Toshihiro Kaneko

Increased plasma-soluble fibrin monomer levels in patients with disseminated intravascular coagulation.

Plasma‐soluble fibrin monomer (SFM) level in patients with disseminated intravascular coagulation (DIC) was significantly higher than the level in patients with pre‐DIC or in non‐DIC patients, and the level in patients with pre‐DIC was significantly higher than that in non‐DIC patients. There was no significant difference in plasma SFM levels among various diseases underlying DIC. Plasma SFM level in patients with good outcome was significantly decreased after treatment for DIC. The sensitivity of fibrin degradation products and platelet number was high for DIC, but not for pre‐DIC. The sensitivity of thrombin‐antithrombin III complex, plasmin‐plasmin inhibitor complex, and SFM was high for both DIC and pre‐DIC. The specificity of these markers was also high. Receiver operating characteristic analysis suggests that plasma SFM level could be the most useful marker for the diagnosis of both DIC and pre‐DIC.

Effect of lipoproteins on tissue factor activity and PAI-II antigen in human monocytes and macrophages

Expression of the tissue factor (TF) and the plasminogen activator inhibitor-II were induced in cultured human monocytes-macrophages by incubation with lipoproteins. Very low-density lipoprotein (VLDL) augmented the TF and PAI-II expression the most, followed by low-density lipoprotein (LDL) and a very weak effect by high-density lipoprotein (HDL). In macrophages pre-cultured for 3 days, oxidized LDL augmented the expression of TF activity in the macrophages to a greater extent than native LDL. These findings indicate that lipoproteins affect both monocytes and macrophages, and that they induce a hypercoagulable-hypofibrinolytic state. Thus hyperlipidemia may be a direct risk factor for thrombotic disease.

Frequency of Abnormal Biphasic aPTT Clot Waveforms in Patients with Underlying Disorders Associated with Disseminated Intravascular Coagulation

Abnormal biphasic waveform (BPW) patterns were previously reported when the activated partial thromboplastin time (aPTT) was performed in plasma from patients with disseminated intravascular coagulation (DIC). In this study, the prevalence of the BPW was examined in a cohort of 508 hospitalized patients with elevated fibrinogen degradation products (FDP) levels (>10 μg/mL). The presence of a BPW was automatically flagged by the MDA® analyzer when the slope of the precoagulation phase in the waveform exceeded a threshold value of -0.25%T/sec. In our cohort, 76 patients (15%) were diagnosed with overt DIC according to the criteria recently proposed by the International Society of Thrombosis and Haemostasis (ISTH), whereas 96 patients (18.9%) were diagnosed with DIC following the criteria of the Japanese Ministry of Health and Welfare (JMHW). The JMHW and ISTH criteria agreed in 93% of cases (kappa coefficient 0.76). The concordance between both scoring systems was high in patients with infection but low in solid cancer. The BPW appeared in 65 patients (12.8%), with the highest prevalence (23.6%) in patients with infection. The BPW was more prevalent in the subgroup of patients with DIC: 59.2% and 47.9% for DIC diagnosed by ISTH and JMWH scores, respectively. The prevalence of the BPW was particularly high in patients with DIC and infection: 86.4% and 75.0% for DIC diagnosed by ISTH and JMWH scores, respectively. For the total cohort, the presence of the BPW was significantly associated with DIC. Odds ratios were 29.9 and 19.0 for ISTH and JMWH scores, respectively (p<0.0001). The BPW showed a moderate sensitivity (59.2% for the ISTH score; 47.9% for the JMWH score), but a high specificity (95.4% for both scores). Waveform analysis of the aPTT potentially provides a practical tool in risk assessment of critical care patients, in whom development of DIC is known to worsen the prognosis.

Reduced neutrophil CD10 expression in nonhuman primates and humans after in vivo challenge with E. coli or lipopolysaccharide

