Haemophiliac hands--a three year follow-up study

The total absence of literature regarding the affects of haemophilia on the hand prompted this three year study at the Israel National Haemophilia Centre. The hands of all haemophiliacs were examined and X-rayed at the time of their annual check-up. Apart from a number of established Volkmann's contractures in elderly patients and multiple bone cysts of the carpus, surprisingly little pathology was found. When considering the extensive damage done to the musculoskeletal system by this haemarthritic pathogenesis it is astounding how the hand, with its multiple small joints, constant movement and trauma, escapes significant damage.

Angio-immunoblastic lymphadenopathy: a case with a 17-year follow-up

A case of angioimmunoblastic lymphadenopathy with a 17-year follow-up is reported. The patient, who first presented with benign hypergammaglobulinaemic purpura of Waldenstrom and autoimmune haemolytic anaemia appears to be the longest survivor with this condition reported so far.

The marked variations in the clinical course of patients with angio-immunoblastic lymphadenopathy in conjunction with immunological characteristics are discussed.

Ilio-psoas hematoma--its detection, and treatment with special reference to hemophilia

Pain around the hip joint and femoral neuropathy in a patient with a bleeding coagulopathy should alert the physician to the possibility of an iliopsoas haematoma. Unfortunately this diagnosis is often missed. Clinically, reduced hip motion, a mass in the iliac fossa and alteration in the motor and sensory function of the femoral nerve may be noted. If the pain is on the right side, appendicitis must be excluded. Ultrasound is the diagnostic aid of choice, being more sensitive than computerized tomography or radioisotope investigations. Treatment should be gradual, gentle and protracted to avoid recurrent bleeding episodes.

Definition of the population at risk of bleeding due to factor XI deficiency in Ashkenazic Jews and the value of activated partial thromboplastin time in its detection

The previously found high gene frequency of hereditary Factor XI deficiency among Ashkenazic Jews, and the risk of bleeding following trauma in this disorder, prompted us to define the population at risk of bleeding and to evaluate the activated partial thromboplastin time (APTT) as a screening test for its detection. The APTT values of 30 patients with severe Factor XI deficiency (0 to 0.14 unit/ml) overlapped only minimally with the APTT of 56 healthy subjects with Factor XI levels greater than 0.5 unit/ml. In contrast, APTT values of partially deficient patients (Factor XI: 0.15 to 0.49 unit/ml) overlapped substantially with the APTT values of the healthy subjects. However, when only subjects at risk of bleeding were considered (Factor XI less than 0.3 unit/ml), the overlap of APTT values was much smaller. The apparent frequency of this population at risk in the general Ashkenazic population was found to be 3.05%. If a cutoff point of an APTT value at the 80th percentile of the normal range is taken for detection of subjects belonging to this group, one will miss only 4.4% of these cases, with confidence limits of 0.1 to 21%.

Activation of human factor VII in plasma and in purified systems: roles of activated factor IX, kallikrein, and activated factor XII

Factor VII can be activated, to a molecule giving shorter clotting times with tissue factor, by incubating plasma with kaolin or by clotting plasma. The mechanisms of activation differ. With kaolin, activated Factor XII (XII(a)) was the apparent principal activator. Thus, Factor VII was not activated in Factor XII-deficient plasma, was partially activated in prekallikrein and high-molecular weight kininogen (HMW kininogen)-deficient plasmas, but was activated in other deficient plasmas. After clotting, activated Factor IX (IX(a)) was the apparent principal activator. Thus, Factor VII was not activated in Factor XII-,HMW kininogen-, XI-, and IX-deficient plasmas, but was activated in Factor VIII-, X-, and V-deficient plasmas. In further studies, purified small-fragment Factor XII(a) (beta-XII(a)), kallikrein, and Factor IX(a) were added to partially purified Factor VII and to plasma. High concentrations of beta-XII(a) activated Factor VII in a purified system; much lower concentrations of beta-XII(a) activated Factor VII in normal plasma but not in prekallikrein or HWM kininogen-deficient plasmas. Kallikrein alone failed to activate partially purified Factor VII but did so when purified Factor IX was added. Kallikrein also activated Factor VII in normal, Factor XII-, and Factor IX-deficient plasmas. Purified Factor IX(a) activated partially purified Factor VII and had no additional indirect activating effect in the presence of plasma. These results demonstrate that both Factor XII(a) and Factor IX(a) directly activate human Factor VII, whereas kallikrein, through generation of Factor XII(a) and Factor IX(a), functions as an indirect activator of Factor VII.

