Factor VIII Clotting Antigen (VIIICAg) in Haemophilia Measured by Two Immunoradiometric Assays (IRMA) using Different Antibodies, and the Measurement of Inhibitors to Procoagulant Factor VIII (VIIIC) by IRMA

Factor VIII clotting antigen (VIIICAg) was measured by immunoradiometric assay (IRMA) using two different antibodies. Both antibodies arose in polytransfused severe haemophiliacs and had similar titres against VIIIC. In 12 normal plasmas there was no significant difference in VIIICAg values obtained (VIIICAg (AbI) = VIIICAg (AbII)). In the majority of 15 severe haemophiliacs tested VIIICAg was undetectable by both antibodies. In 28 mild to moderate haemophiliacs VIIICAg (AbII) was significantly greater than VIIICAg (AbI) ( P < 0·01) suggesting different antigenic determinants. The difference, however, was small and does not affect diagnosis of haemophilia. A modified IRMA has been used to measure and VIIIC inhibitors by competition of the inhibitor with ¹²⁵I labelled VIIICAg antibodies for common antigenic determinants. Using an inhibitor of 225 Bethesda units as a standard, results by IRMA of inhibitors in severe haemophiliacs have been similar to those obtained by clotting assay, but with a sensitivity of 0·01 u/ml suggesting the possible use in the detection of weak inhibitors.     

Carrier Detection in Haemophilia A by Immunological Measurement of Factor VIII Related Antigen (VIIIRAg) and Factor VIII Clotting Antigen (VIIICAg)

23 obligate carriers of mild and severe haemophilia A and 26 normal females were bled on three occasions, and their plasmas assayed for procoagulant factor VIII (VIIIC), factor VIII related antigen (VIIIRAg) and factor VIII clotting antigen (VIIICAg). A comparison of the ratios VIIIC/VIIIRAg and VIIICAg/VIIIRAg indicated that, although the two ratios gave the same proportional misclassification of carriers as normals (four of 23), the latter ratio showed greater discriminatory power when an unequal variances predictive method was used to calculate likelihood ratios (for carrier status). This greater power was shown to be due to a greater reproducibility between visits for the VIIICAg/VIIIRAg ratio. Discrimination was considerably better when the median of the three median values for each variable was analysed, compared to the median value obtained at the first visit. There was also no statistical difference between VIIICAg/VIIIRAg (or VIIIC/VIIIRAg) ratios obtained from carriers of severe compared to mild haemophilia.     

Immunoradiometric Assay of Factor VIII Related Antigen, with Observations in 32 Patients with von Willebrand''s Disease

A solid phase non-competitive immunoradiometric assay (IRMA) has been developed which allows measurement of factor VIII related antigen (VIIIR:AG) levels in normal plasma as low as 2.5 x 10(-4) U/ml. The assay is based on the extraction of VIIIR:AG from test plasma by means of polystrene tubes coated with a specific unlabelled anti-VIIIR:AG rabbit antiserum and subsequent labelling of the extracted antigen with 125I-labelled anti-VIIIR:AG rabbit IgG.     

Synthesis of Procoagulant Factor VIII, Factor VIII Related Antigen and other Coagulation Factors by the Isolated Perfused Rat Liver

The synthesis of factor VIII and other coagulation factors has been studied using an isolated, perfused rat liver. Synthetic function of the liver was validated by adding [35S]L-methionine to the perfusion medium and performing two-dimensional crossed immunoelectrophoresis and autoradiography on samples obtained during perfusion. Progressive incorporation of radioactivity into plasma proteins was demonstrated. This was inhibited by cycloheximide. Coagulation factor assays demonstrated synthesis of factors II, IX and X and of factor V and procoagulant factor VIII (VIIIC). Synthesis of factor VIII related antigen (VIIIRAg), measured in an immunoradiometric assay, was not significantly demonstrated. Addition of warfarin to the perfusion medium inhibited the synthesis of factors II, IX and X but not of factors V and VIII. Cycloheximide completely inhibited synthesis of all coagulation factors but actinomycin acted only after a latent period. Reticuloendothelial cell blockade was attempted by adding ethionine to the perfusion medium or by administration of Indian ink to the donor animals prior to removal of the livers. In these instances synthesis of factor V and factor VIIIC was inhibited but not that of factors II, IX and X. The results confirmed the functional capacity of the isolated liver for synthesizing proteins and the vitamin K dependent coagulation factors, and suggested similar kinetic features for the synthesis of factors V and VIIIC. Failure to detect significant VIIIRAg synthesis in these experiments is consistent with the hypothesis that this protein is released by vascular endothelial cells throughout the body and is activated or joined to VIIIC or stimulates its production in the liver.     

