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Janjetovic S, Holstein K, Dicke C, Bokemeyer C, Langer F. Apixaban for the Treatment of Chronic Disseminated Intravascular Coagulation: A Report of Two Cases. Hamostaseologie 2018; 39:294-297. [PMID: 30453340 DOI: 10.1055/s-0038-1675386] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Characteristic features of disseminated intravascular coagulation (DIC) are the opposing risks of bleeding (due to consumptive coagulopathy and hyperfibrinolysis) and organ failure (due to widespread microvascular thromboses). The purpose of anticoagulation in DIC is to attenuate excessive thrombin generation and fibrin deposition. While heparins have been shown to be beneficial in this context, the safety and efficacy of direct oral anticoagulants have not yet been sufficiently addressed. Here, we report two patients in whom chronic DIC was stabilized upon administration of apixaban: an elderly male with aortic dissection presenting with significant mucocutaneous bleeding and a younger female with Klippel-Trénaunay-Weber syndrome presenting with multiple superficial vein thromboses (SVTs). In addition to an improvement in DIC parameters, both patients benefited clinically with resolution of bleeding symptoms and prevention of further SVTs, respectively. Oral apixaban thus showed promising safety and efficacy in the management of DIC caused by vascular abnormalities; still further investigations are needed to support these findings.
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Affiliation(s)
- Snjezana Janjetovic
- Department of Oncology and Hematology, BMT with Section of Pneumology, Hubertus Wald Tumorzentrum - University Cancer Center Hamburg, University Medical Center Eppendorf, Hamburg, Germany
| | - Katharina Holstein
- Department of Oncology and Hematology, BMT with Section of Pneumology, Hubertus Wald Tumorzentrum - University Cancer Center Hamburg, University Medical Center Eppendorf, Hamburg, Germany
| | - Christina Dicke
- Department of Oncology and Hematology, BMT with Section of Pneumology, Hubertus Wald Tumorzentrum - University Cancer Center Hamburg, University Medical Center Eppendorf, Hamburg, Germany
| | - Carsten Bokemeyer
- Department of Oncology and Hematology, BMT with Section of Pneumology, Hubertus Wald Tumorzentrum - University Cancer Center Hamburg, University Medical Center Eppendorf, Hamburg, Germany
| | - Florian Langer
- Department of Oncology and Hematology, BMT with Section of Pneumology, Hubertus Wald Tumorzentrum - University Cancer Center Hamburg, University Medical Center Eppendorf, Hamburg, Germany
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Garralda E, van Hoef M, Ochsenreither S, Gianni L, Lorusso D, Fiedler W, Keilholz U, Klinghammer K, Dicke C, Kebenko M, Matos I, Tabernero J, Raspagliesi F, Del Conte G, Habel B, Baumeister H, Zurlo A. The GATTO study: A phase I of the anti-EGFR tomuzotuximab (TO) in combination with the anti-MUC1 gatipotuzumab (GAT) in patients with EGFR positive solid tumors. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy292.131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Ochsenreither S, Keilholz U, Klinghammer KF, Dicke C, Kebenko M, Garralda E, Tabernero J, Matos I, Lorusso D, Raspagliesi F, Gianni L, Del Conte G, Habel B, Baumeister H, Belli R, Zurlo A, Fiedler WM. The GATTO study: A phase I of the anti-MUC1 Gatipotuzumab (GAT) in combination with the anti-EGFR Tomuzotuximab (TO) in patients with EGFR positive solid tumors. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.tps2596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | - Christina Dicke
- University Medical Center Hamburg-Eppendorf, Hubertus-Wald University Cancer Center, Hamburg, Germany
| | - Maxim Kebenko
- University Medical Center Hamburg-Eppendorf, Hubertus-Wald University Cancer Center, Hamburg, Germany
| | - Elena Garralda
- Medical Oncology Department, Vall d’Hebron University Hospital; Molecular Therapeutics Research Group, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | | | - Ignacio Matos
- Vall d'Hebron UNiversity Hospital and Institute of Oncology (VHIO), Barcelona, Spain
| | | | | | | | | | | | | | | | | | - Walter M. Fiedler
- University Medical Center Hamburg-Eppendorf, Hubertus-Wald University Cancer Center, Hamburg, Germany
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Dicke C, Langer F. Pathophysiology of Trousseau’s syndrome. Phlebologie 2018. [DOI: 10.1055/s-0038-1639387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
SummaryClinically relevant clotting abnormalities in cancer patients are referred to as Trousseau’s syndrome. While thrombotic complications such as venous thromboembolism are most frequent in every day’s practice, cancer patients may also experience severe bleeding symptoms due to complex systemic coagulopathies, including disseminated intravascular coagulation, haemolytic thrombotic microangiopathy, and hyperfibrinolysis. The pathophysiology of Trousseau’s syndrome involves all aspects of Virchow’s triad, but previous basic research has mainly focused on the cellular and molecular mechanisms underlying blood hypercoagulability in solid cancers and haematological malignancies. In this regard, over-expression of tissue factor (TF), the principal initiator of the extrinsic coagulation pathway, by primary tumour cells and increased shedding of TF-bearing plasma microparticles are critical to both thrombus formation and cancer progression. However, novel findings on intrinsic contact activation in vivo, such as the release of polyphosphates or DNA by activated platelets and neutrophils, respectively, have pointed to additional pathways in the complex pathophysiology of Trousseau’s syndrome.
