Heparin neutralization of PGI2: effects upon platelets.

Heparin neutralizes the inhibitory effect of prostacyclin (PGI2) on platelet aggregation. The PGI2-induced enhancement of platelet cyclic adenosine monophosphate levels is also inhibited. The mechanism appears to involve a direct interaction in which heparin neutralizes the inhibitory effects of PGI2 on platelet aggregation but, at the same time, does not lose its own anticoagulant activity. These findings may explain instances in which heparin infusions have been reported to produce hyperaggregation of platelets, thrombotic episodes, and thrombocytopenia in patients.

Efficacy of decitabine in the treatment of patients with chronic myelomonocytic leukemia (CMML).

Chronic myelomonocytic leukemia (CMML) characterized by cytopenias, bone marrow and peripheral blood cell dysplasia is notoriously hard to treat. Recent reclassification of CMML as a myelodysplastic/myeloproliferative (MDS/MPS) disease rather than a myelodysplastic syndrome (MDS) by the World Health Organisation (WHO) has led to a review of CMML patients treated with decitabine. Overall response rates (ORR) (complete response [CR]+partial response [PR]) in the subset of patients with CMML in one pivotal phase 3 trial (D-0007) and two phase 2 trials (PCH 95-11, PCH 97-19) decitabine were reviewed. For consistency across trials, all decitabine-treated patients were evaluated using the phase 2 response criteria (CR was defined by normocellular bone marrow with <5% blasts and normal Hgb, WBC, and platelet counts, and PR required 50% decrease in blast count, increases in Hgb by >1.5 mmol/L, WBC count by >1000, and platelet count by >50,000). A total of 31 patients diagnosed with CMML are included in this review. Similar demographics and disease characteristics were observed in all three studies, with an average age of 70.2 years and 71% of patients male. Baseline WBC of >20,000 were observed in 8/28 (29%) patients and baseline bone marrow blasts >5% in 11/28 (39%) patients. All clinical responses were centrally reviewed. The ORR was 25% (14% CR+11% PR). Hematologic improvement was observed in 11% of patients and stable disease in 39% of patients. The decitabine adverse event profile seen in CMML patients was similar to observations in other hematologic patient populations, with myelosuppression and related infectious complications. These data demonstrate encouraging activity for decitabine in CMML, and suggest that studies in other myeloproliferative diseases may be warranted.

The anticoagulant activity of lysosomal cationic proteins from polymorphonuclear leukocytes.

A cationic protein fraction from rabbit polymorphonuclear leukocyte lysosomes has been shown to exert a potent anticoagulant effect on human blood in vitro. The anticoagulant activity is detectable in the whole blood clotting time, the recalcification time of platelet-rich plasma, the prothrombin time, the partial thromboplastin time, and the thromboplastin generation test. The lysosomal cationic proteins do not inhibit any of the known specific procoagulants. They appear to inhibit clotting by blocking the formation of intrinsic thromboplastin possibly by interfering with the role of phospholipids in the reaction involving Factors V and X and calcium.

Myelodysplastic syndromes in the elderly: the role of growth factors in management.

Myelodysplastic syndrome (MDS) comprises a group of heterogeneous clonal bone marrow disorders leading to peripheral cytopenia(s) and hypercellular marrow in the majority of the patients. The morphology of the cell lines is characterized by dysplastic features in some or all cell lines. The FAB classification has divided MDS in five subgroups, namely (1) RA (refractory anemia); (2) RARS (refractory anemia with ring sideroblasts); (3) CMML (chronic myelomonocytic leukemia); (4) RAEB (refractory anemia with excess blasts); and (5) RAEB-T (refractory anemia with excess blasts in transformation). Myelodysplastic syndrome remains primarily a disease of the elderly. With a reported median age of 74.4 years, patients have a chronic relentless course with complication of cytopenias, and a significant number of MDS patients, especially from the RAEB and RAEB-T categories, end up in acute myeloid leukemic transformation. Cytogenetic abnormalities are present in 40-58% of the cases and can provide not only help in diagnosis, but also understanding regarding the clinical course and prognostic aspect. Management of MDS is quite pragmatic and at this stage far from satisfactory. Various modalities have included use of differentiating agents, aggressive chemotherapy, bone marrow transplant and, more recently, significant interest has been generated in the use of hematopoietic growth factors. Differentiating agent trials have been unrewarding so far; chemotherapy trials have resulted in less benefit and more early toxic deaths, especially in the elderly MDS patients where the disease predominates. Bone marrow transplant appears suitable for some patients who are at a younger age. Salvation from this disease is being searched in the proper usage of hematopoietic growth factors and cytokines. There has been concern, however, that usage of growth factors has led to early and enhanced transformation of these patients to frank acute leukemic states. This concept appears to be somewhat refuted by newer controlled trials with GM-CSF and G-CSF, emphasizing that the acute leukemic transformation is the natural course of the disease and is not hastened by growth factor use. Preliminary studies are also suggesting that a combination of growth factors, especially G-CSF and erythropoietin as compared to chemotherapies, could be more beneficial in prolonging the survival of MDS patients who have progressed to the acute leukemic phase. More studies are needed for the understanding of the pathogenetic mechanism(s) in order to facilitate a more suitable and appropriate management strategy for MDS.

