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Diagnostic and therapeutic problems associated with hereditary deficiency of the C1 esterase inhibitor.

Six patients in a family with a history of hereditary angioedema reported swelling of the extremities and recurrent abdominal pain occurring spontaneously or after trauma. Attacks of oedema involving the airways, the greatest danger with this disorder, were present only in one case. This autosomal dominant disease is due to deficient activity of the inhibitor of the first component of complement. Low levels of C4, and absence of C1 esterase inhibitor confirm the diagnosis. Two asymptomatic cases with the appropriate biochemical abnormality are reported in this study. For short term prophylaxis of attacks (before surgery expecially), fresh frozen plasma is used, or better still, C1 esterase inhibitor. For long term prophylaxis of attacks antifibrinolytic and hormonal drugs are used: in two cases, the authors obtained good results with methyltestosterone after failure of tranexamic acid.

Adult↗

Intra-ocular haemorrhage, a frequent complication of acute promyelocytic leukaemia.

We have found a high incidence of ocular haemorrhage in patients with acute promyelocytic leukaemia (APL). We describe a series of seven consecutive cases of APL, five of which developed ocular haemorrhage. There were no consistent detectable abnormalities in coagulation predictive of ocular damage. Ocular haemorrhage occurred despite the use of aggressive blood product support and its incidence was not altered by the use of the anti fibrinolytic agent tranexamic acid or by the use of heparin. Complete spontaneous resolution of the ocular pathology occurred in three of the five cases of ocular haemorrhage and partial recovery occurred in one. The fifth patient required surgical intervention. The mechanisms underlying the coagulopathy associated with APL are poorly understood. We discuss the evidence in support of primary disseminated intravascular coagulation and primary fibrinolysis. A logical approach to the management of the bleeding complications in APL can only follow greater understanding of the underlying pathophysiology.

Adult↗

Current understanding of von Willebrand's disease in women - some answers, more questions.

Considerable progress has been made in the past decade in describing the obstetrical and gynaecological aspects of von Willebrand's disease (VWD). In addition, epidemiological studies have established an approximately 11-16% prevalence of the laboratory diagnosis of VWD in women presenting with menorrhagia. However, it is not established presently whether an upfront VWD screening should be a part of the standard evaluation of menorrhagia. This is because it is presently not known whether therapy in the VWD patient tailored specifically for VWD will appreciably alter the natural history of menorrhagia compared with the non-VWD menorrhagia patient. There are also subtleties involved in securing the diagnosis of VWD in women presenting with menorrhagia in terms of fluctuation of von Willebrand factor (VWF) levels vis-à-vis the menstrual cycle and the potential impact of oral contraceptive on VWF levels. Regarding management of VWD-related menorrhagia, pending ongoing comparative trials of intranasal desmopressin (DDAVP), tranexamic acid, oral contraceptive and the levonorgestrel intrauterine device, specific recommendations cannot be made presently regarding the superiority of one intervention compared with the other. The management of VWD-related postpartum haemorrhage is also an area of active debate in terms of 'best practice' in type 1 (? prophylactic DDAVP), type 2 [? expectant management if factor VIII:C (FVIII:C) level normalizes] and type 3 patients (? intensity and duration of infusional therapy with a VWF-containing plasma-derived FVIII concentrate). This review summarizes the present state of knowledge and highlights numerous questions for future study based on our present understanding of VWD in women.

Deamino Arginine Vasopressin↗

Haemorrhagic problems in obstetrics and gynaecology in patients with congenital coagulopathies.