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Beckmann L, Dicke C, Spath B, Lehr C, Sievers B, Klinke A, Baldus S, Rudolph V, Langer F. Myeloperoxidase Is a Negative Regulator of Phospholipid-Dependent Coagulation. Thromb Haemost 2017; 117:2300-2311. [PMID: 29212118 DOI: 10.1160/th17-04-0266] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Myeloperoxidase (MPO) is a cationic heme enzyme stored in neutrophilic polymorphonuclear leukocytes (PMNs) that has recently been implicated in inflammatory cell signaling and tissue damage. Although PMNs play a critical role in both innate immunity and vascular thrombosis, no previous study has systematically investigated the effect of MPO on blood coagulation. Here, we show that PMN-derived MPO inhibits the procoagulant activity (PCA) of lipidated recombinant human tissue factor (rhTF) in a time- and concentration-dependent manner that involves, but is not entirely dependent on the enzyme's catalytic activity. Similarly, MPO together with its substrate, H2O2, inhibited the PCA of plasma microvesicles isolated from lipopolysaccharide (LPS)-stimulated whole blood, an effect additive to that of a function blocking TF antibody. Treatment of whole blood with LPS or phorbol-myristate-acetate dramatically increased MPO plasma levels, and co-incubation with 4-ABAH, a specific MPO inhibitor, significantly enhanced the PCA in plasma supernatants. MPO and MPO/H2O2 also inhibited the PCA of activated platelets and purified phospholipids (PLs), suggesting that modulation of negatively charged PLs, i.e., phosphatidylserine, rather than direct interference with the TF/FVIIa initiation complex was involved. Consistently, pretreatment of activated platelets with MPO or MPO/H2O2 attenuated the subsequent binding of lactadherin, which specifically recognizes procoagulant PS on cell membranes. Finally, endogenously released MPO regulated the PCA of THP1 cells in an autocrine manner dependent on the binding to CD11b/CD18 integrins. Collectively, these findings indicate that MPO is a negative regulator of PL-dependent coagulation and suggest a more complex role of activated PMNs in haemostasis and thrombosis.