Platelet inhibitory activity in placentas from normal and abnormal pregnancies.

Retroplacental blood flow requires inhibition of coagulation in the absence of an endothelial lining. We confirmed that trophoblast releases an inhibitor of platelet aggregation which functions via degradation of adenosine diphosphate. This inhibitor appears to be deficient in some pregnancies with abruptio placentae and intrauterine growth retardation. Unimpeded retroplacental blood flow may depend upon the local inhibition of platelet aggregation. Placental tissue contains an inhibitor of platelet aggregation which appears to be an adenosine diphosphatase distinct from heat-stable alkaline phosphatase. Placental tissue from patients with abruptio placentae contains abnormally low amounts of this enzyme.

Serum prostacyclin binding and half-life in normal and hypertensive pregnant women.

The effective half-life of prostacyclin in human serum is highly dependent on binding to serum proteins. Abnormalities in prostacyclin binding appear to be important in some patients with thrombotic thrombocytopenic purpura. We investigated prostacyclin binding and half-life in normotensive and hypertensive pregnant women and in nonpregnant controls. Pregnancy was associated with a decrease in serum prostacyclin binding and a shorter prostacyclin half-life. This decrease was even greater in women with hypertensive disorders. The decrease in prostacyclin half-life in hypertensive disorders may play an important role in the pathogenesis of these disorders. Measurement of both production and metabolism, however, will be required to adequately assess the role of prostacyclin in normal and abnormal gestation.

Metastatic seminoma simulating malignant lymphoma in an HIV infected hemophiliac.

Although most common, malignant lymphoma and Kaposi's sarcoma are not the only malignancies encountered in lymph nodes from HIV-infected patients. An increased frequency of testicular germ cell tumors in HIV-infected individuals has been reported. We report here the first case, to our knowledge, of a metastatic seminoma in an HIV-infected hemophiliac. The atypical clinical presentation, cervical and axillary adenopathy, simulated malignant lymphoma. The diagnosis was first suspected when a fine needle aspiration biopsy from an enlarged cervical node revealed a mixture of benign appearing lymphocytes and loosely cohesive large tumor cells in a "tigroid" background. Immunocytochemistry and a subsequent excisional biopsy confirmed the cytologic diagnosis. Metastatic germ cell tumors should be considered in the differential diagnosis of HIV-related lymphadenopathy.

Endotoxin-mediated inhibition of human platelet aggregation.

A variety of endotoxins, when added to human platelet-rich plasma (PRP) or to suspensions of washed platelets (WP), demonstrated an inhibitory effect on platelet aggregation induced by various aggregating agents. Endotoxin blocked the release of 14C serotonin from platelets but had no influence on cyclic AMP production. Endotoxin did not interfere with thromboxane generation by platelets. However, endotoxin-treated platelets failed to respond to added thromboxane. The inhibitory effect of endotoxin on platelet aggregation was more pronounced in the presence of ionophore A23187 as compared to other aggregating agents and was effectively reversed by calcium but not by magnesium, another divalent cation. Furthermore, endotoxin failed to inhibit the ristocetin-induced agglutination of formaldehyde-fixed platelets; a non-calcium dependent phenomenon. These findings appear to suggest that endotoxin-mediated inhibitory activity of platelet aggregation is related to the interference in the role of calcium. The antiaggregatory activity of endotoxin appears to be due to a direct and rapid action on platelets and not due to a non-specific binding, as the effect was not abolished by washing the endotoxin-incubated platelets. Endotoxin-mediated alteration of platelet function may contribute to bleeding diathesis in septecemic and endotoxemic patients.

Antiheparin activity in human endothelial cells.

Human endothelial cells possess antiheparin activity that neutralizes the anticoagulant action of heparin as measured by different tests of the clotting system. The antiheparin activity appears to be associated with an acid-soluble basic protein present in the particulate fraction of the endothelial cell cytoplasm. This finding might have some relevance in the maintenance of hemostasis. Furthermore, it might also have a pharmacological role in terms of resistance to exogenously infused heparin in patients with thromboembolic disorders.

A neurophysiological method of rapid detection and analysis of marine algal toxins.