Detection of Haemophilia A carriers by replicate factor VIII activity and factor VIII antigenicity determinations

Factor VIII (fVIII) activity and antigenicity were determined on replicate fresh blood samples drawn on three separate occasions in 48 normal females and 37 obligatory haemophilia A carriers, in an attempt to improve the detection rate. fVIII activity was assayed by a one-stage method and fVIII antigenicity by the Laurell's technique employing an anti-fVIII antiserum prepared in rabbits. The mean results for the individual subjects were analysed after establishing a discriminant function. The probability of being a carrier was determined on the basis of laboratory data and family history. The probability data were translated into more simple terms applicable for genetic counselling by defining three categories: Definite carriers, doubtful carriers and definite normals. Of the obligatory carriers, 83.8% were classified definite carriers, 13.5% doubtful carriers and 2.7% as definite normals. Of the normal females, 4.2% were classified as definite carriers, 18.7% doubtful carriers and 77.1% as definite normals. Adjustment of the results according to age was found unnecessary. The precision of the determinations of fVIII antigenicity and fVIII activity in individual subjects was calculated for different numbers of replicate tests performed in the same individual. It was found that if only one test is performed, a substantial error might occur. Three replicate tests considerably diminish this error, although it is still in the range of +/- 16--29%. For suspected carriers who fall in the doubtful category it is suggested that six or even more tests are performed.

Presence of Activated Factor VII in Factor IX Concentrates and its Persistence in the Circulation After Infusion

Six brands of Factor IX concentrates were evaluated for their Factor VII content and for the presence of activated Factor VII through use of a coupled amidolytic assay, insensitive to activated Factor VII, and a clotting assay, sensitive to activated Factor VII. The Factor VII content of the concentrates studied (except for one concentrate purposely produced to exclude Factor VII) varied between 33 to 621 U per vial. All concentrates contained activated Factor VII, as indicated by ratios of Factor VII clotting activity to Factor VII amidolytic activity of from 1.6 to 21.5. Higher ratios were found in two brands of activated concentrates than in non-activated concentrates. In 10 patients infused with Factor IX concentrates, plasma Factor VII activity rose strikingly in the clotting assay but not in the amidolytic assay. Thus, the elevated Factor VII levels by the clotting assay after infusion of Factor IX concentrates stem from circulating activated Factor VII. A mean intravascular half-disappearance time of 144 min was found for activated Factor VII. Its persistence in the circulation makes it important to evaluate the possible role of activated Factor VII in the thrombogenicity of Factor IX concentrates and in their reported effectiveness in treating bleeding in Hemophilia A patients with inhibitors.

Mechanisms of Human Blood VII Activation in Plasma During Contact Activation, Clotting and Exposure to Cold

Factor VII(VII) is activated, giving shorter clotting times with tissue factor, when plasma is exposed to kaolin, is clotted or exposed to cold. The mechanisms involved were studied. Incubation of plasma with kaolin resulted in: No activation in XII deficiency plasma (dp), partial activation (2.5 fold) in Prekallikrein (PK) dp and High Molecular Weight Kininogen (HMWK) dp, and 4.5-9 fold activation in normal or other dp. Clotting plasma by recalcification resulted in: No activation with XII dp, HMWK dp, XI dp and IX dp, and 4-5 fold activation with VIII dp, X dp and V dp. The mechanism of cold promoted activation of VII in plasma was studied by adding purified 125-XII or 125I-IX to plasma before storage at 4° and observing the extent of their proteolysis (a measure of activation) from their radioactivity profiles on reduced Polyacrylamide gels following electrophoresis in the presence of SDS. Significantly greater 125I-IX and 125I-XII proteolysis was observed in plasma from 4 subjects whose VII activated in the cold, than in plasma from 5 subjects whose VII was not activated in the cold. Addition of anti-IX antiserum inhibited 50% of the observed cold activation of VII. Thus, with kaolin XIIa was the principal activator of VII; after clotting IXa was the principal activator and in cold activation both XIIa and IXa played roles.

Coupled amidolytic assay for factor VII: its use with a clotting assay to determine the activity state of factor VII

A coupled amidolytic assay for factor VII (VII) has been developed that when used with a clotting assay for VII enables detection of activated VII. In the assay, VII in a test material determines generation of factor Xa in a mixture of purified factor X, tissue factor, and calcium; factor Xa is measured with a chromogenic substrate. Factor VII activity in the coupled amidolytic assay (VIIam) correlated well with VII activity in a one-stage clotting assay (VIIc) in 57 healthy subjects, 5 patients with hereditary VII deficiency, and 11 patients with liver disease. Activation of plasma VII by kaolin, clotting, or cold strikingly increased VIIc but not VIIam levels. Thus the ratio VIIc/VIIam (VII activity ratio) is a measure of VII activation. In 27 warfarin-treated patients the mean VII activity ratio was significantly decreased, reflecting a greater decline in VIIc than in VIIam. This probably stems from partially carboxylated VII being able to act during the 3-min incubation of the amidolytic assay but unable to act rapidly enough to affect the clotting assay. Measurement of VIIc/VIIam should enable evaluation of the activity state of VII in thrombotic disorders and in components for transfusion therapy.

