[Genuine medical accreditation systems in the USA according to standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)--reflections on the transferability of the procedures to Germany]

In a number of anglophone countries in parallel to the industrial trend accreditation systems have been developed for health care organizations and specially for hospitals. These systems were introduced and instituted as a part of the health care system in the countries. Central elements and central procedures of these genuine-medical accreditation systems for hospitals in the United States, in Australia, Canada, France and in Great Britain are mostly identical. They focus primarily on the patient and his way from access to post discharge in a hospital. Core of the systems is a catalogue with standards, which in a systematic and comprehensive way gives ideas of good professional performance in hospitals. The catalogues can be used internally to develop and improve quality and quality management in a hospital. Primarily, however, the accreditation systems are designed to provide most objective measures for external evaluation of quality and quality management.

Independent role of p38 and ERK1/2 mitogen-activated kinases in the upregulation of matrix metalloproteinase-1

Matrix metalloproteinase-1 (MMP-1) plays an important role in the degradation of extracellular matrix components under several physiological and pathological conditions. The expression of this protease is upregulated by mitogenic growth factors and proinflammatory cytokines, which have been shown to activate different sets of mitogen-activated protein (MAP) kinase pathways. Here we provide evidence that activation of the extracellular signal-regulated kinase 1/2 (ERK1/2) or the p38 MAP kinase pathway is sufficient to induce transcription from the MMP-1 promoter in human primary fibroblasts, whereas modulation of mRNA stability seems to be of minor importance. Upregulation of MMP-1 expression by mitogenic or inflammatory stimuli is blocked by specific small molecular weight inhibitors of the ERK pathway or the p38 pathway, respectively, and constitutively active kinases within the ERK1/2 pathway (MEKK1, MEK1) or the p38 pathway (ASK1, MEKK1, MKK3) are potent activators of the MMP-1 promoter. The current study provides evidence that distinct extracellular signals leading to upregulation of MMP-1 expression in fibroblasts are relayed independently through different MAP kinase pathways and are integrated at the level of the promoter.

[Study by the Professional Organization of German Transfusion Physicians on epidemiology of HIV- and hepatitis infections in blood donors]

The frequency of the seromarkers of HIV, HCV, and HBV in the donor population from all donor centers in Germany became available from the multicenter study of the transfusion services. From these data the risk of virus transmission by blood products can be estimated at 1:1 million for HIV and 1:50,000 for HBV. For HCV, preliminary data indicate the risk for Germany in less than 1:20,000. The risk is even lower, with less than 1:200,000 when calculated from seroconversion data of a rural donor population. The safety of blood products has been very much improved due to the continuous donor selection over the last years and by the epidemiologic situation in Germany.

Infektionsmarker bei Blutspenden

<i>Ziel:</i> Die Infektionsrisiken durch Blutpräparate sollen aus aktuellen Daten abgeschätzt werden. <i>Design:</i> Die Häufigkeiten der Infektionsmarker HIV, HCV und HBV unter den Blutspenden wurden erfaβt. <i>Rahmen und Teilnehmen</i> Durch das Studiensekretariat konnten die Befunde bei alien Blutspenden im Jahr 1994 erstmals aus alien staatlichkommunalen und DRK-Blutspendediensten in Deutschland erfaβt und ausgewertet werden. <i>Ergebnisse:</i> Das Risiko einer Infektionsübertragung durch zelluläre Blutpräparate aus Mehrfachspenden ist einzuschätzen als 1 : 1 Million für HIV mit einem Streubereich von 1: 300000 bis 1 : 3 Millionen und für HBV 1: 50000. Für HCV ist das Risiko für den Gesamtbereich noch nicht endgültig festzustellen, liegt jedoch sicher unter 1 : 20 000. Aus Teildaten der Serokonversion von HCV bei Blutspendern aus ländlichen Bereichen errechnen sich sogar Zahlen von kleiner 1 : 200000. <i>Schluβfolgerungen:</i> Durch die effektive Spender-selektion, für HIV seit 1985, für HCV seit 1990, ist ein hohes Maβ an Sicherheit erreicht.

[HIV retrospective study of the German Red Cross blood donation service in Germany]

OBJECTIVE

It was tried to retrospectively identify HIV infections in recipients of transfusions from donors who were tested HIV positive at a subsequent donation. These lookback data were traced back to answer the following questions: 1. How many transfusion recipients were infected before the start of the routine HIV testing in 1985? 2. How great is the risk of HIV infections from infected but not yet HIV antibody-positive donors? 3. Furthermore, the transfusion of HIV-infected transfusion recipients was traced back to the involved donor to establish causality.