OBJECTIVE: To review the obstetric and gynaecological problems in women with congenital coagulopathies. DESIGN: Retrospective review. SETTING: Regional Adult Haemophilia Unit, Glasgow Royal Infirmary. SUBJECTS: All women in contact with the Unit over a period of 30 years, comprising eight with von Willebrand's disease, 18 obligate carriers of haemophilia A and five obligate carriers of Christmas disease. Each woman was interviewed and details of their obstetric and gynaecological histories were obtained and their case records were reviewed. MAIN OUTCOME MEASURES: Haemostatic changes associated with pregnancy and gynaecological problems. RESULTS: In 14 pregnancies in seven patients with von Willebrand's disease, there were four primary and four secondary post-partum haemorrhages and a large perineal haematoma complicating an episiotomy. These problems arose despite the endogenous rise in factor VIIIc seen with pregnancy. All women seen with von Willebrand's disease complained of menorrhagia and had been referred to gynaecologists. Treatment included danazol, tranexamic acid and the contraceptive pill. Diagnostic curettage resulted in severe haemorrhage in one woman and two women with pelvic pain and dyspareunia were found to have spontaneous broad ligament haematomas, one requiring surgery. In 43 pregnancies in obligate carriers of haemophilia A and Christmas disease there were five post-partum haemorrhages and a large perineal haematoma. CONCLUSION: In von Willebrand's disease it should be noted that adequate laboratory correction of factor VIIIc levels does not ensure clinical haemostasis; hence platelet function should also be measured. Patients with congenital coagulopathies pose particular problems for the obstetrician and gynaecologist and should be managed in close association with the local haemophilia centre.

Blood Coagulation Disorders↗

Reduction of menstrual blood loss in women suffering from idiopathic menorrhagia with a novel antifibrinolytic drug (Kabi 2161).

OBJECTIVE: To compare the effect of Kabi 2161 (a prodrug of tranexamic acid) and placebo on the reduction of menstrual blood loss in women suffering from idiopathic menorrhagia and to evaluate tolerance and effectiveness in a two-dose regimen. DESIGN: A randomised, double blind parallel group study using double dummy technique. SETTING: The departments of gynaecology at three medical centres in Sweden. SUBJECTS: Ninety-one outpatients visiting the gynaecological clinics from March 1991 to May 1992 were randomised into the study; 68 women fulfilled the study. INTERVENTIONS: Two run-in cycles, followed by administrations of Kabi 2161 (600 mg) tablets (1 four times daily or 2 twice daily) or placebo for the first five days of three menstrual cycles. MAIN OUTCOME MEASURES: Objective measurement of the change in menstrual blood loss during the treatment periods compared with menstrual blood loss during the run-in periods. RESULTS: A statistically significant reduction of menstrual blood loss was found for each treatment group, compared with the placebo group (P < 0.001). The mean reduction with 95% confidence interval (CI) was 33% (24-40) in the group treated with 1 four times daily and 41% (33-49) in the group treated 2 twice daily. The difference between the treated groups in reduction of menstrual blood loss is not significant. No significant differences were found in the frequencies of reported unwanted events during run-in and during treatment between the different treatment groups. There were also no significant differences between the treatment groups and the placebo group. CONCLUSION: Kabi 2161 in a dosage of 2.4 g per day gave a statistically significant reduction in objectively measured menstrual blood loss in a two (41%) as well as in a four (33%) dosage regimen compared with placebo. Frequency of unwanted events did not differ from those during run-in or from those in the placebo group. The optimal daily dosage needs to be further evaluated in a dose titration study.

Adult↗

The effect of defibrotide on thromboembolism in the pulmonary vasculature of mice and rabbits and in the cerebral vasculature of rabbits.

