The fibrinolytic system and thrombotic tendency

The degradation of gelatin/alginate/fibrin hydrogels is cell type dependent and can be modulated by targeting fibrinolysis

In tissue engineering, cell origin is important to ensure outcome quality. However, the impact of the cell type chosen for seeding in a biocompatible matrix has been less investigated. Here, we investigated the capacity of primary and immortalized fibroblasts of distinct origins to degrade a gelatin/alginate/fibrin (GAF)-based biomaterial. We further established that fibrin was targeted by degradative fibroblasts through the secretion of fibrinolytic matrix-metalloproteinases (MMPs) and urokinase, two types of serine protease. Finally, we demonstrated that besides aprotinin, specific targeting of fibrinolytic MMPs and urokinase led to cell-laden GAF stability for at least forty-eight hours. These results support the use of specific strategies to tune fibrin-based biomaterials degradation over time. It emphasizes the need to choose the right cell type and further bring targeted solutions to avoid the degradation of fibrin-containing hydrogels or bioinks.

A review: progress in preventing tissue adhesions from a biomaterial perspective

Postoperative adhesions (POA) are one of the main problems suffered by patients and are a common complaint. It is considered to be closely associated with the healing mechanism of damaged tissues. Tissue adhesions accompany other symptoms such as inflammation, pain, and even dyskinesia under certain conditions, compromising the patients' quality of life. On the other hand, common treatments involve high costs, re-surgery or long-term hospital stays. Therefore, alternative approaches need to be formulated so that aforementioned problems can be resolved. To this end, a review of recent advances in this context is imperative. In this review, we have highlighted the mechanism of adhesion formation, advances in common therapeutic approaches, and prospective treatments in preventing tissue adhesions. Based on the literature, it can be determined that the disadvantages of available commercial products in the treatment of tissue adhesion have led researchers to utilize alternative methods for designing anti-adhesive products with different structures such as electrospun fibrous mats, hydrogels, and nanospheres. These studies are on the fast track in producing optimal anti-adhesion materials. We hope that this article can attract attention by showing various mechanisms and solutions involved in adhesion problems and inspire the further development of anti-adhesion biomaterials.

Battling adhesions: from understanding to prevention

Adhesions represent a major burden in clinical practice, particularly following abdominal, intrauterine, pericardial and tendon surgical procedures. Adhesions are initiated by a disruption in the epithelial or mesothelial layer of tissue, which leads to fibrin adhesion sites due to the downregulation of fibrinolytic activity and an increase in fibrin deposition. Hence, the metabolic events involved in tissue healing, coagulation, inflammation, fibrinolysis and angiogenesis play a pivotal role in adhesion formation. Understanding these events, their interactions and their influence on the development of post-surgical adhesion is crucial for the development of effective therapies to prevent them. Mechanical barriers, antiadhesive agents and combination thereof are customarily used in the battle against adhesions. Although these systems seem to be effective at reducing adhesions in clinical procedures, their prevention remains still elusive, imposing the need for new antiadhesive strategies.

Identification and characterization of α1 -antitrypsin in fibrin clots

BACKGROUND AND OBJECTIVES

Preliminary studies indicated that α1 -antitrypsin (A1AT) is the most abundant protein that is non-covalently bound to fibrin clots prepared from plasma. The aim of this study was to identify and characterize fibrin(ogen)-bound A1AT.

METHODS AND RESULTS

Plasma clots were prepared and extensively washed with saline. Clot-bound A1AT could only be extracted using denaturing agents such as urea, thiourea or SDS, pointing to an apparently strong association. Purified fibrinogen, but still containing A1AT as a contaminant, was gel filtered, which showed that the A1AT was bound to fibrinogen. A specific ELISA detected the presence of A1AT-fibrinogen complexes in both purified fibrinogen and pooled normal plasma. Finally, fibrin(ogen)-Sepharose chromatography indicated that A1AT purified from plasma contained a small fraction of fibrin(ogen)-binding A1AT. To study the inhibitory activity of fibrin(ogen)-bound A1AT, both fibrinogen containing A1AT and washed plasma clots were incubated with increasing amounts of elastase. SDS-PAGE and Western blotting showed under both conditions the generation of the A1AT-elastase complex as well as cleaved A1AT. The inhibitory activity of fibrin(ogen)-bound A1AT was also demonstrated by measuring elastase-induced lysis of fibrin clots.

CONCLUSION

Fibrin clots contain strongly bound A1AT, which is functionally active as a serine protease inhibitor (serpin). This A1AT might play a role in the local regulation of proteases involved in coagulation or fibrinolysis and represent a novel link between the inflammatory and hemostatic systems.

