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Journal of Clinical Medicine 12(5), 1913 (2023). doi:10.3390/jcm12051913 special issue: "Topical Collection "Cardiovascular Disease: Risk Factors, Comorbidities, and Prevention" / Editor: Prof. Dr. François Roubille, Guest Editor", Published by MDPI, Basel

Background Increased platelet reactivity (PR) is an established predictor of cardiovascular (CV) and all-cause mortality. However, therapeutic targeting of PR by tailored antiplatelet therapy (APT) failed to show significant clinical benefit. It remains unclear whether increased PR constitutes a risk-modifier that identifies patients that benefit from risk-factor adjustment. Purpose To identify risk factors that allow modification and/or elimination of increased CV and all-cause mortality in patients with altered PR. Methods ADP- and TRAP-induced PR was measured by CD62P and CD63 expression in 1780 patients who were referred for coronary angiography between 1997 and 2000 and participated in the LURIC study. Statistical analysis was performed by SPSS v25.0 and R v3.6.1 Results ADP-induced PR was an excellent predictor of CV-mortality and risk-equivalent to the presence of coronary artery disease (Figure 1A). Stratification of platelet ADP-response into tertiles demonstrated that patients with high-PR (HPR) and low-PR (LPR) were at increased risk for CV-mortality when compared to the reference group (HPR: HR 1.7 [95% CI: 1.3–2.3]; LPR: HR 1.4 [95% CI: 1.0–1.8]) (Figure 1B). Multivariable-adjustment did not change the association of PR with CV-mortality. Using a relative weight analysis, we identified HbA1c and estimated glomerular filtration rate (eGFR) as potential risk-modifiers. In addition, presence of APT appeared to be an exclusive risk-modifier in the HPR-group. In an multivariable-adjusted risk assessment, we verified that in the HPR group (i) treatment of PR by APT reduced CV-mortality with a HR of 0.5 (95% CI: 0.3–0.7) p=0.0004), (ii) HbA1c of >7.0% in patients with diabetes increased CV-mortality with a HR of 2.0 (95% CI: 1.2–3.2 p=0.004) and (iii) eGFR In the HPR group, risk modification by APT and HbA1c 0.05). Risk modification by an eGFR >60ml/min led to a profound risk reduction in the HPR group but remained statistically different from the reference group (Figure 1C). Conclusion Here, we demonstrate that HPR and LPR are predictors for CV mortality in the LURIC study. Treatment of platelet hyperreactivity by APT, HbA1c of ≤7% in patients with diabetes and an eGFR ≥60ml/min were associated with a reduced CV-mortality in HPR patients and might constitute adjustable risk factors in this group. In addition, we were unable to identify any significant risk factors for patients with LPR underlining a high-risk patient group with insufficient therapeutic options. Figure 1 Funding Acknowledgement Type of funding source: None

IntroductionElevated leukocyte counts are associated with cardiovascular disease. Smoking induces inflammation and alters levels of leukocyte subtypes.Aims and MethodsOur aim was to investigate the effect of smoking on circulating immune cells and their association with mortality. Lymphocyte subtypes were identified by flow cytometry of fluorescent-labeled cells. We analyzed the association of leukocytes with mortality using Cox regression and assessed their effect on risk prediction based on principle components (PCs) using area under the receiver operating characteristic curve and net-reclassification in 2173 participants from the Ludwigshafen Risk and Cardiovascular Health Study, a prospective case–control study in patients who underwent coronary angiography.ResultsThe numbers of T cells, monocytes, and neutrophils were higher and natural killer cells were lower in smokers compared with never-smokers. In never-smokers, lymphocyte counts were inversely associated with mortality while a positive association was observed for neutrophils. The neutrophil-to-lymphocyte ratio (NLR) had the strongest association in never-smokers with a hazard ratio (95% confidence interval) of 1.43 (1.26–1.61). No associations were found in smokers. Adding the first five PCs or the NLR to a risk prediction model based on conventional risk factors did not improve risk prediction in smokers, but significantly increased the area under the curve from 0.777 to 0.801 and 0.791, respectively, in never-smokers.ConclusionsLymphocyte counts were inversely associated with mortality in never-smokers but not in active smokers. Markers of innate immunity, namely total neutrophils and CD11b+/CD18+ and CD31+/CD40− granulocytes, were directly associated with mortality. Adding markers of immune function like PCs or the NLR to basic risk models improved risk prediction in never-smokers only.ImplicationsTotal leukocyte counts were higher in active smokers as compared to never-smokers due to elevated counts of neutrophils and monocytes but declined in ex-smokers with increasing time since quitting. In the never-smokers but not in smokers, lymphocyte counts were inversely associated with mortality while there was a direct association with neutrophils, even after adjustment for conventional cardiovascular risk factors. Adding markers of immune function to basic risk models improved risk prediction in never-smokers only. Our data indicate that smoking status has an important impact on the ability of leukocyte counts to predict long-term cardiovascular outcomes.