We have examined the effectiveness of the in vitro rat hippocampal slice preparation as a means of rapidly and specifically detecting the marine algal toxins saxitoxin, brevetoxin, and domoic acid and have identified toxin-specific electrophysiological signatures for each. Brevetoxin (PbTX3, 50-200 nM) produced a significant reduction in orthodromic population spike amplitude which was quick to reverse during a 50 min wash-out, while antidromic population spikes and field EPSPs exhibited only slight reductions, and fibre spiof orthodrokes showed no change at all. Domoic acid (100 nM) produced a robust, reversible increase in amplitude mic spikes, and the appearance of multiple spikes (i.e., epileptiform activity) within minutes of toxin wash-in. Other notable features of the domoic acid signature included a significant decrease in amplitude of the field EPSPs, and a complete absence of effect on either antidromic or fibre spikes. Fifty nanomolar saxitoxin (PSP) abolished all responses in all slices. Only antidromic spikes showed any recovery during wash-out. Field EPSP and fiber spike analysis further demonstrated that the preparation is capable of reliably detecting saxitoxin in a linearly responsive fashion at toxin concentrations of 25-200 nM, and tests of naturally contaminated shellfish confirmed the utility of this assay as a screening method for PSP. Our findings suggest that the in vitro hippocampal slice preparation has potential in the detection and analysis of three marine algal toxins important to the shellfish industry.

Histiocytic medullary reticulosis: association with myeloproliferative state and desmoplasia.

A patient with histiocytic medullary reticulosis also had two unusual associations: myeloproliferative state and desmoplastic reaction. These alterations appear to be more than mere chance associations, ie, they seem to be intimately involved with the histiocytic proliferation.

Heparin-mediated neutralization of platelet antiaggregatory activity of prostacyclin (PGI2): studies on mechanism.

Prostacyclin (PGI2) is a well-known potent inhibitor of platelet aggregation. Its role has been implicated in physiological and pathological states of hemostasis. Heparin blocks the prostacyclin-mediated antiaggregatory activity on platelets. Prior treatment of heparin with heparinase as well as with protamine destroyed heparin's ability to neutralize PGI2. Studies on the mechanism of heparin blocking of PGI2 activity suggested that heparin interacted directly with PGI2, as shown by the loss of PGI2 mobility on thin layer chromatography concomitant with the loss of PGI2-mediated inhibition of platelet aggregation. PGI2 in this combination with heparin, nevertheless, retained its time-dependent ability to be hydrolyzed to 6-keto-PGF1 alpha. Findings of these studies may have implications in thrombosis and hemostasis, particularly in heparin-mediated abnormalities of circulating platelets.

IgM Myeloma: An IgM Gammopathy Distinct from Waldenstrom's Macroglobulinemia.

A 65-year-old patient with an IgM gammopathy, plasma cell infiltration of the bone marrow, lytic lesions of the skeleton, and symptoms of hyperviscosity was evaluated. A diagnosis of IgM myeloma was made. Treatment for multiple myeloma was initiated and resulted in a significant clinical response. There is ongoing debate whether IgM myeloma exists as a unique entity, oras a variant of Waldenstrom's macroglobulinemia. We reviewed the English literature and discovered only six cases documented as IgM multiple myeloma. Further investigation revealed 30 reported cases, which had characteristics typical of an IgM myeloma, but were documented as variations of B-cell neoplastic disease. We acknowledge IgM myeloma to be an entity distinct from Waldenstrom's macroglobulinemia. It is characterized by an IgM monoclonal gammopathy, a predominance of plasma cells infiltrating the bone marrow, and typically associated with osteolytic lesions and/or osteoporosis. Recognizing IgM myeloma is necessary for appropriate disease management.

Effect of heparin on platelet aggregation.

The effect of heparin on platelet aggregation was systematically examined on platelets in plasma (PRP), as well as on gel-filtered, washed, and formaldehyde-fixed platelets. Results indicate that, although heparin causes a mild potentiation of platelet aggregation in the PRP systems, a significant inhibitory activity is observed when heparin is added to isolated platelets. This inhibitory activity appears to be specific and not related to the impurities in the heparin preparations, as heparinase, as well as protamine, effectively neutralizes the heparin-mediated inhibitory activity on platelet aggregation. Although heparin-mediated inhibitory activity can be demonstrated in the presence of a number of different agonists (ADP, arachidonic acid, thrombin, Ionophore A23187, epinephrine, and ristocetin), the most pronounced inhibition is seen in the presence of ristocetin. Further studies show that heparin enhances thromboxane generation in isolated platelets. Platelets pretreated with heparin, however, fail to respond to preformed thromboxane. These findings suggest that, in addition to the potentiation of thromboxane production in platelets, heparin may also attribute some change(s) to the platelet(s)/platelet membrane, which interferes with their ability to respond to the agonists of platelet aggregation. This antiaggregatory activity of heparin was found to be inhibited by a factor(s) present in plasma but not in serum.