Haemophilus influenzae uses the surface protein E to acquire human plasminogen and to evade innate immunity

Pathogenic microbes acquire the human plasma protein plasminogen to their surface. In this article, we characterize binding of this important coagulation regulator to the respiratory pathogen nontypeable Haemophilus influenzae and identify the Haemophilus surface protein E (PE) as a new plasminogen-binding protein. Plasminogen binds dose dependently to intact bacteria and to purified PE. The plasminogen-PE interaction is mediated by lysine residues and is also affected by ionic strength. The H. influenzae PE knockout strain (nontypeable H. influenzae 3655Δpe) bound plasminogen with ∼65% lower intensity as compared with the wild-type, PE-expressing strain. In addition, PE expressed ectopically on the surface of Escherichia coli also bound plasminogen. Plasminogen, either attached to intact H. influenzae or bound to PE, was accessible for urokinase plasminogen activator. The converted active plasmin cleaved the synthetic substrate S-2251, and the natural substrates fibrinogen and C3b. Using synthetic peptides that cover the complete sequence of the PE protein, the major plasminogen-binding region was localized to a linear 28-aa-long N-terminal peptide, which represents aa 41-68. PE binds plasminogen and also vitronectin, and the two human plasma proteins compete for PE binding. Thus, PE is a major plasminogen-binding protein of the Gram-negative bacterium H. influenzae, and when converted to plasmin, PE-bound plasmin aids in immune evasion and contributes to bacterial virulence.

Matrix metalloproteinase-9, -10, and tissue inhibitor of matrix metalloproteinases-1 blood levels as biomarkers of severity and mortality in sepsis

Introduction

Matrix metalloproteinases (MMPs) play a role in infectious diseases through extracellular matrix (ECM) degradation, which favors the migration of immune cells from the bloodstream to sites of inflammation. Although higher levels of MMP-9 and tissue inhibitor of matrix metalloproteinases-1 (TIMP-1) have been found in small series of patients with sepsis, MMP-10 levels have not been studied in this setting. The objective of this study was to determine the predictive value of MMP-9, MMP-10, and TIMP-1 on clinical severity and mortality in a large series of patients with severe sepsis.

Methods

This was a multicenter, observational, and prospective study carried out in six Spanish Intensive Care Units. We included 192 (125 surviving and 67 nonsurviving) patients with severe sepsis and 50 age- and sex-matched healthy controls in the study. Serum levels of MMP-9, MMP-10, TIMP-1, tumor necrosis factor (TNF)-alpha, and interleukin (IL)-10 were measured in patients with severe sepsis at the time of diagnosis and in healthy controls.

Results

Sepsis patients had higher levels of MMP-10 and TIMP-1, higher MMP-10/TIMP-1 ratios, and lower MMP-9/TIMP-1 ratios than did healthy controls (P < 0.001). An association was found between MMP-9, MMP-10, TIMP-1, and MMP-9/TIMP-1 ratios and parameters of sepsis severity, assessed by the SOFA score, the APACHE-II score, lactic acid, platelet count, and markers of coagulopathy. Nonsurviving sepsis patients had lower levels of MMP-9 (P = 0.037), higher levels of TIMP-1 (P < 0.001), lower MMP-9/TIMP-1 ratio (P = 0.003), higher levels of IL-10 (P < 0.001), and lower TNF-α/IL-10 ratio than did surviving patients. An association was found between MMP-9, MMP-10, and TIMP-1 levels, and TNF-α and IL-10 levels. The risk of death in sepsis patients with TIMP-1 values greater than 531 ng/ml was 80% higher than that in patients with lower values (RR = 1.80; 95% CI = 1.13 to 2.87;P = 0.01; sensitivity = 0.73; specificity = 0.45).

Conclusions

The novel findings of our study on patients with severe sepsis (to our knowledge, the largest series reporting data about MMP levels in sepsis) are that reduced MMP-9/TIMP-1 ratios and increased MMP-10 levels may be of great pathophysiologic significance in terms of severity and mortality, and that TIMP-1 levels may represent a biomarker to predict the clinical outcome of patients with sepsis.

An age-adapted approach for the use of D-dimers in the exclusion of deep venous thrombosis

A normal D-dimer (DD) concentration for the exclusion of deep venous thrombosis (DVT) has a low specificity in older patients and compression ultrasonography is often required. Three D-dimer assays, STA Liatest, Tina-quant, and Innovance, are evaluated in symptomatic outpatients suspected for DVT with emphasis on its performance in older patients by using different cut-off levels. This study includes 466 outpatients suspected for having DVT. The diagnostic accuracy, measured as sensitivity and area under the curve of the receiver operation characteristic curve is good for all DD assays. The specificity of the DD assays combined with a low pretest probability varies from 42.6 to 51.5%. The specificity of the three DD assays in patients > or = 60 years varies, however, between 24.6 and 40.9%. Several cut-off values in different age-subgroups are studied. For patients < 60 years, the most accurate cut-off value is 500 microg/L for all DD assays. For patients > or = 60 years, a threshold of 750 microg/L has the best results with NPV of 100% for all assays and specificity of 48.5% (STA Liatest), 60.6% (Tina-quant), and 49.2% (Innovance), respectively. For the three assays, the number needed to test (NNT) decreases in both subgroups of patients compared to the standard algorithm. A cut-off level of 750 microg/L for patients > or = 60 years improves the clinical performance of DD assays in combination with the PTP score without the loss of NPV. The NNT improves substantially with an age-adapted algorithm.

