New quantitative aPTT waveform analysis and its application in laboratory management of haemophilia A patients

Diagnosis of haemophilia A is usually made by the measurement of factor VIII (FVIII) activity that allows categorization of the disease severity. However, tests that assess global haemostasis may better reflect clinical features and give additional clinically relevant information. The aim of this study was to develop a new quantitative activated partial thromboplastin time (aPTT) waveform analysis and compare it with FVIII activities to find out whether waveform parameters are superior determinants of clinical phenotype. A total of 81 haemophilia A patients divided into two groups (37 severe, 44 non‐severe) were included in the study. The control group comprised 101 healthy male volunteers. Quantitative aPTT waveform analysis was performed with Actin FS on BCS (Siemens Healthcare Diagnostics, Marburg, Germany) using three parameters (DELTA, RATIO‐1, RATIO‐2) obtained from a single aPTT measurement with two evaluation modes. FVIII activities were measured by one‐stage clotting and two‐stage chromogenic assay. Statistically significant difference (P < 0.001) between control group and all haemophilia A patients, as well as between severe and non‐severe haemophilia A patients was obtained for all quantitative waveform parameters. Our study revealed parameter DELTA as the best waveform parameter, showing significant correlation with FVIII activities and clinical parameters, and excellent performance for distinguishing between severe and non‐severe haemophilia A patients (ROC analysis: sensitivity 97.3%, specificity 93.2%). The results obtained by new quantitative aPTT waveform analysis were superior to those obtained by standard laboratory methods. The simplicity and cost‐benefit of the method make this approach a reasonable and promising tool for assessing coagulation in haemophilia A patients.     

Pulse Wave Velocity for Assessment of Arterial Stiffness Among People With Spinal Cord Injury: A Pilot Study

Background/Objective: The most significant complication and leading cause of death for people with spinal cord injury (SCI) is coronary artery disease (CAD). It has been confirmed that aortic pulse wave velocity (PVW) is an emerging CAD predictor among able-bodied individuals. No prior study has described PWV values among people with SCI. The objective of this study was to compare aortic (the common carotid to femoral artery) PWV, arm (the brachial to radial artery) PVW, and leg (the femoral to posterior tibial artery) PVW in people with SCI (SCI group) to able-bodied controls (non-SCI group).

Methods: Participants included 12 men with SCI and 9 non-SCI controls matched for age, sex, height, and weight. Participants with a history of CAD or current metabolic syndrome were excluded. Aortic, arm, and leg PVW was measured using the echo Doppler method.

Results: Aortic PVW (mean ± SD) in the SCI group (1,274 ± 369 cm/s) was significantly higher (P < 0.05) than in the non-SCI group (948 ± 110 cm/s). There were no significant between-group differences in mean arm PVW (SCI: 1,152 ± 193 cm/s, non-SCI: 1,237 ± 193 cm/s) or mean leg PVW (SCI: 1,096 ± 1 73 cm/s, non-SCI: 994 ±178 cm/s) values.

Conclusions: Aortic PVW was higher among the SCI group compared with the non-SCI group. The higher mean aortic PVW values among the SCI group compared with the non-SCI group indicated a higher risk of CAD among people with SCI in the absence of metabolic syndrome.     

The Value of Predischarge ICD Tests in Patients with a Successful Peroperative Test

An internal cardioverter defibrillator (ICD) is normally extensively tested during implantation. The necessity of retesting prior to discharge of the patient is a matter of debate. In our material of 30 patients undergoing first-time implantation of a transvenous internal defibrillator system, we retrospectively compare the predischarge defibrillation test with the peroperative test. A successful peroperative defibrillation test with no failed shocks at 10 J below maximal energy level was followed by a successful predischarge test with the same safety margin in 18/19 patients, while one patient required a maximal energy ICD shock for conversion at the predischarge test. We conclude that the predischarge defibrillation test can be omitted if the peroperative test was successful, with no failed shocks at 10 J below maximal energy level and if the shock therapy is set to maximal energy level.     

Gaze direction affects linear self‐motion heading discrimination in humans

We investigated the effect of eye‐in‐head and head‐on‐trunk direction on heading discrimination. Participants were passively translated in darkness along linear trajectories in the horizontal plane deviating 2° or 5° to the right or left of straight‐ahead as defined by the subject's trunk. Participants had to report whether the experienced translation was to the right or left of the trunk straight‐ahead. In a first set of experiments, the head was centered on the trunk and fixation lights directed the eyes 16° either left or right. Although eye position was not correlated with the direction of translation, rightward reports were more frequent when looking right than when looking left, a shift of the point of subjective equivalence in the direction opposite to eye direction (two of the 38 participants showed the opposite effect). In a second experiment, subjects had to judge the same trunk‐referenced trajectories with head‐on‐trunk deviated 16° left. Comparison with the performance in the head‐centered paradigms showed an effect of the head in the same direction as the effect of eye eccentricity. These results can be qualitatively described by biases reflecting statistical regularities present in human behaviors such as the alignment of gaze and path. Given the known effects of gaze on auditory localization and perception of straight‐ahead, we also expect contributions from a general influence of gaze on the head‐to‐trunk reference frame transformations needed to bring motion‐related information from the head‐centered otoliths into a trunk‐referenced representation.     

