaSO4-adsorbed plasma as well as autologous and allogeneic serum, was not abolished by removal of serum lipoproteins, and did not require the presence of T cells for its expression. Sera from 28 different normal volunteers were screened for stimulatory activity and demonstrated a wide variation in potency. These results suggest that a potent factor is present in sera that enhances the expression of MTF activity in vitro. This factor is distinct from previously described lipoprotein regulators and may play a role in the initiation of coagulation in both normal hemostasis and pathologic states.

Lipolytic Activity During Storage of Human Milk: Accumulation of Free Fatty Acids 1

Lipolysis was quantitated during storage of fluid and freezedried human whole and skim milks. Fatty acid accumulation was faster in whole fluid milk stored for 1 week at 4°C than in frozen (-20°C) samples stored for 180 d. The rapid accumulation of fatty acids during 24 h of storage at 4°C was enhanced in previously frozen milk samples. While freeze-dried whole milk showed no lipolysis when stored at -20°C, accumulation of free fatty acids was rapid in samples stored at room temperature. Fluid and freeze-dried skim milk samples exhibited no appreciable lipolysis.

Molecular structure of 5,10-dimethoxybenzo[j]fluoranthene

The molecular and crystal structure of the synthetic 5,10-dimethoxy derivative of the carcinogen benzo[j]fluoranthene has been determined by direct methods from X-ray diffractometric data and refined to an R index 0.041 over 2788 independent reflections. The benzo ring is inclined at approximately 3 degrees to the almost planar fluoranthene moiety (carbon atoms have r.m.s. deviation of 0.02 A from the carbon-atom plane); the methoxy carbon atoms lie within 0.2 A of the molecular plane. Corresponding bond lengths (e.s.d. 0.004 A for carbon-oxygen and carbon-carbon) and angles lie within 3 sigma for the two independent molecules, with mean dimensions of methoxy groups: C-C = 1.422, C-O = 1.372 A, C-O-C = 117.4 degrees.

Safety of influenza vaccination in adults with asthma

The results of a study to investigate whether influenza vaccination produces symptoms or exacerbations in adults with asthma are reported. Twenty-eight subjects with asthma were followed up over three-week periods, during which they received both influenza vaccinations and placebo injections. Subjective assessment of asthma symptoms and objective assessment of bronchoconstriction by means of peak expiratory flow rate measurements were carried out each day. No evidence for the asthmagenicity of influenza vaccination was found. The relevance of this finding in the assessment of patients for influenza vaccination is discussed.

Effect of warfarin anticoagulation on survival in carcinoma of the lung, colon, head and neck, and prostate. Final report of VA Cooperative Study #75

VA Cooperative Study #75 was established to test in a controlled, randomized trial the hypothesis that warfarin anticoagulation would favorably affect the course of certain types of malignancy. No differences in survival were observed between warfarin-treated and control groups for advanced non-small cell lung, colorectal, head and neck and prostate cancers. However, warfarin therapy was associated with a significant prolongation in the time to first evidence of disease progression (P = 0.016) and a significant improvement in survival (P = 0.018) for patients with small cell carcinoma of the lung, including the subgroup of patients with disseminated disease at the time of randomization (P = 0.013). A trend toward improved survival with warfarin treatment was observed for the few patients admitted to this study with non-small cell lung cancer who had minimal disease at randomization. These results suggest that warfarin, as a single anticoagulant agent, may favorably modify the course of some, but not all, types of human malignancy, among which is small cell carcinoma of the lung. Further trials of warfarin may be indicated in patients with limited disease who have cell types that failed to respond when advanced disease was present.

Accrual of patients into a multihospital cancer clinical trial and its implications on planning future studies

Little information exists on the population of cancer patients from which individual patients are selected for admission to a clinical trial. In fact, most reports of clinical trials of cancer chemotherapeutic agents begin by describing samples of treated patients but neglect to collect data and describe the population from which the samples were taken. In a multi-institutional VA Cooperative Study in which two different cancer treatments were compared, an attempt was made to screen all lung, colorectal, prostate, and head and neck patients seen at participating hospitals prior to randomization to a therapeutic regimen. Of a total of 2687 patients screened, 437 (16.3%) were randomized and 2250 (83.7%) were excluded for 2981 reasons. Protocol reasons were the basis for 68.6% of all exclusions, 21.3% were physician refusals, and 10.1% were patient refusals. The number of patients randomized did not correlate well with number of patients screened across participating centers. Patients admitted to the study tended to be younger and in better health than excluded patients. Overestimates of randomization rates projected initially from published information point to the need for improved screening data in the planning of future studies. Factors such as screening methods, physician acceptance of the experimental approach, number of competing protocols within each center, and cooperation among medical center departments and personnel all are important ingredients in any screening effort.