Proteolytic enzyme activity as a result of aging

BACKGROUND AND AIMS

The extracellular matrix (ECM) undergoes constant dynamic changes; proteolytic enzymes, particularly the serine proteases plasmin, trypsin and elastase, catalyze critical functions in these processes. Notably, ECM degradation disorders have been reported in various morbid conditions, including cardiac infarction, atheromatosis, and neoplastic diseases, indicating a physiological requirement for proper ECM maintenance. Here we define the role of proteolytic enzymes in the development of aging by assessing changes in proteolytic enzyme activity in serum during aging in rats.

METHODS

The activities of trypsin, elastase and plasmin in rat serum were determined by the fluorometric method using AMC-labeled substrates in 34Wistar rats divided into four age groups: 3 month-olds (n=8), 9 month-olds (n=8), 15 month-olds (n=8) and 24 month-olds (n=10).

RESULTS

Analysis of proteolytic enzyme activity in four age-dependent groups revealed that in comparison to their 3, 9, and 24 month-old counterparts, the 15 month-old rats exhibited a statistically significant increase in average elastase activity. In accordance with previous studies, a statistically significant increase in trypsin levels was found in the 3 month-old rats, suggesting that trypsin activity decreases with age. Average plasma plasmin activity in the 24 month-old rats was, moreover, statistically significantly higher than that in the other three age groups.

CONCLUSIONS

Analysis of combined proteolytic activity indicates that age-dependent patterning of blood serine protease enzyme activity may be related to age-related diseases.

Successful treatment of ligneous gingivitis with warfarin

Ligneous gingivitis is a rare condition characterized by inflammation and nodular gingival enlargement secondary to fibrin deposits in the gingival that results from plasminogen deficiency. Several therapeutic approaches have been used with limited success. We report a case of a patient with homozygous plasminogen deficiency and ligneous gingivitis that was initially refractory to local care and systemic antibiotics, but later improved with the addition of warfarin.

In vitro fibrin clot formation and fibrinolysis using heterozygous plasma fibrinogen from γAsn319, Asp320 deletion dysfibrinogen, Otsu I

INTRODUCTION

We have reported a heterozygous dysfibrinogenemia, fibrinogen Otsu I, caused by the deletion of gammaAsn319 and gammaAsp320, which was originally identified in the dysfibrinogen Vlissingen/Frankfurt IV (V/FIV) associated with thrombosis. Unlike the V/FIV family, the Otsu propositus showed no thrombotic tendencies. To analyze the relationship between thrombosis and the heterozygous plasma variant fibrinogen, we used purified plasma fibrinogen from the Otsu patient and compared it with a normal control.

MATERIALS AND METHODS

Thrombin-induced fibrin clot formation and clot structure were observed by fibrin polymerization and scanning electron microscopy, respectively. For in vitro observation of fibrinolysis, plasmin generation and clot lysis assays were performed by the addition of tissue type plasminogen activation (tPA) and plasminogen.

RESULTS AND CONCLUSIONS

Polymerization of Otsu was markedly impaired, while fibrin fibers were much thicker and the density of the bundles of fibrin fibers was less and porous compared with normal. Lysis of the Otsu clot was not significantly different from normal when a tPA and plasminogen mixture was overlaid onto the clots. For Otsu, the penetration of the tPA/plasminogen mixture into the clot was much faster than normal and the protection against plasmin cleavage was impaired; however, tPA-induced plasmin activation of the Otsu fibrin was slower than that of normal fibrin, resulting in a clot lysis of Otsu similar to normal.

Normal Clotting

OBJECTIVE

To review the normal coagulation process and the mechanisms that lead to abnormal clotting.

DATA SOURCES

Primary and tertiary literature and the authors' clinical experience.

CONCLUSION

The process of coagulation is complex and can be easily misunderstood. It is important to be familiar with normal coagulation before one can comprehend the coagulopathies associated with malignancies.

IMPLICATIONS FOR NURSING PRACTICE

A thorough understanding of the coagulation process is a critical prerequisite to caring for patients with clotting disorders. Once the normal clotting process is understood, the abnormal becomes easier to recognize and the cancer-associated dysfunctions more readily identified.