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Affiliation(s)
- Lennart Beckmann
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Christina Dicke
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Brigitte Spath
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Carina Lehr
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Bianca Sievers
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Anna Klinke
- Medizinische Klinik III, Herzzentrum, Uniklinik Köln, Köln, Germany
| | - Stephan Baldus
- Medizinische Klinik III, Herzzentrum, Uniklinik Köln, Köln, Germany
| | - Volker Rudolph
- Medizinische Klinik III, Herzzentrum, Uniklinik Köln, Köln, Germany
| | - Florian Langer
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
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Dicke C, Amirkhosravi A, Spath B, Jiménez-Alcázar M, Fuchs T, Davila M, Francis JL, Bokemeyer C, Langer F. Tissue factor-dependent and -independent pathways of systemic coagulation activation in acute myeloid leukemia: a single-center cohort study. Exp Hematol Oncol 2015; 4:22. [PMID: 26251762 PMCID: PMC4527228 DOI: 10.1186/s40164-015-0018-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 07/29/2015] [Indexed: 11/28/2022] Open
Abstract
Background In acute myeloid leukemia (AML), disseminated intravascular coagulation (DIC) contributes to morbidity and mortality, but the underlying pathomechanisms remain incompletely understood. Methods We conducted a prospective study on 69 patients with newly diagnosed AML to further define the correlates of systemic coagulation activation in this hematological malignancy. Tissue factor procoagulant activity (TF PCA) of isolated peripheral blood mononuclear cells (PBMCs) and TF expression by circulating microparticles (MPs) were assessed by single-stage clotting and thrombin generation assay, respectively. Soluble plasma TF antigen and secretion of vascular endothelial growth factor (VEGF) by cultured PBMCs were measured by ELISA. Cell-free plasma DNA was quantified by staining with a fluorescent dye. Result TF PCA of PBMCs was significantly increased in AML patients as compared to healthy controls. Furthermore, TF PCA was significantly associated with decompensated DIC at presentation, as defined by a plasma fibrinogen level of ≤1 g/L (n = 11). In addition to TF PCA and circulating blasts, serum lactate dehydrogenase, a surrogate marker for leukemic cell turnover, correlated with plasma D-Dimer in the total patient cohort and was significantly increased in DIC patients, suggesting a role for myeloblast apoptosis/necrosis in activation of the TF-dependent coagulation pathway. Consistently, TF-bearing plasma MPs were more frequently detected and levels of soluble TF antigen were significantly higher in DIC vs. non-DIC patients. No association was found between TF PCA expression and VEGF secretion by isolated PBMCs, but significantly increased levels of cell-free plasma DNA pointed to a contribution of the intrinsic contact pathway to systemic coagulation activation in the total patient cohort and in patients with lower TF PCA expression. While PBMC-associated TF PCA had no effect on long-term survival, DIC occurrence at presentation increased the risk of early mortality. Conclusion In newly diagnosed AML, TF expression by PBMCs and shedding of TF-bearing plasma MPs are central to the pathogenesis of DIC, but additional pathways, such as DNA liberation, may contribute to systemic coagulation activation.
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Affiliation(s)
- Christina Dicke
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum, Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Ali Amirkhosravi
- Florida Hospital Center for Thrombosis Research, 2566 Lee Road, Winter Park, FL 32789 USA
| | - Brigitte Spath
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum, Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Miguel Jiménez-Alcázar
- Institut für Klinische Chemie und Laboratoriumsmedizin, Universitätsklinikum Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Tobias Fuchs
- Institut für Klinische Chemie und Laboratoriumsmedizin, Universitätsklinikum Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Monica Davila
- Florida Hospital Center for Thrombosis Research, 2566 Lee Road, Winter Park, FL 32789 USA
| | - John L Francis
- Florida Hospital Center for Thrombosis Research, 2566 Lee Road, Winter Park, FL 32789 USA
| | - Carsten Bokemeyer
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum, Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Florian Langer
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum, Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
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Jakus G, Dicke C, Sodnik J. A user study of auditory, head-up and multi-modal displays in vehicles. Appl Ergon 2015; 46 Pt A:184-192. [PMID: 25151313 DOI: 10.1016/j.apergo.2014.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 07/09/2014] [Accepted: 08/04/2014] [Indexed: 06/03/2023]
Abstract
This paper describes a user study on the interaction with an in-vehicle information system (IVIS). The motivation for conducting this research was to investigate the subjectively and objectively measured impact of using a single- or multi-modal IVIS while driving. A hierarchical, list-based menu was presented using a windshield projection (head-up display), auditory display and a combination of both interfaces. The users were asked to navigate a vehicle in a driving simulator and simultaneously perform a set of tasks of varying complexity. The experiment showed that the interaction with visual and audio-visual head-up displays is faster and more efficient than with the audio-only display. All the interfaces had a similar impact on the overall driving performance. There was no significant difference between the visual only and audio-visual displays in terms of their efficiency and safety; however, the majority of test subjects clearly preferred to use the multi-modal interface while driving.
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Affiliation(s)
- Grega Jakus
- Faculty of Electrical Engineering, University of Ljubljana, Trzaska 25, Ljubljana 1000, Slovenia.
| | - Christina Dicke
- Quality and Usability Lab, Telekom Innovation Laboratories, TU Berlin, Ernst-Reuter-Platz 7, 10587 Berlin, Germany.
| | - Jaka Sodnik
- Faculty of Electrical Engineering, University of Ljubljana, Trzaska 25, Ljubljana 1000, Slovenia.