Nonalcoholic Fatty Liver Disease as a Risk Factor of Arterial Stiffness Measured by the Cardioankle Vascular Index

Nonalcoholic fatty liver disease (NAFLD) is associated with risk factors for cardiovascular disease. The cardioankle vascular index (CAVI), a new measure of arterial stiffness, was recently developed and is independent of blood pressure. We investigated whether NAFLD is associated with arterial stiffness as measured using the CAVI in an apparently healthy population.A total of 2954 subjects without any known liver diseases were enrolled. NAFLD was diagnosed via typical ultrasonography. The clinical characteristics examined included age, sex, body mass index (BMI), waist circumference (WC), and the levels of aspartate aminotransferase, alanine aminotransferase, total cholesterol, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol triglycerides, and glucose. Arterial stiffness was defined using an age- and sex-specific threshold of the upper quartile of the CAVI.NAFLD was found in 1249 (42.3%) of the analyzed subjects. Using an age-, sex-, and BMI-adjusted model, NAFLD was associated with a 42% increase in the risk for arterial stiffness (highest quartile of the CAVI). The risk for arterial stiffness increased according to the severity of NAFLD (adjusted odds ratio [95% confidence interval], 1.27 [1.02 − 1.57] vs 1.78 [1.37 − 2.31], mild vs moderate-to-severe, respectively). When adjusted for other risk factors, including BMI, WC, smoking status, diabetes, and hypertension, these relationships remained statistically significant.Patients with NAFLD are at a high risk for arterial stiffness regardless of classical risk factors. The presence of cardiometabolic risk factors may attenuate the prediction of arterial stiffness by means of NAFLD presence. Thus, physicians should carefully assess subjects with NAFLD for atherosclerosis and associated comorbidities.     

Fibroblast Growth Factor 21 as a Marker of Prediabetes in Patients with Non-alcoholic Fatty Liver Disease

BackgroundFibroblast growth factor 21 is a peptide primarily secreted by the liver in response to peroxisome proliferator-activated receptor-α activation which plays an important role in regulating carbohydrate and lipid metabolism. This study investigated the association between fibroblast growth factor 21 and prediabetes in obese patients with non-alcoholic fatty liver disease in adult population.MethodsA total of 85 obese non-alcoholic fatty liver disease patients without (n = 49) and with prediabetes (n = 36) were included. Serum fibroblast growth factor 21 levels were determined by enzyme-linked immunosorbent assay.ResultsHigher fibroblast growth factor 21 serum levels were observed in patients with prediabetes, metabolic syndrome, dyslipidemia, and insulin resistance. There were significant correlations between fibroblast growth factor 21 and waist-to-stature ratio, visceral adiposity index, triglycerides, very low-density lipoproteins, alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT), Quantitative Insulin Sensitivity Check Index, and Stumvoll index of insulin sensitivity. Fibroblast growth factor 21 level ≥320 pg/mL was associated with a 4.2-fold higher risk of prediabetes and ≥270 pg/mL for metabolic syndrome approximately 4 times.ConclusionFibroblast growth factor 21 is associated with increased risk for prediabetes, metabolic syndrome, and insulin resistance in obese patients with non-alcoholic fatty liver disease.     

Factor VIII:C and VIII:CAg Response in Patients with Haemophilia A and von Willebrand's Disease after Administration of Different Factor VIII Concentrates or Plasma

S ummary . Factor VIII procoagulant activity (VIII:C) and factor VIII procoagulant antigen (VIII:CAg) were studied in seven patients with haemophilia A after administration of three different factor VIII concentrates or plasma. The in vivo recovery of VIII:CAg was less than that of VIII:C and the disappearance rate of VIII:CAg was much higher either when concentrates or plasma were given. The half-life of VIII:C was thus about 12 h but of VIII:CAg only about 3 h or less. Six patients with von Willebrand's disease were studied after administration of AHF- Kabi. In contrast to haemophilia A the discrepancy between VIII:C and VIII:CAg disappearance rates was not present in von Willebrand's disease, since both VIII:C and VIII:CAg showed a typical progressive increase. We conclude that factor VIII:C given to haemophilia patients does not behave like native VIII:C, not even when fresh plasma is used. Patients with von Willebrand's disease are capable of forming a normal VIII:C when appropriately stimulated.     

Hyperprolactinemia and Thyrotropin-Releasing Factor (TRH) Responses in Men with Alcoholic Liver Disease

Prolactin responses to provocative thyrotropin-releasing factor (TRH) stimulation were evaluated in 43 chronic alcoholic men were divided into groups for analysis based on the presence or absence of gynecomastia and the histologic appearance of their livers as determined by percutaneous liver biopsy. Compared to the normal volunteers, alcoholics with reversible liver disease (fatty liver) had reduced basal prolactin levels and exaggerated TRH responses. In contrast, alcoholics with cirrhosis and gynecomastia had markedly elevated basal prolactin levels and reduced responses to TRH. The results of this study combined with previously reported findings in cirrhotic men provide a basis for a possible explanation for the signs of feminization frequently found in alcoholic men.     