1. Administration of bovine thrombin (100 u kg-1) into the carotid artery of rabbits induces a sustained accumulation of 111 Indium-labelled platelets within the cranial vasculature over the subsequent 3 h. 2. Intracarotid (i.c.) administration of defibrotide (64 mg kg-1 bolus plus 64 mg kg-1 h-1 for 1 h) prior to i.c. thrombin (100 u kg-1) significantly reduces the ability of thrombin to induce cranial thromboembolism in rabbits. 3. Intravenous (i.v.) administration of thrombin (20 u kg-1) in rabbits induces a reversible accumulation of radiolabelled platelets into the thoracic circulation which is significantly reduced by i.v. administration of defibrotide (64 mg kg-1 bolus plus 64 mg kg-1 h-1 for 1 h) prior to i.v. thrombin. In contrast, platelet accumulation in response to adenosine diphosphate (ADP; 20 micrograms kg-1, i.v.) or platelet activating factor (PAF; 50 ng kg-1, i.v.) is not significantly affected by this treatment. 4. Intravenous administration of the nitric oxide (NO)-synthase inhibitor NG-nitro-L-arginine methyl ester (L-NAME; 10 mg kg-1) potentiates platelet accumulation induced by low dose thrombin (10 u kg-1, i.v.) within the pulmonary vasculature of rabbits. The potentiated response is significantly abrogated following pretreatment with defibrotide (64 mg kg-1 bolus plus 64 mg kg-1 h-1 for 1 h, i.v.). 5. Intravenous injection of human thrombin (1250 u kg-1) to mice induces death within the majority of animals which is significantly reduced by pretreatment with defibrotide (150-175 mg kg-1, i.v.). In contrast, death induced by i.v. collagen (1.25 mg kg-1) plus adrenaline (75 microg kg-1) is not significantly affected by defibrotide pretreatment.6. The inhibitory effect of defibrotide in mice is abolished following concomitant treatment with the inhibitor of fribrinolysis, tranexamic acid (100 mg kg-1, i.v.), but is unaffected following treatment with the cyclo-oxygenase inhibitor, aspirin (300 mg kg-1, i.p.).7. The protective effect of defibrotide against thrombin-induced thromboembolism in the mouse is potentiated by recombinant tissue-plasminogen activator (rt-PA; 1 mg kg-1, i.v.) or unfractionated heparin (10 u kg-1, i.v.) administration.8. The results suggest that defibrotide may possess antithrombotic activity on thrombin-induced thromboembolism which, at least in the mouse, may be partially mediated via induction of the fibrinolytic pathway.

Animals↗

A central role for plasminogen in the inflammatory response to biomaterials.

The inflammatory response to implanted biomaterials severely limits their deployment in patients. Plasminogen has been shown to play a central role in cell migration, and therefore could regulate this inflammatory response. We sought to determine if plasminogen influences recruitment of inflammatory cells to a biomaterial implanted into plasminogen-deficient (Plg(-/-)) mice. Small disks of polyethylene terephthalate, a material used in vascular grafts, were surgically implanted into the peritoneum of wild-type and Plg(-/-) mice. Recruitment of neutrophils and monocytes/macrophages into the peritoneum and onto the disks was measured, primarily at 18 h. Monocyte/macrophage recruitment was markedly blunted in Plg(-/-) mice compared with wild-type mice. Unexpectedly, neutrophil recruitment was also markedly decreased in the Plg(-/-) mice. While recruitment of leukocytes into the peritoneum was plasminogen-dependent, the adhesion of the emigrating cells to the implants was not. In contrast, adhesion but not recruitment was reduced in fibrinogen-deficient mice. Reconstitution of Plg(-/-) mice with intravenous or intraperitoneal plasminogen differentially restored monocyte/macrophage and neutrophil recruitment. Tranexamic acid, an inhibitor of the lysine binding sites of plasminogen, suppressed leukocyte recruitment in wild-type mice, but aprotinin, a plasmin inhibitor, did not. Plasminogen exerts a marked influence on both neutrophil and monocyte/macrophage recruitment to implanted biomaterials. This role is distinct from that of fibrinogen, and the two inflammatory cell types use plasminogen in different ways. Plasminogen represents a therapeutic target for controlling the inflammatory response to implanted materials.

Animals↗

Surgical treatment of severe periodontitis in a haemophilic patient with inhibitors to factor VIII. Report of a case.

This report describes the surgical treatment of advanced periodontitis in a haemophilic patient with inhibitors to Factor VIII. The treatment was performed after substitution therapy with Factor VIII-concentrate, supported by local and systemic antifibrinolytic treatment with tranexamic acid. No complications developed postoperatively, and after 9 months, the patient did not show recurrence of periodontal disease. Although the present case shows, that even severe periodontitis can be treated surgically in haemophilic patients with inhibitors to Factor VIII, this should not be done unless it is absolutely necessary. The treatment of periodontal disease in such patients should be instituted as early as possible in order to prevent the need for extensive surgery or dental extractions.

Antibodies↗

Factor VIII concentrate prepared from DDAVP stimulated blood donor plasma.