DESIGN

Retrospective ('lookback') study.

SETTING

HIV Study Group of the Red Cross Blood Banks of the Federal Republic of Germany.

PARTICIPANTS

Preceding donations of HIV antibody-positive repeat donors were traced back to the transfusion recipients in order to establish their HIV antibody status. In a second lookback study, HIV-infected transfusion recipients and their corresponding donors were investigated after they had been reported to the blood bank as infected by transfusion-associated HIV.

INTERVENTIONS

None.

RESULTS

Recipients of 156 respectively 133 transfusions from repeat donors found to be Western blot-positive were investigated from 1985 to 1987 and from 1987 to 1992, respectively. About 50% of the recipients had died. About 40% of the recipients could not be examined, because they either were not available for testing or refused to be tested or because it was impossible to clarify the fate of the blood products. 25 HIV recipients were identified from 1981 to 1985, when routine HIV testing began. Nine transfusion-associated HIV infections were identified from 1985 to 1992. 25 million units of blood were prepared during this period.

CONCLUSIONS

The risk of HIV transmission by tested transfusions is extremely rare (in the order of 1:1 million). The second lookback study suggests that in more than 50% of the blood recipients in whom HIV infection was attributed to transfusion, a causal relationship to an infected donor could not be established.

HIV-Lookback-Studie der DRK Blutspendedienste in der BRD

<i>Ziel:</i> Ziel der vorliegenden Untersuchung war es, durch eine Lookback-Studie 1. die Zahl der HIV-Infektionen durch Bluttransfusionen vor Beginn der routinemäßigen HIV-Testung abzuschätzen, 2. auf die Zahl der HIV-Übertragungen durch HIV-negativ getestete Blutspenden nach der Anti-HIV-Testung zu schließen, 3. den Infektionsmodus bei HIV-positiv gemeldeten Transfusionsempfängern durch Rück-verfolgung der Präparate zum Spender abzuklären. <i>Design:</i> Retrospektive («Lookback»-)Untersuchung. <i>Rahmen</i>: HIV-Studiengruppe der DRK-Blutspendedienste in Deutschland, die 80% der Gesamtblutversorgung leisten. <i>Teilnehmer:</i> Die Blutpräparate der Spenden von HIV-Antikörperpositiven Mehrfachspendern wurden, soweit möglich, zum Empfänger zurückverfolgt und diese auf ihren HIV-Antikörperstatus untersucht. In dem Untersuchungszeitraum von 1981 bis 1992 wurden etwa 25 Mio. Blutspenden auf HIV-Antikörper untersucht. <i>Interventionen:</i> Keine. <i>Ergebnisse</i>: Von 289 HIV-Western-blot-positiven Mehrfachspendern wurde versucht, Spenderserien zum Empfänger zurückzuverfolgen. Etwa 50% der Transfusionsempfänger waren an ihrer Grundkrankheit verstorben. Etwa 40% der Spenderserien konnten nicht vollständig abgeklärt werden, da entweder die Empfänger nicht zur Verfügung standen oder eine HIV-Testung verweigerten, oder die Blutpräparate nicht bis zum Empfänger verfolgt werden konnten. Aus den Lookback-Serien von 289 positiven Mehrfachspendern wurden 25 HIV-positive Empfänger vor Beginn der Testung (1982-1985) und 9 HIV-positive Empfänger von HIV-negativ getesteten Blutpräparaten nach Beginn der Testung (1985-1992) identifiziert. Beim empfänger-bezogenen Lookback wurden die transfundierten Blutpräparate von 135 HIV-positiv gemeldeten Transfusionsempfängern zum involvierten Spender zurückverfolgt. Bei mehr als 50% konnte keine Kausalität hergestellt werden, d.h., die benannten Blutpräparate waren nicht Ursache der Infektion, wobei 40% der Fälle nicht vollständig abgeklärt werden konnten. <i>Schlußfolgerungen:</i> Die Übertragung von HIV-Infektionen durch getestete Bluttransfusionen ist extrem selten (1:1 Mio.) und war auch vor der HIV-Testung in

Phage display as a rapid gene expression system: production of bioactive cytokine-phage and generation of neutralizing monoclonal antibodies

Proteins, such as hormones, enzymes, or antibody binding sites, can be expressed in an active conformation on the surface of filamentous bacteriophage. Although the phage display technology was originally developed for binding studies, we demonstrate here that this technique can rapidly provide cytokines for studies of biological activity and for raising neutralizing monoclonal antibodies. A phage M13-based cloning vector was constructed that facilitated the expression of human interleukin 3 (hIL-3) on the phage surface. The recombinant phage could stimulate the growth of the hIL-3 dependent cell line M-07, providing evidence for the display of hIL-3 in an active form. Injection of recombinant phage into mice provoked an immune response to hIL-3, and neutralizing monoclonal antibodies directed against native hIL-3 could be established from these mice with a high frequency.