The Detection of Factor-VIII-like Antigen in Haemophilic Carriers and in Patients with Raised Levels of Biologically Active Factor VIII

S ummary . A rabbit antibody has been prepared against therapcutic factor VIII of intermediate purity. Using this antibody in quantitative immunoelectrophoresis, the results of Zimmerman et al (1971a, b) have been confirmed. Female carriers of haemophilia were classified with greater certainty than by the use of bioassay alone. The factor-VIII-like antigen was present in all haemophilic patients tested, and was reduced or absent in patients with von Willebrand's disease. The antigen was increased in all cases following physical exercise, the infusion of adrenaline and following major gynaecological surgery. Raised values of factor-VIII-like antigen correlated well with increase in biological activity of factor VIII. The method has been applied to whole plasma and the antigen may be quantitated directly without the necessity for initial ethanol fractionation of plasma.     

Increased Level of Factor VIII and Physiological Inhibitors of Coagulation in Patients with Sickle Cell Disease

Sickle cell disease (SCD) is a hemoglobinopathy characterized by hemolysis, oxidative stress, and vaso-occlusive crises. Thromboembolism also remains a serious complication and probably underestimated in the SCD. Our objective was to seek the existence of hemostasis abnormalities that predispose to thrombosis such as elevation of FVIII and Physiological inhibitors of coagulation deficiency. We studied 81 patients with SCD, including 32 homozygous S/S, 20 double heterozygous S/β thalassemia and 29 heterozygous S/A. Controls AA were in number 60. For each patient and control we assayed the physiological coagulation inhibitors (Protein C, Protein S and Antithrombin) and the clotting FVIII. We found a significant increase in FVIII in all phenotypes of SCD compared to controls. Also, a significant decrease in levels of protein C and S was observed in patients with sickle cell homozygous or double heterozygous S β Thalassemia compared to controls. As against, for antithrombin no difference was observed between patients and controls. These hemostasis abnormalities therefore reflect the existence of a pro thrombotic state in sickle cell disease that can explain the increase of incidence of thrombosis in this pathology. Factor VIII clotting consistently high in SCD may well be a prime therapeutic target in the treatment of thrombotic manifestations of this disease.     

A Radial Immunodiffusion Method for the Assay of Factor VIII:C Antigen (VIII:C Ag) in Plasma

S ummary . A method has been developed for the immunological quantitation of factor VIII:C Ag using a medium titre (50 new Oxford units) factor VIII:C antibody arising in a severe multitransfused haemophiliac. The method, which utilizes clotting inhibition in an agarose gel medium, gave close and significant correlation with the two-stage factor VIII:C procoagulant assay ( r = 0.83, P < 0.01) for 54 normal subjects. Similar or higher values were found in 19 mild, moderate and severe haemophiliacs with 2–30% average normal plasma levels of factor VIII:C ( r = 0.72, P < 0.01). Four mild von Willebrand patients gave similar results by immunoassay and procoagulant assay methods. A previously identified patient with cross reacting material (CRM⁺) gave an immunoassay within the normal range (66%) with only 4% VIII:C activity detectable. The method offers a simple, sensitive and apparently reliable procedure for the assay of plasma factor VIII:C Ag which may prove useful in the further investigation of factor VIII:C Ag and antibody heterogeneity. The procedure offers an alternative to immunoradiometric assay and may be of potential use in the assessment of the haemophilia carrier state and possibly the early detection of thrombosis.     

Response of Factor VIII/von Willebrand Factor to DDAVP in Healthy Subjects and Patients with Haemophilia A and von Willebrand's Disease

S ummary . These studies were designed with the purpose of providing clinico-pharmacological information relevant to the use of DDAVP in the management of mild haemophilia and von Willebrand's disease (VWD). In healthy subjects, intravenous DDAVP produced its maximal response at a dose of 0.3 μg/kg. The extent of the increase in factor VIII coagulant activity (VIII:C) and factor VIII related antigen (VIIIR:Ag) induced by this dose was not significantly different from that observed with the same dose in haemophiliacs and VWD patients. In these, the bleeding time was not shortened. DDAVP given intranasally was followed by a two-fold increase of VIII:C. This route of administration might be adopted to provide an emergency aid in bleeding patients and to yield higher VIII:C levels in blood donors. In healthy subjects, the half-disappearance time of autologous VIII:C after increase induced by i.v. DDAVP is similar to that observed in patients with VWD treated in the same conditions, whereas the response appears to be more prolonged in haemophiliacs. This study shows that the consistency of the VIII:C response tends to decrease when repeated doses are given to healthy subjects. Repeatedly-treated haemophiliacs and VWD patients showed varied patterns, ranging from no change of the response to its early abolishment.     