CD10, also known as neutral endopeptidase or CALLA, is a major metalloproteinase that regulates levels of biologically active peptides that initiate inflammatory, cardiovascular, and neurogenic responses. Relative tissue expression levels of CD10, its peptide substrates, and their receptors constitute the basic regulatory mechanism. Neutrophils contain abundant CD10 and are rapid responders to an inflammatory septic challenge. Expression of neutrophil surface antigens in response to inflammation was studied in the primate model of Escherichia coli-mediated sepsis and in human volunteers injected with lipopolysaccharide (LPS). There was a rapid and profound (up to 95%) reduced baboon neutrophil CD10 expression in response to E. coli injections of 5.71 × 106 CFU/kg to 2.45 × 109 CFU/kg that gradually resolved to preinjection levels. The reduction was both dose and time dependent. Reduced CD10 antigen on mature baboon neutrophils and bands was observed by immunohistochemistry. Human volunteers challenged with 4ng/kg LPS experienced transient chills, nausea, fever, and myalgia. Up to ∼20% of their neutrophils had reduced CD10 expression, peaking at 2 to 8 h after injection. By 24 h, neutrophil CD10 expression resolved to preinjection levels. In contrast, in both the baboon and human studies, other neutrophil surface antigens were only slightly decreased (CD11a) or increased (CD11b, CD18, CD35, CD66b, and CD63). These data present the novel observation that neutrophil CD10 expression decreases significantly in response to in vivo inflammatory challenge. This decrease appears to be unique to CD10 and may contribute to a reduced regulation of bioactive peptides released in response to inflammatory challenge.

Haemostatic abnormalities and thrombotic disorders in malignant lymphoma.

We examined haemostatic abnormalities and thrombotic disorders in 217 patients with malignant lymphoma. Plasma levels of fibrinogen and D-dimer were significantly higher in patients with malignant lymphoma than in healthy subjects. The incidence of severe complications, such as disseminated intravascular coagulation (DIC) and interstitial pneumonia (IP), differed with each clinical stage or histological type, but they occurred frequently in stage IV or natural killer (NK) cell lymphoma. Plasma levels of fibrinogen degradation products (FDP) and D-dimer, leukocyte tissue factor (TF) mRNA and plasma TF antigen were significantly higher in stage IV than in stage I, II or III. Plasma levels of FDP, D-dimer, and leukocyte TF mRNA in NK cell lymphoma were markedly higher than in other types of lymphoma. Immunohistochemical staining of NK cell lymphoma revealed that granulocyte macrophage colony-stimulating factor was positive in tumour cells, whereas von Willebrand factor and TF were positive in vascular endothelial cells of surrounding tissue. Our results suggested that patients with stage IV disease and NK cell lymphoma were in abnormal thrombotic and haemostatic state, and may frequently develop DIC and IP. One of the mechanisms of DIC and IP may involve elevated cytokine production by lymphoma cells, which can stimulate the expression of TF in blood cells or surrounding tissue.

Proteinase 3 expression on neutrophil membranes from patients with infectious disease.

ABSTRACT Proteinase-3 (PR3) is an abundant serine proteinase stored in the azurophilic granules of neutrophils and released to the cell surface upon activation where it contributes to local tissue destruction and inflammation. The sub-population of membrane PR3 (mPR3) high expression (PR3-high) varies among individuals. There are many reports about PR3 in Wegeners granulomatosis, but few about PR3 expression in patients with common inflammatory disorders, such as sepsis. The mPR3 expression on neutrophils from 56 patients with inflammatory disorders and from 64 healthy volunteers was examined by flow cytometry. High variability in the percentage of PR3-high (%PR3-high) neutrophils was observed in healthy volunteers and patients with inflammatory disease, and the %PR3-high was significantly greater in the patients (72 ± 19% vs 55 ± 20%, P < 0.0001). Overall neutrophil PR3 expression in patients with infectious diseases, especially systemic inflammatory response syndrome (SIRS) was significantly high (P < 0.01) and showed a positive correlation with C-reactive protein (CRP). Even under inflammatory conditions not involving autoimmune vasculitis, there are significant increases in both the absolute surface expression of PR3 and the numbers of neutrophils expressing high levels of PR3 and these correlate with CRP levels. The data are consistent with a model in which neutrophil membrane expression of PR3 is greatly influenced by an in vivo inflammatory environment.

The Membrane Proteinase 3 Expression on Neutrophils Was Downregulated After Treatment With Infliximab in Patients With Rheumatoid Arthritis

Proteinase 3 (PR3) expression on neutrophils was examined in rheumatoid arthritis (RA) patients before and after antitumor necrosis factor (TNF)-α therapy. Membrane PR3 expression from patients with either an infection or RA significantly increased. Membrane PR3 expression on neutrophils from RA patients treated with infliximab (anti-TNF-α antibody) therapy was less than in those without such treatment in a resting state, but the expression later increased after stimulation in vitro. Membrane PR3 expression increased because of the stimulation of TNFα, whereas it was significantly suppressed by plasma or α1-proteinase inhibitor. The condition of patients with RA improved after treatment with infliximab. Membrane PR3 expression on neutrophils in RA patients was downregulated by infliximab. As a result, PR3 might play an important role in the neutrophil-mediated inflammatory reaction in patients with either RA or an infection.