[Risk of infection transmission by blood components]

OBJECTIVE

Assessment of the present risk of blood-borne infection associated with homologous blood transfusion in Central Europe with particular emphasis on HIV and HCV infections.

DATA SOURCES

The relevant literature in the English and German language and the authors' data.

STUDY SELECTION

No special study has been carried out for the present paper.

RESULTS

The recognition of the risk for transmitting HIV by transfusion has led to a bundle of measures which have improved the safety of blood supply in Germany. A stricter donor selection as well as screening for HIV 1 and HIV 2 have reduced the risk to transmit HIV to the order of 1 per 1 million units transfused. The transmission of hepatitis B is estimated to be in the order of 1:50,000. The anti-HCV testing, introduced in 1990, has markedly reduced the transmission of HCV to less than 1:5,000 per unit as judged from our own data. A further reduction is expected by an improved HCV screening in the near future. Fatal disease from bacterial contamination is rare, with an estimated risk of one in a million units. Syphilis transmitted by transfusion is virtually not occurring anymore. However, increased efforts should continue to enhance the safety of blood, bearing in mind that a zero risk is not achievable for effective therapies. The estimation of risks is a dynamic, time-dependent value which has to be estimated for a geographically defined population for a given time period.

CONCLUSIONS

The risk of transfusion-associated infection has been markedly reduced in recent years. Albeit there is a small but definitive risk, which is often overestimated. The risks have to be defined to estimate the risk/benefit ratio of the homologous as well as the autologous transfusion for the individual patient.

Das Risiko einer Infektionsübertragung durch Blutkomponenten

<i>Ziel: </i>Das aktuelle Risiko transfusionsassoziierter Infektionen, besonders mit dem Human Immunodeficiency Virus (HIV) und dem Hepatitis-C-Virus (HCV), für Mitteleuropa zu definieren. <i>Quellen: </i>Relevante neueste englische und deutsche Veröffentlichungen und eigene Daten. <i>Auswahlkriterien: </i>Keine spezielle Literaturrecherche über die Zeit. <i>Ergebnisse: </i>Durch verstärkte Spenderselektion, zusätzliches und verbessertes Labor-Screening und eine sich ändernde Epidemiologie ist das Risiko eine dynamische Gröβe, deren gegenwärtiger Stand immer wieder neu bestimmt werden muβ. Das Risiko einer HIV-Übertragung wird auf 1:1 Million per transfundierte Blutkomponente geschätzt. Durch die seit 1990 durchgeführte Testung aller Blutspenden auf Anti-HCV wurde die Posttransfusionshepatitis-C-(PTH-C-)Übertragung um 80% reduziert und nach eigenen Daten auf 1 per 5000 transfundierte Blutpräparate geschätzt. Eine zu erwartende Verbesserung des HCV-Screenings wird das Risiko, HCV durch Blut zu übertragen, weiter reduzieren. Das Risiko, Hepatitis B zu übertragen, liegt in der Gröβenordnung von 1 per 50000 transfundierte Blutkomponenten. <i>Schluβfolgerung: </i>Dieses in den letzten Jahren deutlich verminderte, aber häufig überschätzte Infektionsrisiko muβ bei einer Nutzen/Risiko-Abschätzung für alternative Methoden zur homologen Bluttransfusion für den einzelnen Patienten in Betracht gezogen werden.

Anti-lipopolysaccharide-immunoglobulin (IgG-anti-LPS) therapy in intensive care patients following surgery from infectious disease

In 18 intensive care patients the effect of a IgG-Anti-Lipopolysaccharide (Anti-LPS), was investigated in a randomized study following surgery after bacterial infections, mostly peritonitis. Fresh frozen plasma was administered during the first 5 postoperative days, containing either more than 65 micrograms/ml Anti-LPS in the therapy group or less than 12.5 micrograms/ml in the control group. The serum level of Anti-LPS was monitored. Clinical and chemical parameters were recorded to evaluate infectious complications and outcome of the patients. The mortality in the treatment group was not different from the control group with 30% (3 out of 10) and 25% (2 out of 8), respectively. No beneficial effect was observed either from the administration of Anti-LPS or from endogenously produced Anti-LPS on any clinical parameter in our patients.

