Expression of melanoma cell adhesion molecule-1 (MCAM-1) in natalizumab-treated multiple sclerosis.

The objectives were to study the expression of very late antigen (VLA)-4, melanoma cell adhesion molecule-1 (MCAM-1) and activated leukocyte cell adhesion molecule (ALCAM) on CD4+ T cells during natalizumab treatment and to investigate the association with disease activity. We find that subgroups of autoreactive T cells are retained in peripheral blood, in particular MOG-reactive CD4+ T cells expressing MCAM-1. The expression of MCAM-1 or ALCAM on CD4+ T cells was, however, not clearly associated with disease activity (clinical or MRI) during natalizumab treatment. We confirm upregulation of MCAM-1 on CD4+ T cells during natalizumab treatment while VLA-4 is downregulated.

Cerebrospinal fluid biomarkers for predicting development of multiple sclerosis in acute optic neuritis: a population-based prospective cohort study.

BACKGROUND: Long-term outcome in multiple sclerosis (MS) depends on early treatment. In patients with acute optic neuritis (ON), an early inflammatory event, we investigated markers in cerebrospinal fluid (CSF), which may predict a diagnosis of MS. METHODS: Forty patients with acute ON were recruited in a prospective population-based cohort with median 29 months (range 19-41) of follow-up. Paired CSF and serum samples were taken within 14 days (range 2-38), prior to treatment. Prospectively, 16/40 patients were by a uniform algorithm diagnosed with MS (MS-ON) and 24 patients continued to manifest isolated ON (ION) during follow-up. Levels of cytokines and neurofilament light chain (NF-L) were measured at the onset of acute ON and compared to healthy controls (HC). Significance levels were corrected for multiple comparisons ("q"). The predictive value of biomarkers was determined with multivariable prediction models using nomograms. RESULTS: CSF TNF-α, IL-10, and CXCL13 levels were increased in MS-ON compared to those in ION patients (q = 0.021, 0.004, and 0.0006, respectively). MS-ON patients had increased CSF pleocytosis, IgG indices, and oligoclonal bands (OCBs) compared to ION (q = 0.0007, q = 0.0058, and q = 0.0021, respectively). CSF levels of IL-10, TNF-a, IL-17A, and CXCL13 in MS-ON patients correlated with leukocyte counts (r > 0.69 and p < 0.002) and IgG index (r > 0.55, p < 0.037). CSF NF-L levels were increased in ON patients compared to those in HC (q = 0.0077). In MS-ON, a progressive increase in NF-L levels was observed at 7 to 14 days after disease onset (r = 0.73, p < 0.0065). Receiver-operating characteristic (ROC) curves for two multivariable prediction models were generated, with IL-10, CXCL13, and NF-L in one ("candidate") and IgG index, OCB, and leukocytes in another ("routine"). Area under the curve was 0.89 [95% CI 0.77-1] and 0.86 [0.74-0.98], respectively. Predictions of the risk of MS diagnosis were illustrated by two nomograms. CONCLUSIONS: CSF TNF-α, IL-10, CXCL13, and NF-L levels were associated with the development of MS, suggesting that the inflammatory and neurodegenerative processes occurred early. Based on subsequent diagnosis, we observed a high predictive value of routine and candidate biomarkers in CSF for the development of MS in acute ON. The nomogram predictions may be useful in the diagnostic work-up of MS.

In vitro effects of inogatran, a selective low molecular weight thrombin inhibitor.

The thrombin inhibitor inogatran is a synthetic peptidomimetic with a molecular weight of 439 dalton. In vitro studies have shown that inogatran is a classical competitive inhibitor of the active site of thrombin with a Ki of 15 x 10(-9) mol/l. Inogatran doubles the thrombin clotting time in human plasma at 20 x 10(-9) mol/l, APTT at 1.2 x 10(-6) mol/l, and prothrombin time at 4 x 10(-6) mol/l. The effects on rat and dog plasma are similar although slightly weaker. IC50 for inhibition of thrombin-induced aggregation of human platelets is 17 x 10(-9) mol/l. Inogatran has no effect on platelet aggregation induced by ADP or collagen. Up to a concentration of 10 x 10(-6) mol/l inogatran does not inhibit t-PA-induced fibrinolysis as seen in an ECLT system. Inogatran has good selectivity for thrombin as compared to several other serine proteases occurring in the blood. It is concluded that the properties of inogatran in vitro make the compound suitable for further studies in animals and man.

Social influences and cardiovascular risk factors as determinants of plasma fibrinogen concentration in a general population sample of middle aged men.