Thus far, no data has become available to evaluate systematically the prevalences of prothrombin polymorphism A19911G (PT A19911G), factor V HR2 haplotype A4070G (FV A4070G), or plasminogen activator-inhibitor-1 polymorphism 4G/5G (PAI-1 4G/5G) in patients who develop retinal vein occlusion (RVO) without cardiovascular risk factors.We retrospectively evaluated comprehensive thrombophilia data from 42 preselected RVO patients without cardiovascular risk factors. The prevalences of different gene mutations and polymorphisms including factor V Leiden mutation G1691A (FVL), FV A4070G, prothrombin mutation G20210A, PT A19911G, and PAI-1 4G/5G were compared with 241 healthy controls matched for age and sex.A total of 20 patients (47.7%) were found to carry thrombophilic gene polymorphisms including FVL, FV A4070G, and homozygous PT A19911G compared with 72 of 241 controls (29.9%; p = 0.03). Subgroup analysis of patients with a significant personal or family history of thromboembolism revealed a high prevalence of FVL, FV A4070G, and homozygous PT A19911G (p = 0.005). FV A4070G was found to be significantly associated with at least two other heterozygous or one homozygous gene polymorphisms (p = 0.02). Multivariate analysis revealed the presence of FVL (p = 0.0017) and homozygous PT A19911G (p = 0.03) polymorphism as independent risk factors for the development of RVO.Our results indicate that in selected RVO patients screening for thrombophilic gene polymorphisms including FVL, FV A4070G and homozygous PT G19911A may be helpful in a high percentage of cases. Our findings suggest that hereditary thrombophilia associated with RVO is more likely to be multigenic than caused by any single risk factor.

Platelet quality in different platelet concentrates (PCs) has been the subject of several studies. Nonetheless, there is a lack of robust data on the correlation and agreement among platelet function tests as a prerequisite for the association of PC functionality in vitro with platelet function in vivo post PC transfusion. The purpose of our study was to correlate a larger panel of platelet function assays in PCs and to assess whether the methods agree sufficiently and can be used interchangeably. Twelve apheresis platelet concentrates in plasma (APC), 16 pooled platelet concentrates in plasma (PPC), and 12 PPC in T-sol (PPCA) were examined on days 1 and 4 after production. PCs were tested for platelet count, light transmission aggregation (LTA) induced by ADP, collagen, or TRAP; platelet ATP release induced by collagen; and spontaneous and ADP and TRAP-induced increase in CD62P and PAC1 expression measured by flow cytometry. All tests were performed in undiluted platelet-rich plasma, recalcified and mixed with an inhibitor of factor Xa and thrombin. Most platelet function parameters correlated significantly with each other, but agreement among methods was insufficient. A proper inverse correlation was observed between ADP-induced LTA and spontaneous platelet activation assessed by CD62P expression (

Purpose: To investigate the prevalence of various thrombophilic disorders among young patients with retinal artery occlusion (RAO). Procedures: We retrospectively reviewed thrombophilia screening data of young patients ≤60 years of age with RAO and healthy controls matched for gender and age. Results: Thrombophilia screening data of 25 young patients and 62 healthy controls were analyzed. Mean patient age by the time of the RAO was 43.3 ± 10.8 years. Overall, thrombophilic defects were found to be present in 17 patients (68%) compared with 11 of 62 controls (17.7%; p < 0.0001). Multivariate logistic regression analysis confirmed a statistically significant association between the development of RAO and increased levels of lipoprotein(a) (odds ratio: 9.48; p = 0.001) and factor VIII (odds ratio: 6.41; p = 0.024). There was a strong association between the presence of thrombophilic disorders and a personal or family history of thromboembolism (p = 0.01). Conclusions: Our results indicate that screening for thrombophilic disorders among selected young patients with RAO yields positive results in a high percentage of cases.

Background The quality of whole blood (WB)-derived plasma preparations has been the subject of several studies, but there has been a lack of robust, comparative data for the different methods of processing and freezing. Study Design and Methods Six WB-derived plasma units were pooled and split (n = 16) and frozen within either 8 or 24 hours after WB collection, stored at 4°C or at room temperature (RT), and then frozen either slowly at −20°C or rapidly to below −30°C. Plasma units were tested for fibrinogen, Factor (F)V, FVII, FVIII, FXI, and von Willebrand factor (VWF), protein C (PC), protein S (PS) activity and free PS, prothrombin time, and partial thromboplastin time. Results FVIII was reduced by 9% to 19% after having been stored for 24 hours irrespective of storage temperature. Slow freezing (SF) reduced FVIII by 17% to 25% compared to rapid freezing (RF) to below −30°C. Storage temperature, but not 24-hour storage, decreased PS activity by 20% to 28%. PS activity was 8% to 17% lower in plasma units frozen slowly compared to RF. Storage and freezing had no influence on free PS. SF caused small losses of FVII and FXI activity. Conclusion Twenty-four-hour hold at RT and SF both reduce FVIII levels below 70 U/dL in many plasma units. PS activity is affected substantially by storage temperature and SF, but free PS is not. With regard to plasma quality, freezing to below −30°C within 1 hour is superior to SF at −20°C.