[Current data on the prevalence and epidemiology of HIV from the HIV study by the German Red Cross of West Germany]

From the multicenter study of the Red Cross Blood Banks in the FRG HIV-antibody prevalences and incidences are documented since July 1985. Constantly low prevalences and incidences since 1987 of less than 2 Western blot (Wb)-positive donors and less than 1 Wb-positive donor per 100,000 donors respectively confirm our estimate of the rest risk of an HIV-infection by blood products of 1:500,000 to 1:3 million donations. In the epidemiologic details there seems to be a trend to an increase of the incidence in male repeat blood donors. The modes of HIV-infection in blood donors have changed to an increasing number of infections acquired in heterosexual contacts to persons at risk.

HIV prevalence in blood donors in urban and in rural areas of the Federal Republic of Germany

HIV infection rates in blood donors from the FRG were compared with the prevalence in donors from Berlin to obtain information on the HIV infections in donors of rural versus urban origin. The HIV prevalences decrease similarly in the first years of testing, although on different levels. They are lower in rural areas by a factor of 15 in the first year and of 10 thereafter. The modes of infectivity in both groups are similar although drug abuse seems to be more frequent amongst infected donors of urban areas. Ninety percent of the infected donors are either persons at risk or sexual partners of risk persons. During the observed time period there seems to be a trend from homo-/bisexuality and i.v. drug abuse to heterosexual contacts with persons at risk as the mode of infection. In conjunction with the stabile low and constant rates of infection for the last two years, these data indicate that the risk of HIV infection by blood transfusion is reduced to an acceptable minimum even in urban areas.

Risk of HIV infection from former blood donations of donors found to be HIV antibody-positive in blood bank routine testing. "Look-back" study in German Red Cross Blood Banks in the FRG

Recipients of blood given by 52 repeat blood donors found to be positive by Western blot analysis for anti-HIV from April 1985 to December 1987, among a total of 1.6 million blood donors in the German Red Cross Blood Banks in the FRG, were investigated. Of 149 recipients identified, 76 (51%) had died. Ten recipients refused to be tested. Of those recipients who were tested at least 5 months after transfusion, 46 were HIV antibody negative and 17 were Western blot-positive. In 14 of the HIV antibody-positive recipients, transfusion was given during the period from 1982 to the begin of routine testing in 1985. Three recipients of HIV antibody-negative donations were subsequently identified as HIV positive. The blood had been donated a median of 3 months before HIV antibodies were detected in the donors. From a total of 3 million donations since testing has been introduced, the risk of HIV transmission in tested blood is 1:1 million in our donor population where the HIV antibody prevalence (in Western blot) is about 1 per 100,000 donations/donors.

Aktuelle Daten zur Prävalenz und Epidemiologie des HIV aus der HIV-Studie der DRK-Blutspendedienste der BRD

Seit nun mehr als 4 Jahren dokumentieren die DRK-Blutspendedien-ste in einer HIV-Studie ihre Befunde. Dabei bestätigen sich die weiterhin niedrigen HIV-Prävalenzen und -Inzidenzen von weniger als 2 bzw. weniger als 1 HIV-Antikörper-positiven Spender je 100000 Spender. Daraus ergibt sich unsere Schätzung des Restrisikos einer HIV-Infektion mit den entsprechenden Blutpräparaten im Bereich von 1:500000 bis 1:3 Mio. In den epidemiologischen Details zeichnet sich als Trend eine leichte Zunahme von Inzidenz und Prävalenz bei männlichen Spendern ab. Unter der spezifischen Selektion bei Blutspendern hat sich die Verteilung der Infektmodi von 1985 bis 1988 von homosexuellen Kontakten und i.v.-Drogenabusus zu heterosexuellen Kontakten zu HIV-Risikopersonen verschoben.