OBJECTIVE: To analyse the relation between fibrinogen concentration and social class and other social factors found to be related to mortality. The results regarding cardiovascular disease are unpublished, as yet. DESIGN: Cross sectional population study. SETTING: City of Gothenburg, Sweden. SUBJECTS: 639 Men from a population sample of 1016 men aged 50 in 1983. They were all employed and had no history of myocardial infarction or stroke. Fibrinogen values were available for all of them. MAIN OUTCOME MEASURE: Fibrinogen concentration in relation to socioeconomic state according to occupation, and other social influences determined as number of people in the household and scores of social activities and activities in and outside the house. RESULTS: Men with low scores for activities at home had a mean plasma fibrinogen concentration of 3.34 g/l (95% confidence interval 3.21 to 3.47), whereas those with an intermediate score had a mean concentration of 3.16 (3.00 to 3.32) g/l and those with a high score 3.02 (2.95 to 3.10) g/l. Similar inverse relations were noted for the two other activity scores and for occupational class (class 1 being unskilled and semiskilled workers and class 5 professionals and executives) and the number of people in the household. Smoking exerted a strong influence on fibrinogen concentration, the relations between fibrinogen concentration and social factors being evident only in non-smokers. The mean difference in fibrinogen value between the non-smokers with the lowest activity scores at home and those with the highest scores was 0.36 (0.19 to 0.54) g/l, and similar differences were seen for the two other activity scores. Multiple regression analyses showed smoking, body mass index, the sum of all activities (inverse relation), and diabetes to be independently associated with fibrinogen value, whereas occupational class (p = 0.81) and the number of people in the household (p = 0.09) were not. CONCLUSIONS: Psychosocial influences seem to influence the coagulation system in the body in a way that is associated with cardiovascular disease and premature death.

Thrombosis after hip replacement. Relationship to the fibrinolytic system.

Twenty-nine patients were operated on with the Charnley hip prosthesis. All the patients were given dextran 70 as thrombosis prophylaxis. Deep vein thrombosis (DVT) was diagnosed in 10 patients with the radioactive fibrinogen uptake test and phlebography. Variables of coagulation and fibrinolysis were studied before and after surgery. Tissue plasminogen activator (t-PA) activity in the plasma without venous occlusion decreased postoperatively, but there was no correlation with DVT. The t-PA activity in venous occlusion plasma was not reduced after surgery. Plasminogen activator inhibitor (PAI-1) levels were raised immediately postoperatively. There was a significant correlation between preoperative PAI-1 activity and development of postoperative DVT (P less than 0.05). Patients developing DVT had higher levels of PAI-1 postoperatively than patients not developing DVT. A defective fibrinolytic system, as defined by high PAI-1 activity, thus predisposed to postoperative DVT.

A comparison between effects of estradiol valerate and low dose ethinyl estradiol on haemostasis parameters.

Ethinyl estradiol (EE) is still used to some extent as hormonal replacement therapy (HRT) in the climacteric period. As regards oral contraception, it is well known that the induced increase in cardiovascular disease is related to the estrogen component (invariably EE) in a dose-related fashion. Considerably lower doses of EE are needed in HRT compared to oral contraception. To delineate and compare effects of EE and estradiol valerate (E2V) in doses needed in HRT on haemostasis parameters, 24 postmenopausal women were engaged in a study with an open cross-over design. The doses compared (10 micrograms EE and 2 mg E2V daily) are the lowest which eliminate climacteric symptoms in a majority of women. Unlike E2V, EE caused increased levels of factor VII:Ag, factor VIII:C and beta-thromboglobulin, which may be changes towards hypercoagulability. Both estrogens decreased the AT III activity. Long-term administration (6 + 12 w) of the estrogens induced further changes in haemostatic parameters. 10 micrograms EE increased factor VII:Ag in contrast to 2 mg E2V. Furthermore both estrogens increased factor VIII:C and factor II-VII-X. A decrease in platelet count was induced by both EE and E2V. Oral contraception and adjuvant estrogen therapy in men with prostatic carcinoma are known to imply an increased cardiovascular risk. It is noteworthy that the pattern of changes in haemostatic parameters induced by as little as 10 micrograms of EE is the same as seen after the administration of combined oral contraceptives or the substantially higher doses of EE given as adjuvant therapy to men with prostatic carcinoma.

Thrombosis prophylaxis with low molecular weight heparin in total hip replacement.