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Abstract
Clinically relevant clotting abnormalities in cancer patients are referred to as Trousseau's syndrome. While thrombotic complications such as venous thromboembolism are most frequent in every day's practice, cancer patients may also experience severe bleeding symptoms due to complex systemic coagulopathies, including disseminated intravascular coagulation, haemolytic thrombotic microangiopathy, and hyperfibrinolysis. The pathophysiology of Trousseau's syndrome involves all aspects of Virchow's triad, but previous basic research has mainly focused on the cellular and molecular mechanisms underlying blood hypercoagulability in solid cancers and haematological malignancies. In this regard, over-expression of tissue factor (TF), the principal initiator of the extrinsic coagulation pathway, by primary tumour cells and increased shedding of TF-bearing plasma microparticles are critical to both thrombus formation and cancer progression. However, novel findings on intrinsic contact activation in vivo, such as the release of polyphosphates or DNA by activated platelets and neutrophils, respectively, have pointed to additional pathways in the complex pathophysiology of Trousseau's syndrome.
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Affiliation(s)
| | - F Langer
- Priv.-Doz. Dr. med. Florian Langer, II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Martinistr. 52, 20246 Hamburg, Germany, Tel. +49/(0)40/741 05-24 53, -06 64; Fax -51 93, E-mail:
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Dicke C, Holstein K, Schneppenheim S, Dittmer R, Schneppenheim R, Bokemeyer C, Iking-Konert C, Budde U, Langer F. Acquired hemophilia A and von Willebrand syndrome in a patient with late-onset systemic lupus erythematosus. Exp Hematol Oncol 2014; 3:21. [PMID: 25170428 PMCID: PMC4147383 DOI: 10.1186/2162-3619-3-21] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 08/04/2014] [Indexed: 01/20/2023] Open
Abstract
Acquired hemophilia A (AHA) and acquired von Willebrand Syndrome (AVWS) are both rare bleeding disorders that can be associated with lymphoproliferative or autoimmune diseases. AHA is uniformly caused by inhibitory autoantibodies against coagulation factor VIII (FVIII), while the pathophysiology of AVWS comprises several distinct mechanisms, including reduced synthesis, accelerated clearance, or increased proteolysis. In this regard, autoantibodies to von Willebrand factor (VWF) have been described in patients with systemic lupus erythematosus (SLE) or monoclonal gammopathy. Here, we report the case of a 71-year-old patient with a recent onset of spontaneous mucocutaneous and soft-tissue bleeding due to severely decreased FVIII and VWF. While there was no evidence for monoclonal gammopathy, specific IgG antibodies against both FVIII and VWF were detected. Furthermore, VWF multimer analysis revealed the presence of ultralarge plasma multimers and absence of the typical multimeric triplet structure, a finding consistent with decreased proteolytic processing of massively released, but rapidly cleared VWF. Both FVIII and VWF readily responded to immunosuppressive therapy with prednisolone. Interestingly, clinical and laboratory findings established the diagnosis of “late-onset SLE” in our patient. Thus, about 45 years after the first description of AVWS in a 12-year-old boy with SLE, we present another unusual case of concomitant autoimmune-mediated AHA and AVWS in an elderly SLE patient, which, to the best of our knowledge, has not been reported so far.
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Affiliation(s)
- Christina Dicke
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Katharina Holstein
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Sonja Schneppenheim
- Gerinnungslabor, MEDILYS Laborgesellschaft mbH, c/o Asklepios Klinik Altona, Paul-Ehrlich-Str. 1, 22763 Hamburg, Germany
| | - Rita Dittmer
- Gerinnungslabor, MEDILYS Laborgesellschaft mbH, c/o Asklepios Klinik Altona, Paul-Ehrlich-Str. 1, 22763 Hamburg, Germany
| | - Reinhard Schneppenheim
- Klinik und Poliklinik für Pädiatrische Hämatologie und Onkologie, Universitätsklinikum Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Carsten Bokemeyer
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Christof Iking-Konert
- III. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Ulrich Budde
- Gerinnungslabor, MEDILYS Laborgesellschaft mbH, c/o Asklepios Klinik Altona, Paul-Ehrlich-Str. 1, 22763 Hamburg, Germany
| | - Florian Langer
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
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Dicke C, Kertész A, Henke RP, Hasenkamp J, Jung W, Trümper L, Wulf GG. Retroperitoneal fibrosis as manifestation of chronic GVHD after allogeneic hematopoietic SCT. Bone Marrow Transplant 2012; 48:467-8. [PMID: 22964591 DOI: 10.1038/bmt.2012.165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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