[Transfusion hepatitis. Occurrence and comparison of risks of blood transfusion and surgery]

The incidence of hepatitis (B and non-A, non-B) was determined in a prospective multicentre study of 1100 hospital patients during 12 months without or after surgery and with or without transfusion. The incidence was 3.6% (4 of 111 patients) after surgery and transfusion, and 0.5% (5 of 989) without transfusion - with or without surgery. The incidence of hepatitis B was significantly higher in the transfused group, while non-A, non-B hepatitis had the same incidence in all three groups. Hepatitis was clinically manifest in only three of the nine patients. The remaining six silent ones were uncovered by a careful prospective follow-up plan. Thus the incidence of hepatitis in this study was higher than has been reported in retrospective series. However, the absolute number of cases is small and the confidence limits thus rather wide: the incidence of non-A, non-B hepatitis must be interpreted with caution.

[Epidemiology of HIV in blood donors in West Germany]

Of a total of 5.6 million blood donations by 1.6 million German Red Cross donors between July, 1985 and December, 1987 tested for HIV antibodies 210 were found to be positive in at least one Western blot. Calculated per quarter, the prevalence (for first-time donors) of 10 per 100,000 in 1985 decreased to 4 per 100,000 in 1986, while the incidence (for multiple donors) was a constant 2 per 100,000 for each quarter in 1987. This indicates that new HIV infections were rare in blood donors and there was no exponential increase. Further analysis revealed that over 90% of those with confirmed Western blot positive results were members of risk groups or their direct contacts. The age and sex distribution conformed to the known pattern for AIDS cases in the Federal Republic of Germany. The data demonstrate that there is at present no indication of a rapid spread of HIV infections transmitted heterosexually among blood donors.

[Autologous blood transfusion. Goals and benefits, limitations and risks demonstrated in a practical concept]

Autologous transfusion as an alternative to homologous blood is useful, but its applicability is limited to a few patients, as we have shown in the autologous program at the University Hospital of Ulm. Each concept, even more an interdisciplinary one as autologous transfusion, includes risks. Risk factors arising primarily from donation and hemodilution are determined by the patient himself. As it is impossible to evaluate these risks in advance of anesthesia and surgical procedures the program has to provide guidelines and stringent limits to guarantee safety. Should these be ignored, the risks for the patient will be even higher than the risks of homologous transfusion that provide motivation for autotransfusion.

[Prevalence of HIV antibodies in blood donors in the West Germany and West Berlin]

Since 1985 all donor blood in the Federal Republic of Germany (FRG) and West Berlin (WB) have been routinely tested for HIV antibodies. The blood donor services of the German and Bavarian Red Cross have pooled their anti-HIV test data for the first year of operation (July 1985-June 1986) to obtain information on the prevalence of HIV antibodies in blood donors and in donated blood. Of 2.27 million units of blood, donated by 1.33 million donors, 218 were anti-HIV positive in the Western Blot Test, i.e. a prevalence rate of 10 per 100,000 donors. The prevalence was, as expected, higher in males than females. During the test period the anti-HIV prevalence fell, both as a total and in all subpopulations. In the second quarter of 1986 it had decreased to 6 per 100,000 donated units.

Lipopolysaccharide-induced elaboration of interleukin 1 by human monocytes: use for detection of lipopolysaccharide in serum and the influence of serum-lipopolysaccharide interactions

An assay of interleukin 1 (IL-1) production by human monocytes was used to detect minute amounts of bacterial lipopolysaccharide (LPS) in sera or serum components designed for use in experiments or for injection into humans. Elaboration of IL-1 is a more sensitive criterion for the presence of LPS than is the rabbit pyrogenicity assay, and contamination of a given solution with LPS can be semiquantitatively determined by comparison with a standard. Interaction of (exogenously added) LPS with serum interferes with the recognition of LPS by monocytes but in a manner different from that encountered in the limulus test. Recognition of LPS by monocytes was not affected by the presence of naturally occurring antibodies to LPS. With use of IL-1 elaboration as an indicator, the presence of functionally active LPS in the sera of some patients with sepsis could be demonstrated.

[Collection of thrombocyte concentrates and coagulation active fresh plasma with the Haemonetics PCS system]

More intensive chemotherapeutic regimens in patients with leukemia or malignant disease lead to an increasing demand for platelet concentrates. As conventional preparation of platelets from fresh whole blood is limited by the number of blood donors, new methods have to be investigated. Plasmapheresis with simultaneous collection of platelets is favored. We tested the new Haemonetics PCS system (Haemonetics Corp., Braintree, Mass.). Beside the effectivity of the measure, we were interested in the quality of the products. The simultaneous collection of hemostatic active plasma and platelet concentrates did not produce the same quality as our routine products.