Human fraction I-0 (AHF-Kabi) was prepared from plasma from blood donors who had received an i.v. injection of DDAVP (0.2 microgram per kg b.w.) and tranexamic acid (0.01 g per kg b.w.) 15 min before collection of the blood. The factor VIII preparation from such plasma contained twice as much VIII:C,VIIIR:Ag, and VIIIR:RFC as normal fraction I-0. Normal fraction I-0 and DDAVP fraction I-0 were given to 2 patients with severe haemophilia A. The in vivo response of the DDAVP fraction I-0 corresponded to the in vitro values. No differences in survival time were seen. Hence, it is possible to produce factor VIII concentrates with at least double the yield by increasing the factor VIII level in blood donors by i.v. injection of DDAVP.

Adult↗

Acquired von Willebrand's syndrome and Ehlers-Danlos syndrome presenting with gastro-intestinal bleeding.

The clinical and laboratory findings in a patient with severe gastro-intestinal bleeding and the Ehlers-Danlos syndrome are described. Coagulation studies and a lack of history of previous haemorrhage were consistent with a diagnosis of acquired von Willebrand's syndrome. His response to treatment with blood transfusion, Factor VIII, cimetidine, tranexamic acid and cyclophosphamide is described. Family studies revealed other members with Ehlers-Danlos syndrome but normal coagulation.

Aged↗

Pregnancy and parturition in a patient with severe Glanzmann's thrombasthenia.

A 35-year-old woman with severe Glanzmann's thrombasthenia became pregnant involuntarily. As a late abortion might cause a bleeding as severe as a delivery, legal abortion was not considered indicated. Treatment with ordinary platelet concentrates was not considered since even HLA-matched platelets did not enhance the platelet function, measured as the aggregability of transfused platelets. This inability was thought to indicate that the patient might have developed antibodies against one of the glycoproteins deficient in this disease. A delivery per vaginam was then preferred because of the local compressing effect. Spontaneous delivery occurred at the end of the 42nd week of pregnancy. The patient delivered a boy with transient thrombocytopenia, probably due to maternal antibodies. To stimulate the haemostasis, uterine contracting drugs were used in unusually large doses and for a relatively long period of time. Tranexamic acid was also given. No haemorrhagic complications could he observed during the puerperium.

Adult↗

Disseminated intravascular coagulation (DIC) in adult patients with acute leukaemia.

In 71 patients with acute leukaemia admitted for remission induction, disseminated intravascular coagulation (DIC) was looked for in 50 patients and diagnosed in 10 (20%). Of 10 patients with acute lymphoblastic leukaemia, 3 had DIC, and of 40 patients with acute myeloblastic leukaemia, 7 had DIC. The presence of DIC was related to bleeding manifestations within the first 2 weeks. A haemorrhagic diathesis was present in all DIC patients: 4 had minor and 6 had major bleeding, i.e. WHO grade > or = 2. In addition to blood product support, most DIC patients were treated with low doses of heparin and tranexamic acid. In all DIC patients the haemorrhagic symptoms preceded the heparin administration. Among 40 screened patients without DIC, 17 patients had minor and 3 had major haemorrhagic manifestations. Thus, the proportion of patients with major bleeding was significantly greater among the DIC patients (6/10 vs 3/40, p < 0.001). In conclusion, DIC at presentation was associated with a significantly increased risk for severe haemorrhagic complications and should be looked for in adults with acute leukaemia.

Adolescent↗

Views of cardiac-valve prosthesis patients and their dentists on anticoagulation therapy.

By administering a questionnaire to 253 patients with cardiac-valve prostheses (89.3% responding), and another to 136 of their attending dentists (79% responding), the level of knowledge among both groups of anticoagulant therapy in connection with dental treatment was investigated. The cardiothoracic department monitored all anticoagulation therapies. Of the anticoagulated patients, 96.6% were able to state their medication (94.1% received phenprocoumon); and of 86 dentists with patients on anticoagulation treatment, 94% were aware of their patients' medication. All 20 dentists stating that their patients did not receive anticoagulants were correct. The great majority (98%) of the dentists employed a special measure to reduce the risk of bleeding associated with invasive dental procedures, most commonly (86%) referring patients to their general practitioner or hospital department for adjustment of the anticoagulant therapy. Around 60% of the dentists considered extractions and operations to require measures to reduce the risk of bleeding complications. We recommend referral of patients to the attending physician for adjustment of anticoagulation to a target International Normalized Ratio (INR) of 4.0 or possibly 3.0 before undergoing dental procedures involving the risk of bleeding. Additional reduction of the bleeding risk can be obtained by local application of an inhibitor of fibrinolysis (tranexamic acid).