In a randomized prospective trial, the efficacy of low molecular weight heparin (LMWH) (Fragmin) and dextran 70 (Macrodex) in preventing deep vein thrombosis (DVT) in the legs was evaluated in 98 consecutive patients undergoing elective total hip replacement. The patients were randomly allocated to receive either 2500 anti-factor Xa units LMWH twice daily for 7 days, with the first dose given 2 h before surgery; or 500 ml dextran 70 twice during the day of operation, followed by a single infusion of 500 ml on the first and again on the third postoperative day. DVT was assessed by 125I-fibrinogen test for 2 weeks postoperatively, a positive test being followed by phlebography. DVT developed in 22 (45 per cent) of 49 patients receiving dextran 70 and in 10 (20 per cent) of 49 patients in the LMWH group (P less than 0.01). LMWH was thus statistically significantly better than dextran 70 in preventing DVT in the legs. It was not firmly established whether this benefit was also valid in the high ileofemoral region. Two patients with non-fatal pulmonary embolism were found in each group. Per- and postoperative blood loss and blood transfusion requirements were significantly lower in the LMWH group.

Ultrastructure and function of thrombocytes in a family with congenital bleeding tendency.

Freshly isolated blood from controls and from three members of a family with congenital bleeding tendency were examined with respect to ultrastructure of platelets. The fixation protocol, which included tannic acid, permitted the visualization of substructures in the marginal bundle. Whereas nearly all platelets from the controls had a discoid shape, those from one of the patients (mother of the other two cases) were mostly flat or else roundish with two or three marginal bundles in different orientations. One portion of the thrombocyte fraction of each person was briefly exposed to adenosine diphosphate in order to activate the platelets and thereby to induce shape changes. Most platelets from the controls reacted as expected by rounding up and by projecting some pseudopods. A certain percentage (between 10 and 20%) of the microtubules in these activated platelets had 14 or even 15 protofilaments. The platelets from patients (and in particular the mother) either reacted by an abnormal bulging of the cytoplasm or did not react visibly at all. The microtubules retained their 13-subunit composition or in the abnormally reacted ones often had an open C-shaped cross-sectional profile. The bleeding tendency in this family might be due to a defect in the cytoskeleton of the platelet making it unable to react properly to stimuli.

Platelet reactivity, fibrinogen and smoking.

40 young healthy male volunteers (20 habitual smokers and 20 non-smokers) were investigated with respect to platelet reactivity, plasma fibrinogen and coagulation factor VIII. Smokers had significantly lower systolic blood pressures and higher venous platelet counts. The results for ADP-induced platelet aggregation, plasma concentrations for the 2 alpha-granule proteins, beta-thromboglobulin and platelet factor 4, did not differ between the 2 study groups involved; nor was there any difference between serum thromboxane B2 formation or plasma factor VIII:C activity. However, as compared to non-smokers, plasma fibrinogen levels were significantly higher among the smokers.

A sensitive assay for tissue plasminogen activator activity in plasma, using adsorption on lysine-sepharose.

Tissue plasminogen activator (t-PA) in plasma was separated from inhibitors by adsorption on lysine-Sepharose. It was then determined indirectly by measuring the plasmin generated from plasminogen with poly-lysine as stimulator, in a chromogenic, parabolic rate assay. The reaction proceeded with tissue plasminogen activator and plasmin(ogen) adsorbed on the gel, and followed the kinetics described for similar parabolic rate assays in soluble systems. The assay was standardized against melanoma plasminogen activator (m-PA) and had the sensitivity range of 0.001-0.020 IU (4-80 pg). Anti-m-PA IgG quenched the activity generated in plasma on venous occlusion and part of the activity in pre-occlusion plasma. The method was sensitive to purified urokinase. The basic plasma values in resting normal individuals were: mean 0.08, range 0.01-0.26 X 10(3) IU/l (n = 19), and after 20 min of venous occlusion: mean 2.48, range 0.24-4.34 X 10(3) IU/l (n = 10). The assay correlates well with a fibrin plate method, r = 0.96.

Influence of fibrin clots on development of granulation tissue in preformed cavities.

To examine the influence of fibrin clots, perforated Teflon cylinders have been implanted subcutaneously in rats. Fibrin clots made from both species specific fibrinogen and from an non-species specific preparation, together with ingrowing granulation tissue, kept the implanted cylinder filled during the four week study period. This was valid for both concentrations investigated. Interaction between granulation tissue and fibrin clot differed between the two fibrin types.

Prostacyclin infusion during extracorporeal circulation foe coronary bypass.