Success rates of nuclear short tandem repeat typing from different skeletal elements

Aim

To evaluate trends in DNA typing success rates of different skeletal elements from mass graves originating from conflicts that occurred in the former Yugoslavia (Bosnia and Herzegovina and Kosovo) during the 1990s, and to establish correlation between skeletal sample age and success of high throughput short tandem repeat (STR) typing in the large data set of the International Commission on Missing Persons.

Method

DNA extraction and short tandem repeat (STR) typing have been attempted on over 25 000 skeletal samples. The skeletal samples originated from different geographical locations where the conflicts occurred and from different time periods from 1992 to 1999. DNA preservation in these samples was highly variable, but was often significantly degraded and of limited quantity. For the purpose of this study, processed samples were categorized according to skeletal sample type, sample age since death, and success rates tabulated.

Results

Well-defined general trends in success rates of DNA analyses were observed with respect to the type of bone tested and sample age. The highest success rates were observed with samples from dense cortical bone of weight-bearing leg bones (femur 86.9%), whereas long bones of the arms showed significantly lower success (humerus 46.2%, radius 24.5%, ulna 22.8%). Intact teeth also exhibited high success rates (teeth 82.7%). DNA isolation from other skeletal elements differed considerably in success, making bone sample selection an important factor influencing success.

Conclusion

The success of DNA typing is related to the type of skeletal sample. By carefully evaluating skeletal material available for forensic DNA testing with regard to sample age and type of skeletal element available, it is possible to increase the success and efficiency of forensic DNA testing.The aftermath of the 1992-1995 conflict in the area of former Yugoslavia was marked with estimated 40 000 missing individuals. To address the issue of missing persons, the International Commission on Missing Persons (ICMP) was created in 1996 following the G-7 Summit in Lyon, France. ICMP’s mandate was expanded to also cover the DNA typing of missing persons resulting from 1999 conflict in Kosovo region.ICMP employs a “population based, DNA-led” identification system for the identification of missing persons in the region of former Yugoslavia. On a regional scale, DNA profiles from reference samples of living relatives of missing persons are continuously compared in a batch mode to the DNA profiles obtained from mortal remains of victims. To date, more than 84 000 blood samples representing over 28 000 missing individuals have been collected, analyzed, and entered into the database. Since 2001, short tandem repeat (STR) profiles from more than 21 000 skeletal samples, representing more than 15 000 different individuals, have also been entered into the ICMP database (1). DNA matching reports of greater than 99.95% probability of identity have been issued for over 11 600 individuals.ICMP DNA laboratories currently operate at a target rate of 105 bone or tooth extractions per day, using a silica-based extraction method (1-3). Bone and teeth samples tested are between 8 and 15 years post mortem. The quality of DNA preservation in these bones is highly variable and often substantially limited or/and degraded. This reflects the fact that the remains were buried or disposed in many different environmental contexts, with differential exposure to potentially harsh extrinsic factors such as temperature, UV radiation, humidity, and exposure to animals, insects, and microbes. Different disposal conditions are marked by burial in different soil types, complete or partial immersion of remains in water, contact with fire, or use of plastic sheeting. Microbial degradation is variably evidenced in these samples by both bone morphology and co-extraction of sometimes large amounts of microbial DNA (our unpublished observation). As always in this type of work, co-extraction of DNA inhibitors is a serious issue, and is also variable among samples.Bone and teeth samples clearly protect DNA through their physical and/or chemical robustness to environmental degradation and/or biological attack. An elementary manifestation of this is that bone and teeth are often the only surviving material that can be tested. However, the mechanisms by which DNA is preserved in bone are not very well characterized (4). Bone tissue is primarily composed of protein and mineral. The two most abundant proteins in bone tissue are collagen and osteocalcin. Approximately 70% of the mineral portion of the bone is composed of hydroxyapatite, which includes calcium phosphate, calcium carbonate, calcium fluoride, calcium hydroxide, and citrate. Structural arrangement of bone tissue is such that the mineral portion provides structural support to the protein portion in the bone and, by doing so, physically excludes exogenous/extracellular agents/enzymes that are potentially harmful to the protein portion of the bone (4). DNA has a very strong affinity for hydroxyapatite. DNA degradation is linked to the loss of crystallinity in the hydroxyapatite, but it may also be related to the loss of collagen (5).Overall, it seems reasonable to suppose that the characteristics of the bone that are correlated with its general long term survival, ie its resistance to morphological degradation at the macroscopic and microscopic level, would be those that contribute to the protection of DNA from degradation. Bone density, ie the extent of mineralization, is one of the most important intrinsic factors in survival of bone material. There is a significant difference in bone density between men and women, with the latter showing lower density values. The difference in bone density is also specific for different areas of the skeletal element morphology, with the highest density values noted for the mid-shaft region (6). Teeth are the hardest tissue in the human body because of the dental enamel (7).To know which bones best preserve DNA is of fundamental importance to DNA identification casework in mass fatality incidents and mass graves from armed conflict or genocide. The question equally applies to “ancient DNA” analyses in archaeological or human molecular evolutionary investigations. Despite the logical expectation that denser, more intact bones may be preferable, there is very little empirical data published on this issue (8). We also note that a successful recovery of DNA is linked not only to the degree of protection within the bone, but also the total amount of starting DNA. One reason for the lack of precise information on the best samples for DNA testing from degraded bone is the difficulty in performing controlled experiments, with regard to the effect of relevant environmental variables, inter-individual variation (related to for example sex or age), the long periods of time involved, and the need for large sample size.The aim of our study was to analyze DNA typing success rates from very large sample sizes of various skeletal elements from victims of conflict in the former Yugoslavia. Given the large number of variables affecting DNA preservation, a large sample size helps to average out the influences of a wide range of environmental contexts and permit general conclusions. Further, we divided our data into three time periods, with respect to time since death. This allows the analysis of the relative rate of degradation in different skeletal elements over time. These empirical data can serve as a useful guide to sampling strategies from degraded skeletal remains.     