Adult↗

Separation of plasma kallikrein and a kallikrein-like plasminogen activator generated by acetone in rat plasma.

Plasminogen activator (PGA), kininogenase (Kase) and benzoyl arginine ethyl ester (BAEe) activities generated in plasminogen-free rat plasma by incubation with acetone (23% v/v) at 22 degrees were purified. The activities passed unadsorbed through columns of DEAE-Sephadex A-50 (pH 7.8) and arginine methylester-Sepharose 4B (pH 8.5). Part of the activities (rat plasma kallikrein) was adsorbed onto a soybean trypsin inhibitor (SBTI)-Sepharose 4B column at pH 8.5. At pH 7.0 a fraction with higher ratios PGA/BAEe esterase and Kase/BAEe esterase was also adsorbed. Both fractions could be eluted with 5 mM sodium hydroxide. The fraction not adsorbed at pH 8.5, but adsorbed at pH 7.0 was designated low molecular weight plasminogen activator (LMr-PGA), a plasminogen activator fraction with higher molecular weight, but without esterase activity being also present (Berstad & Briseid 1982). LMr-PGA was strongly inhibited by tranexamic acid (AMCA) 0.10 mM, whereas the fraction designated rat plasma kallikrein was not. By polyacrylamide gel electrophoresis Mr-values in the range 120,000 to 130,000 were established for native samples of both rat plasma kallikrein and LMr-PGA, whereas Mr-values of 78,000 to 80,000 were established after treatment with SDS.

Acetone↗

Recombinant factor VIIa in an infant with haemophilia A and inhibitors.

Post-traumatic bleeding from the gingiva in a 16-month-old boy with severe haemophilia A did not stop after treatment with factor VIII concentrate and tranexamic acid, and it was demonstrated that he had developed antibodies to factor VIII. Treatment with recombinant factor VIIa 60-90 micrograms/kg body weight four to eight times daily, together with local measures, stopped the bleeding and no complications were seen.

Factor VIII↗

High permissivity of human HepG2 hepatoma cells for influenza viruses.

Human HepG2 hepatoma cells are highly permissive for influenza virus type A and type B, even without the addition of trypsin, and they exhibit a marked cytopathic effect. This property greatly facilitates the primary isolation of influenza viruses. Virus replication was significantly reduced by the plasmin(ogen)-specific inhibitor tranexamic acid, and this suggests a potential role played by the plasminogen/tissue plasminogen activator complex at the surface of HepG2 cells. This might represent a new approach for study of the interrelations of this complex with influenza viruses.

Animals↗

Desmopressin and bleeding time in patients with cirrhosis.

Desmopressin acetate 0.3 microgram/kg was given intravenously to nine patients with chronic liver disease and to a further six such patients in a double blind controlled study versus placebo. Desmopressin acetate significantly shortened the bleeding time compared with basal values in both groups and compared with placebo. There was also a significant decrease in partial thromboplastin time (but not prothrombin time) and significant increases in factor VIII and its components, von Willebrand factor and ristocetin cofactor activity, but not in factors VII, IX, X, XI, or XII. Increased fibrinolysis could be blocked by concomitant administration of tranexamic acid. No important side effects were seen. The multimer pattern of von Willebrand factor was studied for the first time in chronic liver disease. It was normal, but after administration of desmopressin acetate the percentage of multimers of higher molecular weight increased significantly. This may be an important mechanism in the shortening of the bleeding time in cirrhosis, as has been shown in uraemia and other conditions after administration of desmopressin acetate. Desmopressin acetate may be useful in correcting defects in primary haemostasis in chronic liver disease.

Bleeding Time↗

Best evidence topic report. Antifibrinolytics for the initial management of sub arachnoid haemorrhage.

A short cut review was carried out to gather the evidence for and against the use of tranexamic acid to patients who have suffered subarachnoid bleeding. 267 papers were found using the reported search, of which one presented the best evidence to answer the clinical question. The author, date, and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of this best paper are tabulated. A clinical bottom line is stated.

Adult↗