乙、丙型肝炎病毒在慢性肝炎、肝硬化患者胃黏膜表达的临床研究

目的:探讨乙、丙型肝炎病毒(HBV、HCV)的泛嗜性.方法:选择慢性乙、丙型肝炎(慢肝组)28例、肝炎肝硬化(肝硬化组)44例,共72例作为研究对象.受检者常规胃镜检查,取胃窦幽门周围3cm以内活体组织两块,除普通病理检查外,分别做乙型肝炎病毒表面抗原(HBsAg)、乙型肝炎病毒核心抗原(HBcAg)、丙型肝炎病毒抗原(HCVAg)免疫组化法检测.结果:慢肝组有不同程度的胃黏膜慢性炎症者达92.9%(26/28)、肝硬化组达95.5%(42/44),排除年龄影响因素外,慢肝组以单纯慢性炎症为多,而肝硬化组以伴萎缩和肠化者为多.慢肝组与肝硬化组患者分别有53.6%(15/28)、81.8%(36/44)胃黏膜HBVAg阳性,其中HBsAg、HBcAg双阳性31例.在51例患者胃黏膜HCVAg检测中有33例(占64.7%)阳性表达、66.7%(22/33)与HBcAg同时表达.肝硬化组HBVAg及HBsAg、HBcAg双阳性者均高于慢肝组(P值均＜0.05).结论:HBV、HCV在慢性及肝硬化患者胃黏膜表达明显,应重视其在胃黏膜病变发病中的作用,并加强防护措施.     

Clinical Evaluation of a Recombinant Factor VIII Preparation (Kogenate) in Previously Untreated Patients with Hemophilia A

The safety and efficacy of a recombinant factor VIII (rFVIII) preparation (Kogenate) for the treatment of bleeding episodes was studied in previously untreated patients (PUPs) with severe, moderate, and mild hemophilia A. Patient peripheral blood samples taken at baseline and at 3, 6, 9, 12, 18, and 24 months after the first infusion were evaluated for FVIII inhibitor antibodies by the Bethesda assay, for antibodies formed against trace proteins derived from the rFVIII production process, and for general changes in laboratory test results. Samples for general laboratory testing were also drawn every 6 months after the first 24 months. Hemostatic efficacy was assessed by physicians, and adverse events were recorded throughout the study period. Forty-three PUPs (30 with FVIII:C <1%; 10 with FVIII:C 1%-5%; and 3 with FVIII:C >5%) aged 3 months to 32 years were enrolled at 33 centers in Japan. Patients were studied for a mean of 51 months (range, 11-80 months), and the mean exposure time was 83 days (range, 2-571 days). The incidence of occurrence of FVIII inhibitors was 34.9% (high responders [> or = 10 Bethesda U/mL], 11.6%; low responders [0.5-<10 Bethesda U/mL], 23.3%). The median cumulative exposure time of inhibitor detection was 12 days, indicating inhibitor development at an early stage after the start of infusion of this preparation. Hemostasis was achieved with a single dose of Kogenate in 94.8% of the 951 bleeding episodes recorded in the study. Transient increases in antibodies against baby hamster kidney proteins and antimouse immunoglobulin G were observed in 14.0% and 18.6% of patients, respectively. Anti-rFVIII seroconversion was observed in 18.6% of patients and only in patients with inhibitor antibodies. Antibody responses to trace proteins were not correlated with drug-related adverse events with the exception of FVIII activity inhibition in PUPs with anti-rFVIII seroconversion. These data indicate that Kogenate is safe and effective for the treatment of bleeding in PUPs with hemophilia A.     

A Prospective Study of the Relationship between Disease Activity and Psychologic Distress in Patients with Inflammatory Bowel Disease

Background: The evaluation of psychologic states is very useful in the management of inflammatory bowel disease (IBD) patients, particularly when related to disease activity (DA). Our aim was to prospectively evaluate the relationship between psychologic distress and DA. Methods: DA and psychologic distress were evaluated in 104 IBD outpatients by means of clinical criteria and the Hospital Anxiety and Depression Scale (HADS) at base line and after 6 months. Patients were grouped in unchanged, improved, and worsened DA from base line to follow-up. Results: Repeated-measures ANOVA showed a significant group-by-time interaction for HADS anxiety (F = 89.6, P = 0.0001) and depression (F = 3.67, P = 0.03) subscales. Conclusions: Over time changes in DA significantly affect psychologic distress and are closely related to corresponding increases and decreases in anxiety and depression in IBD patients. Our findings therefore suggest that the assessment of psychologic distress, particularly anxiety, should be included in the clinical management of IBD patients.