Review of 59 patients with hypergonadotrophic amenorrhoea

Fifty-nine patients presented with elevated concentrations of gonadotrophins and secondary amenorrhoea before the age of 35 years. Fifty-three underwent laparoscopic examination and primordial follicles were observed in 16. Two others had follicles as they later became pregnant and a third showed biochemical evidence of spontaneous ovulation. There were streak ovaries in 12, two with follicles and three others with chromosomal abnormalities, two being 47XXX and one XO/XX. Two other patients had only one ovary each but no follicles. Chromosomal abnormalities were detected in two further patients one being XO/XX and the other a recombinant. Six patients became pregnant, two of them twice, resulting in four term deliveries and four spontaneous abortions. Three other patients showed biochemical evidence of ovulation; one spontaneously, one after oestrogen therapy and the third after treatment with gonadotrophin releasing hormone analogue.

Lipolytic Activity During Storage of Human Milk: Stability of the Bile Salt-Stimulated Lipase 1

Bile salt-stimulated lipase activity was monitored in fresh human milk and skim milk during refrigerated (4°C) and frozen (-20°C) storage, and in the lyophilized milks stored at -20°C and at room temperature. Following a sharp initial drop to approximately 77% of the original lipase activity, lipase was relatively stable in frozen or freeze-dried milks during 180 d of storage at -20°C. Activity losses were greatest (P < .05) in freeze-dried whole milks and skim milks stored at room temperature, approximating a 30% loss during 30 d of storage. Lipase activity was stable during refrigerated (4°C) storage of whole milk for 1 week.

Luteinizing hormone releasing hormone analogue in treatment of hypergonadotrophic amenorrhoea

The effect of a luteinizing hormone releasing hormone analogue (HOE 766) was studied in four patients with hypergonadotrophic amenorrhoea (resistant ovary syndrome). After an initial phase of stimulation, there was a uniform and sustained suppression of gonadotrophin concentrations in all the patients during the 20-24 days of treatment, presumably due to down-regulation of the pituitary receptors. One patient ovulated after stopping treatment.

Expression of procoagulant activity in a human monocyte-like cell line

Peripheral blood monocytes generate the potent membrane-bound procoagulant TF in response to a number of immune-related stimuli. Although the contribution of the monocyte/macrophage and its soluble mediators to the immune response has been recognized, the role of macrophage procoagulant in the pathogenesis of this response is less certain. Previous studies have suggested that MTF generation is important in the pathogenesis of fibrin deposition in the inflammatory response. In order to pursue this relationship, we have studied the activation of a procoagulant in a human monocyte-like cell line, the U937. The U937 procoagulant has been characterized as TF by the following criteria: the PCA requires factors VII and X for expression; the PCA is not due to serine protease activity; PCA is neutralized by a monospecific antibody to purified bovine TF. The expression of TF in these cells was amplified after stimulation with LPS, a potent activator of peripheral blood MTF expression, and was inhibited by actinomycin D and cycloheximide. Cytosine arabinoside, an inhibitor of cell division, failed to affect U937 TF generation. The U937 cell line appears to be a useful in vitro model for the study of the activation of MTF.

Abnormalities of blood coagulation in patients with cancer. Fibrinopeptide A generation and tumor growth

Fibrinopeptide A (FPA) levels have been followed sequentially in a three-year study of 50 patients with advanced carcinoma. Evidence for activation of blood coagulation was found in 26 of 43 subjects (60%) at the time of entry into the study. Serial FPA determinations revealed an upward trend which paralleled the progression of clinical disease. Persistent elevation of the FPA level suggested treatment failure and a poor prognosis. Anticoagulation with sodium warfarin significantly reduced the FPA level in subjects with cancer. Short-term anticoagulation with heparin decreased FPA levels in two patients with thromboembolic disease but failed to reduce FPA to the normal range in any of the three patients with cancer so tested. These data suggest that most patients with advanced cancer have evidence for activation of blood coagulation and suggest that serial FPA determinations may be useful in following tumor progression or response to therapy in patients with cancer.