Gewinnung von Thrombozytenkonzentraten und gerinnungsaktivem Frischplasma mit dem System Haemonetics PCS

Der durch intensivere Chemotherapie-Schemata bei hämatologischen und onkologischen Patienten deutlich gesteigerte Bedarf an Thrombozyten-Konzentraten forderte, neben der Präparation von Thrombozyten-Konzentraten (TK) aus frischem Vollblut Verfahren zur selektiven Gewinnung von TK zu erschlieβen. Die Möglichkeit, Plasma in kürzeren Zeitintervallen als Vollblut spenden zu können, regte die Entwicklung und den Einsatz von konventionellen Maschinen zur Plasmapherese mit simultaner Thrombozytengewinnung an. In einer Testreihe untersuchten wir die Effektivität des Verfahrens und die Qualität der Präparate Frischplasma und Thrombozyten-Konzentrat bei dem von der Firma Haemonetics Corp. (Braintree, Mass.) als Weiterentwicklung neu angebotenen System PCS. Die durch unsere Routinepräparate Fresh frozen plasma und TK vorgegebenen Qualitätskriterien konnten bei der gleichzeitigen Gewinnung von beiden Präparaten nicht erreicht werden.

[Therapy using blood components. Prerequisites, indications and clinical use]

The therapeutic benefit of blood components for specific substitution and volume replacement has been recognized for more than ten years. The increasing demand for blood and blood products, especially for albumin in connection with an only moderate growth of the base of blood donors has promoted the idea of a more efficient utilization of blood by specific replacement with blood components. The component therapy has reduced the side effects and improved the efficacy of blood transfusion and last but not least has led to a positive cost-effectiveness. Our clinical management of blood transfusion with a nearly complete use of components in surgical patients is presented. Particularly, the therapeutic strategy for massive transfusions by component therapy is discussed. In face of the technical and logistic problems, a transfusion schedule was developed which outlines the nearly exclusive therapeutic use of components. It applies with modifications and adjustment to the critical parameters to all cases of rapid and massive blood loss. In addition, diagnostic and therapeutic strategies are considered to preserve hemostasis or correct occurring hemostatic defects and to prevent thrombo-embolic events.

Die Therapie mît Blutkomponenten

Die Transfusion von Blutbestandteilen zur spezifischen Substitution sowie als Volumenersatz wurde vor mehr als 10 Jahren eingeführt. Die Idee der «Hämotherapie nach Maβ» gründete sich auf der Tatsache, daβ dem steigenden Bedarf an Blutpräparaten, insbesondere Albumin, ein kaum steigerbares Aufkommen an Blutspenden gegenüber-stand. Die alleine daraus abgeleitete Notwendigkeit, Blutkomponenten zu verwenden, hat sich bestätigt. Darüber hinaus ergeben sich eine positive Kosten-Nutzen-Analyse und nicht zuletzt gravierende Vorteile für eine verbesserte Indikationsstellung mit einer gleichzeitigen Verminderung unerwünschter Nebenwirkungen. Die klinische Erfahrung mit einem Blutkomponenten-Schema für die routinemäβige wie notfallmäβige Substitution bei chimrgischen Patienten einer Universitätsklinik wird dargestellt. Das Vorgehen bei Massentransfusionen wurde dabei besonders beachtet. Unter Berück-sichtigung technischer und organisatorischer Probleme wurde ein Transfusionsplan entwickelt, der als Basis die Maβgabe für den quantitativen Einsatz der Einzelpräparate darstellt. Die Konditionen sowie die Grenzparameter, die eine Modifizierung notwendig machen oder erfordern, werden aufgezeigt. Zusätzliche therapeutische Maβnahmen zur Schaffung oder Erhaltung eines suffizienten Hämostasepotentials und der effektiven Thrombo-Embolie-Prophylaxe werden diskutiert.

[The significance of fibrin/fibrinogen for growth and metastasis of malignant tumors (author's transl)]

It seems evident that fibrinogen and fibrin representing the final substrate und product of clotting system act as pathogenetic connecting links for development and spread of malignant tumors. The results reported demonstrate the influence of fibrin on the initial phase of haematogenic metastasis particularly. Several tumor-specific mechanisms are shown to cause frequently an accumulation of fibrin in malignant tumors. The results discussed here stress the importance of fibrin in tumors for tumor cells and tumor cell units. In the literature a large number of indications to fibrin depositions in experimental tumors is found, an attempt is made to compare these findings semiquantitatively. The last part of this article discusses the therapeutic and diagnostic consequences based on the possible key position of fibrin-(ogen) in the tumor pathology.