Tissue factor messenger RNA levels in leukocytes compared with tissue factor antigens in plasma from patients in hypercoagulable state caused by various diseases

We compared the levels of tissue factor (TF) mRNA in leukocytes with plasma TF antigens of patients in hypercoagulable state caused by various diseases. Flow cytometric analysis showed absence of TF antigen expression on neutrophils and monocytes in healthy subjects but strong expression in both cell types of patients with infections.TF mRNA levels in leukocytes were low in healthy subjects but they were significantly elevated in patients with underlying diseases of disseminated intravascular coagulation (DIC), especially in acute myeloid leukaemia (AML) and infections.TF mRNA levels in leukocytes were significantly high in patients with all diseases except those with thrombosis, and plasma TF antigen levels were significantly high in all diseases. TF mRNA in leukocytes and plasma TF antigen levels were significantly high in patients with overt-DIC, and TF mRNA/antigen ratio was significantly high in patients with overt-DIC. In patients with solid cancers, TF mRNA and TF mRNA/antigen ratio were significantly higher in patients with metastases than those without. TF mRNA levels in leukocytes and plasma levels of TF antigen did not correlate in normal subjects and all patients, but they tended to be correlated in patients with AML, infections or overt-DIC. Our analysis suggests that TF expression in leukocytes plays an important role in various diseases but the expression level does not always correlate with plasma levels of TF antigen.

Postmortem computed tomography is an informative approach for prevention of sudden unexpected natural death in the elderly.

Introduction Less than 10% of unnatural death cases have been examined by autopsy in Japan. In particular, the causes of death in the elderly have not yet been actively investigated. Here, we evaluated the possible use of postmortem computed tomography (PMCT) to investigate the causes of sudden unexpected natural death (SUND) in the elderly. Methods and subjects Death cases confirmed within 24 hours since the onset of symptoms at the Emergency Department of Mie University Hospital were defined as sudden death cases. A total of 212 sudden death cases, including 175 SUND cases, that occurred in a 3-year period from September 2006 to August 2009 were investigated. Results and discussion The number of sudden death cases was highest in patients in their seventies (56 cases, 26%), followed by patients in their eighties and sixties. Sudden death occurred more in men than in women in their fifties to seventies, while it occurred more in women than in men over the age of 90. PMCT was performed in more than 80% of SUND cases regardless of age of the deceased. The causes in 26 cases (27.1%) were established by PMCT, many of which were hemorrhagic diseases. Signs of aortic aneurysm rupture were detected by PMCT in the thoracic and abdominal areas of 8 patients in their seventies and over, whereas signs were absent in the younger group. Also, more than 18% of sudden death cases in patients in their seventies and over were bathing-related sudden death (BRSD). BRSD was rarely caused by hemorrhagic diseases, suggesting that a drop in blood pressure caused by bathing is an important factor in BRSD. Conclusion PMCT is a method that is relatively acceptable by bereaved families. It is useful for establishing the causes of approximately 30% of the SUND cases examined. The PMCT findings suggested that early detection and treatment of thoracic and abdominal aortic aneurysms and preventive measurements of bathing-related drop in blood pressure are important for the prevention of SUND in the elderly.

Central venous catheter-related thrombosis after replacement therapy for intracranial bleeding in a patient with afibrinogenaemia

T. MATSUMOTO,* H. WADA, S. TAMARU, § Y. SUGIMOTO,* A. FUJIEDA,* K. YAMAMURA,* T. KOBAYASHI,* T. KANEKO, – M. YAMAGUCHI,* T. NOBORI and N. KATAYAMA* *Department of Haematology and Oncology, Mie University Graduate School of Medicine; Haemophilia and Thrombophilia Centre, Mie University Hospital; Clinical Laboratory Medicine, Mie University Graduate School of Medicine; §Institute of Human Reseach Promotion and Drug Development, Mie University Graduate School of Medicine; and –Patient Safety Division, Mie University Hospital, Mie, Japan