The New Acetylcholinesterase Inhibitors PC‐37 and PC‐48 (7‐Methoxytacrine‐Donepezil‐Like Compounds): Characterization of Their Metabolites in Human Liver Microsomes,Pharmacokinetics and In Vivo Formation of the Major Metabolites in Rats

The objective of this study was to elucidate the pharmacokinetics and metabolite formation of newly developed non‐selective AChE/BChE 7‐MEOTA‐donepezil‐like inhibitors for potential therapeutic use in Alzheimer's disease (AD) patients. The chemical structures of metabolites were defined during incubation with human liver microsomes, and subsequently, the metabolization was verified in in vivo study. In vitro metabolic profiling revealed the formation of nine major metabolites in the case of PC‐37 and eight metabolites of PC‐48. Hydroxylation and the enzymatic hydrolysis of bonds close to the piperazine ring appeared to be the principal metabolic pathways in vitro. Of these metabolites, M1–M7 of PC‐37 and M1–M6 of PC‐48 were confirmed under in vivo conditions. Pilot pharmacokinetic experiments in rats were focused on the absorption, distribution and elimination of these compounds. Absorption after i.m. application was relatively fast; the bioavailability expressed as AUC_total was 28179 ± 4691 min.ng/mL for PC‐37 and 23374 ± 4045 min.ng/mL for PC‐48. Both compounds showed ability to target the central nervous system, with brain concentrations exceeding those in plasma. The maximal brain concentrations are approximately two times higher than the plasma concentrations. The relatively high brain concentrations persisted throughout the experiment until 24 hr after application. Elimination via the kidneys (urine) significantly exceeded elimination via the liver (bile). All these characteristics are crucial for new candidates intended for AD treatment. The principle metabolic pathways that were verified in the in vivo study do not show any evidence for formation of extremely toxic metabolites, but this needs to be confirmed by further studies.     

Clinical characteristics and functional outcome of patients with West Nile neuroinvasive disease in Serbia

Neurologic manifestations are prominent characteristic of West Nile virus (WNV) infection. The aim of this article was to describe neurological manifestations in patients with WNV neuroinvasive disease and their functional outcome at discharge in the first human outbreak of WNV infection in Serbia. The study enrolled patients treated in the Clinic for Infectious and Tropical Diseases, Clinical Center Serbia in Belgrade, with serological evidence of acute WNV infection who presented with meningitis, encephalitis and/or acute flaccid paralyses (AFP). Functional outcome at discharge was assessed using modified Rankin Scale (mRS) and Barthel index. Fifty-two patients were analysed. Forty-four (84.6 %) patients had encephalitis, eight (15.4 %) had meningitis, and 13 (25 %) had AFP. Among patients with AFP, 12 resembled poliomyelitis and one had clinical and electrodiagnostic findings consistent with polyradiculoneuritis. Among patients with encephalitis, 17 (32.7 %) had clinical signs of rhombencephalitis, and eight (15.4 %) presented with cerebellitis. Respiratory failure with subsequent mechanical ventilation developed in 13 patients with WNE (29.5 %). Nine (17.3 %) patients died, five (9.6 %) were functionally dependent (mRS 3–5), and 38 (73.1 %) were functionally independent at discharge (mRS 0–2). In univariate analysis, the presence of AFP, respiratory failure and consciousness impairment were found to be predictors of fatal outcome in patients with WNV neuroinvasive disease (p < 0.001, p < 0.001, p = 0.018, respectively). The outbreak of human WNV infection in Serbia caused a notable case fatality ratio, especially in patients with AFP, respiratory failure and consciousness impairment. Rhombencephalitis and cerebellitis could be underestimated presentations of WNV neuroinvasive disease.