The effects of prostacyclin on whole blood platelet count, blood coagulation factors, and postoperative bleeding were investigated in 20 patients undergoing aorta-coronary bypass. Eleven patients received heparin 2 mg/kg and prostacyclin 50 ng/kg/min during cardiopulmonary bypass (CPB). Nine patients received only heparin 3 mg/kg. CPB was by roller pump and bubble oxygenator primed with Ringer's acetate. Hypothermia to 28 degrees C was induced. In the control group, platelet count, corrected for hemodilution, was 70% +/- 15% (mean +/- SD) of pre-CPB value after 30 minutes of bypass and remained at this level 1 hour after CPB. In the prostacyclin group, the platelet count after 30 minutes was 85% +/- 17%, after 120 minutes 111% +/- 20%, and 1 hour after CPB 92% +/- 17%. There was a significant difference between the groups (p less than 0.05) from 60 minutes of CPB up to 1 hour after CPB. Prostacyclin allowed reduction of the heparin dosage while retaining anticoagulation as measured by activated coagulation time (ACT), fibrinopeptide A, and fibrinogen determinations. The ACT was more than 900 seconds in the prostacyclin group after 30 minutes of CPB, as compared to 523 +/- 118 seconds (p less than 0.05) in the control group. This difference diminished later during CPB. In the prostacyclin group, arterial blood pressure was 30 mm Hg or less during the first hour of CPB and the systemic vascular resistance was half of that in the control group. All patients survived. There were no clinical signs of neurologic damage. Postoperative bleeding was 352 +/- 61 ml in the prostacyclin group and 550 +/- 338 ml (NS) in the control group.

Hypergonadotropic hypogonadism in oligophrenia.

Eight patients representing five different, probably hereditary neurological syndromes with oligophrenia and hypogonadism as the common features have been examined clinically and endocrinologically. Two sisters suffered from polyneuropathy, one male from ataxia, one male from spastic tetraplegia, two sisters and a brother from myopathy and one male patient from epilepsy and polyneuropathy. The latter patient was diagnosed as having an acute intermittent porphyria. All the patients had degenerative neurological disorders. The karyotypes were normal. The patients all had signs of hypogonadism. Four male patients had marked testicular atrophy but otherwise normal external genitalia. The testosterone levels in the blood were normal or slightly decreased. Three of the females had their menarche at a normal age but a very early menopause. The fourth female has never menstruated. The four females had normal breasts and body hair. All patients had high basal luteinizing hormone (LH) and follicle-stimulating hormone levels and the response to i.v. LH-releasing hormone was exaggerated. The prolactin values were normal. None of the examined patients had any signs of thyroid or adrenal insufficiency and the sella turcica was normal. A possible etiology to their hypergonadotropic hypogonadism is discussed.

Multiple arterial occlusions and hypertension probably caused by an oral contraceptive: a patient in whom the development of renovascular hypertension has been followed.

An 18-year-old woman taking an oral contraceptive was admitted to hospital because of a stroke due to occlusion of three branches of the right middle cerebral artery. She later developed renovascular hypertension due to occlusion of one of two renal arteries on the right side. Occlusion of the ceoliac artery was also found. The circumstances suggest that the occlusions were caused by multiple emboli, the source of which could not be identified. The kidney with the circulatory disturbance was shown to have a persistent abnormal renin secretion three and six months after the stroke, but the peripheral renin level was lower at the second investigation. Cardiac function studies revealed an alarming degree of left ventricular hypertrophy, and satisfactory blood pressure control could not be maintained despite increasing antihypertensive therapy. Surgical corrrction of the circulatory disturbance promptly led to normotension without drugs, and the patient has remained normotensive during the postoperative observation period of twelve months. The oral contraceptive was probably responsible for precipitating the vascular occlusions, but no predisposing factors or warning symptoms were present to identify this patient as being at risk.

PIP: The case history of an 18-year-old patient, who had been taking oral contraceptives for 2 years (ethinylestradiol 50 mcg, megestrol acetate 4 mg) and who developed multiple arterial occlusions and hypertension, is reported. Occlusion of the ceoliac artery was also found. The circumstances suggest that the occlusions were caused by multiple emboli of unknown source. The affected kidney was shown to have an abnormal renin secretion 3 and 6 months after the stroke, but the peripheral renin level was lower at the 6 month investigation. A large degree of left ventricular hypertrophy was seen. Blood pressure was still uncontrolled despite antihypertensive therapy. Surgery was performed on the affected kidney and normal perfusion restored. The patient then became normotensive, and has remained so for a 12-month period. Oral contraceptives were probably responsible for precipitating the vascular occlusion. Predisposing factors or warning symptoms were absent in this patient.

Disseminated intravascular coagulation and congenital neuroblastoma.

A newborn infant with congenital neuroblastoma complicated by disseminated intravascular coagulation is described. At birth the infant showed liver and spleen enlargement and shortly thereafter malignant cells were found in the bone marrow. On the fifth day of life the infant started to bleed and coabulation analysis indicated disseminated intravascular coagulation. Heparin therapy corrected the coagulation anomaly and irradiation and chemotherapy temporarily improved the general condition of the infant. The infant finally succumbed from tis primary neoplastic disease.