Trenbolone, estradiol-17 beta and estrone levels in plasma and tissues and live weight gains of heifers implanted with trenbolone acetate

Twenty-four heifers were allotted into three groups of eight heifers each and designated control, long-term (LT) or short-term (ST). Animals in the latter two groups were implanted in the ear with 300 mg trenbolone acetate (TBA) for 99 or 62 d, respectively. Four heifers in each group were subjected to liver and fat biopsy 60 d after initiation of the experiment. At slaughter, which occurred 15 d after retrieval of the implant, liver and fat were also collected. The implant was analyzed for residual trenbolone (TBOH), and tissues were analyzed for TBOH and estradiol-17 beta (E2 beta). Blood samples were taken weekly after implantation and daily for 14 d before and after implantation. All heifers were weighed weekly. The ST heifers gained faster (P less than .05) than the control or the LT heifers, whereas the LT heifers gained similarly to the controls. Plasma levels of TBOH rose to over 900 pg/ml in response to the implantation in both treated groups, but stabilized at a lower level in the ST group than in the LT group. In both groups plasma E2 beta rose to over 7.5 pg/ml in response to TBA implantation; in fact, a regression analysis of E2 beta on TBOH in individual cows showed that the two hormones varied directly. Fat and liver accumulated substantial TBOH during implantation, but it cleared rapidly during the 15 d withdrawal period. Indications from this experiment are that TBA has promise for promoting rate of gain and efficiency of feed utilization in feedlot heifers. No undesirable effects on carcass quality were detected. The drug cleared blood and tissues rapidly after the implant was withdrawn. Further research is needed to determine the most effective implantation schedule. It would be desirable to determine whether a positive response to TBA will occur in animals being finished predominantly on forages.

Mononuclear cell modulation of fibroblast procoagulant activity

The release of procoagulant material by connective tissue cells as a sequel to cell injury can initiate blood coagulation and may thus play a role in he pathogenesis of inflammatory lesions. Human foreskin fibroblasts were shown to synthesize high levels of the procoagulant TF in vitro. Generation of TF by fibroblasts was inhibited by addition of supernatants of PHA-stimulated human mononuclear cells to fibroblast cultures. The inhibition was independent of supernatant effects on cellular proliferation and was accompanied by up to a 20-fold increases in PGE2 synthesis in the fibroblast cultures. The inhibition of TF generation by MC-SNs was reversed by adding indomethacin to the fibroblast cultures, suggesting that mononuclear cells suppress fibroblast TF generation by stimulation of endogenous fibroblast synthesis of prostaglandin. Regulation of fibroblast PCA by products of immune cells may be important in the pathogenesis of inflammatory lesions.

Abnormalities of blood coagulation in patients with cancer. Mononuclear cell tissue factor generation

Activation of blood coagulation, as characterized by the occurrence of disseminated intravascular coagulation, increased levels of plasma FPA, and the local deposition of fibrin, is common in both experimental animals and patients with malignant tumors. Many mechanisms have been proposed for the mediation of this response to tumors, including tumor-associated proteases, platelet adherence to tumors, surface activation of blood coagulation by tumor cells, and activation of coagulation by tissue factor derived from either tumor tissue or reactive leukocytes. We have investigated the hypothesis that MTF generation may contribute to increased fibrin generation in cancer patients. Plasma FPA levels and in vitro unstimulated MTF generation were measured simultaneously in samples obtained from 35 patients with lung cancer. FPA levels were significantly elevated in these patients as compared to a group of 20 normal volunteers (p = 0.03). Although unstimulated MTF generation showed considerable variability in both the patients and the normal volunteers, a high degree of correlation was observed between simultaneous levels of FPA and MTF regardless of whether MTF was expressed per cell (r = 0.83), per monocyte (r = 0.95), or per volume of peripheral blood (r = 0.96). MTF generation was also significantly decreased in a group of patients receiving sodium warfarin (p less than 0.001). These results suggest a potential role for MTF generation in the activation of blood coagulation in neoplasia and also suggest the possibility that inhibition of MTF generation by warfarin may be partially responsible for the decreased FPA values previously reported in anticoagulated cancer patients.

Studies on a circulating anticoagulant in procainamide-induced lupus erythematosus

Circulating anticoagulant activity that had at least two distinct mechanisms--one directed against factor XII and one directed against blood thromboplastin (prothrombin activator complex)--developed in a patient with clinical and laboratory evidence of procainamide hydrochloride-induced systemic lupus erythematosus. The anticoagulant activity behaved as a gamma-globulin in chromatographic and electrophoretic analyses, with the majority of activity behaving as an IgM immunoglobulin. Despite markedly abnormal coagulation study results, no clinical bleeding occurred. Anticoagulant activity paralleled clinical and laboratory evidence of the inflammatory disease and improved on discontinuance of procainamide therapy.