Factor XI deficiency: detection and management during urological surgery

Hereditary factor XI deficiency may remain undiagnosed until severe bleeding is observed after an operation or trauma. Two such cases were encountered and, therefore, a regular screening test for coagulation disorders among urological patients was initiated. During 2 years (1975 and 1976) 10 additional cases of factor XI deficiency were detected: 5 severe and 5 partial. All patients were Ashkenazic Jews of Eastern European origin. The 5 patients with severe factor XI deficiency underwent an operation without any complications. They were transfused with 5 to 20 ml./kg./day of fresh frozen plasma from the day before the operation until 10 to 14 days postoperatively. Of the 5 patients with partial XI deficiency 4 underwent an operation. In 1 of 3 patients who did not receive transfusions postoperative bleeding was observed. A minimal level of 0.3 U./ml. (30 per cent) factor XI was found necessary to ensure good hemostasis during and after an operation. In view of a recent finding of relatively high gene frequency of factor XI deficiency in Ashkenazic Jews it seems warranted to do a partial thromboplastin time in such patients who need an operation.

Clinical and laboratory aspects of disseminated intravascular coagulation (DIC): a study of 118 cases

The medical records of 118 cases who met laboratory criteria of DIC were studied. The most frequent etiologies were: Generalized infection (39.8%), trauma (16.9%), malignancy (6.8%) and surgical cases (6.8%). The main clinical manifestations which appeared to be related solely to DIC were (in a decreasing order of frequency): Bleeding (64.4%), renal dysfunction (24.6%), liver dysfunction (18.6%), respiratory dysfunction (16.1%), shock (14.4%), thromboembolic phenonmena (6.8%) and central nervous system involvement (1.7%). In 26 patients none of these manifestations were observed. In patients with infection, liver and renal dysfunction were frequent and respiratory dysfunction rare, whereas in trauma cases, liver and renal dysfunctions were rare and respiratory dysfunction frequent. This variability indicates that the clinical manifestations are affected not only by the process of intravascular coagulation but also by the underlying clinical disorders. The most impaired coagulation tests were prothrombin time, partial thromboplastin time, platelet count and thrombin time. The degree of abnormality of these coagulation tests was found to be related to the extensiveness of organ involvement. The mortality (overall 54.7%) increased independently with age, with the number of clinical manifestations and with the degree of abnormality of the above-mentioned four most impaired coagulation tests. In addition, older patients were more likely to have an increased number of clinical manifestations and more impaired coagulation tests. Mortality was similar in the various etiologies except for trauma patients in whom it was lower (30%).

Immunological studies in combined factor V and factor VIII deficiency

Plasma samples from patients with inherited combined factor V and factor VIII deficiency were examined by immunological methods for the presence of factor V and Factor VIII-related antigens. A factor V-related antigen was consistently demonstrated in all plasma samples by inhibitor neutralization assay using a non-precipitating rabbit antibody. Factor VIII-related antigens were detected by inhibitor neutralization using human antibody and by electroimmunoassay using a precipitating rabbit antibody. The amounts of factor V and factor VIII-related antigens present in the patient's samples were similar to those found in normal human plasma. The findings confirm the presence of normal levels of factor VIII-related antigen in the plasma of these patients and suggest that inactive antigenic determinants of procoagulant factor V and procoagulant factor VIII are also present. The results are consistent with the possibility that a common precursor of porcoagulant factor V and factor VIII is defective in these patients.

The Dubin Johnson syndrome and pregnancy

A recent summary of the scanty information about Dubin Johnson Syndrome (DJS) and pregnancy suggests that DJS is accompanied by excessive fetal mortality. This impression could not be corroborated by this study. A fetal mortality of 16% was observed in 75 pregnancies in 18 DJS patients. This value was not significantly different from the 10% mortality observed in 81 pregnancies in 15 matched control subjects. Jaundice was accentuated in 54% of pregnancies in the DJS patients and its time of onset was variable. In 6 instances jaundice was observed only following delivery.

Clinical and genetic aspects of Glanzmann's thrombasthenia in Israel: report of 22 cases

Twenty two patients (12 males and 10 females) from all over Israel fulfilled the criteria for establishing the diagnosis of Glanzmann's thrombasthenia. All have been observed to have a servere bleeding tendency since infancy or early childhood. In 8 out of 10 adult patients (7 females and 3 males) the bleeding manifestations have persisted over the years. In 2 adult patients major surgery was performed under platelet transfusions which appeared to prevent excessive bleeding. Pedigree analysis was possible for 21 patients who belong to 13 unrelated kindreds. Twelve kindreds are Jewish and one is Arab. Eleven of the 12 Jewish kindreds belong to the Iraqi Jewish community. Analysis of 16 sibships disclosed a corrected segregation ratio of 0.2, which is compatible with an autosomal recessive mode of inheritance. No bleeding manifestation whatsoever were observed in 30 obligatory carriers of thrombasthania, and the haemostatic functions tested in 12 of them were entirely normal.

Effects of ADP and ATP on bovine fibrinogen- and ristocetin-induced platelet aggregation in Glanzmann's thrombasthenia

With thrombasthenic platelets, aggregation induced by ristocetin (R) and bovine fibrinogen (BF) is reversible, provided ATP is not added to the system. ADP inhibits BF and R induced aggregation, and when added after the onset of aggregation causes rapid disaggregation. ATP prevents these inhibitory and disaggregation effects of ADP. A mechanism is suggested whereby co-operative effects occur between receptors in the membranes of thrombasthenic platelets.