Pathogen reduction (PR) systems for platelets, based on chemically induced cross-linking and inactivation of nucleic acids, potentially prevent transfusion transmission of infectious agents, but can increase clinically significant bleeding in some clinical studies. Here, we documented the effects of PR systems on microRNA and mRNA levels of platelets stored in the blood bank, and assessed their impact on platelet activation and function. Unlike platelets subjected to gamma irradiation or stored in additive solution, platelets treated with Intercept (amotosalen + ultraviolet-A [UVA] light) exhibited significantly reduced levels of 6 of the 11 microRNAs, and 2 of the 3 anti-apoptotic mRNAs (Bcl-xl and Clusterin) that we monitored, compared with platelets stored in plasma. Mirasol (riboflavin + UVB light) treatment of platelets did not produce these effects. PR neither affected platelet microRNA synthesis or function nor induced cross-linking of microRNA-sized endogenous platelet RNA species. However, the reduction in the platelet microRNA levels induced by Intercept correlated with the platelet activation (p

Characterization and diagnostic work-up of a patient with functionally impaired platelet GP6

BACKGROUND: Variables of hemostasis before surgery might indicate an elevated risk of bleeding. We determined hemostasis tests and standardized bleeding history and their association with bleeding and transfusion requirements in cardiopulmonary bypass (CPB) surgery. STUDY DESIGN AND METHODS: In a prospective trial, variables from 104 patients were associated with postsurgical bleeding and with red blood cells (RBCs) and platelet concentrate (PC) transfusions. Variables included standardized bleeding history, prothrombin time (PT), fibrinogen, fibrin monomers, Factor VIII, von Willebrand factor (VWF), multiple electrode aggregation (MEA), and the day of aspirin or thienopyridine withdrawal before operation. RESULTS: Multiple linear regression revealed bleeding history score, ADP-induced MEA, CPB time, and hemoglobin (Hb) independently associated with postoperative bleeding and bleeding history, arachidonic acid (AA)-induced MEA, CPB time, and PT associated with RBC transfusions. The logistic regression model for the outcome of bleeding within 24 hours after operation indicated ADP-induced MEA, the day of aspirin withdrawal before operation, and CPB time as predictors. AA-induced MEA, CPB time, Hb, and PT were predictors of RBCs transfusion. ADP-induced MEA, the day of aspirin withdrawal, PT, and VWF were associated with PC transfusion. CONCLUSIONS: A standardized bleeding history may help to identify patients undergoing CPB surgery whose risk of bleeding is elevated. ADP-induced MEA appears to predict postoperative bleeding and PC transfusion requirements, while AA-induced MEA and preoperative Hb indicate the need for RBCs. The time of aspirin withdrawal before surgery influences perioperative blood loss and PC transfusion.

Im Jahr 2000 startete das Institut für Pflegewissenschaft in Basel mit einem klinisch ausgerichteten Masterprogramm in Advanced Nursing Practice (ANP). Die mit einem Masterabschluss erlangte Pflegeexpertise beinhaltet vertieftes Wissen und Know-how in einem Spezialgebiet. Zusammen mit anderen Pflegefachpersonen entwickeln diese klinisch tätigen, wissenschaftlich- und praxisorientierten Advanced Practice Nurses (APNs) die Pflegepraxis in der Schweiz weiter, insbesondere für chronisch kranke oder geriatrische Patienten. Bis zu 25 % der über 80-jährigen Menschen erfahren jährlich mindestens einen Spitalaufenthalt. Neben dem akuten Einlieferungsgrund leiden sie oft an zusätzlichen chronischen Erkrankungen, welche gleichzeitig exazerbieren. Diese fragilen Patienten benötigen Unterstützung durch Pflegende, welche erweiterte gerontologische Pflege anbieten können. In der akutgeriatrischen Universitätsklinik Basel findet unter der Leitung einer APN eine systematische, kontinuierliche und effektive Praxisentwicklung statt, welche eine personenorientierte und geriatrisch-spezialisierte Pflege fördert. Die Prinzipien der Aktionsforschung leiten das Praxisentwicklungsprojekt. Der zyklische Prozess «Look-Think-Act» fördert die kritische Auseinandersetzung mit der Praxis. Erste Resultate zeigen eine kürzere Aufenthaltsdauer und verbesserte Betreuungsresultate bei den Patienten sowie eine erhöhte Arbeitszufriedenheit und Selbstwirksamkeit aus Sicht der Pflegenden. Mit dem vorliegenden Artikel wird die Geschichte von ANP kurz eingeführt und anschließend werden die Entwicklung und Einführung des Projekts sowie erste Resultate der Evaluation dargestellt.

Four approved plasma preparations are available in most European countries: fresh frozen plasma, lyophilized plasma, solvent/detergent(SD)-treated plasma and methylene blue/light-treated plasma. Evidence of the clinical efficacy of plasma is mainly based on controlled or uncontrolled observational studies, case reports or expert opinion. As definitions of evidence grades used in previous guidelines and recommendations are sophisticated and difficult to apply to clinical routine, we established a simple system involving 2 recommendation strengths (1 and 2) and 3 evidence grades (A, B, C). Plasma is indicated for complex coagulopathy associated with manifest or imminent bleeding, particularly microvascular bleeding, in massive transfusion, disseminated intravascular coagulation and liver disease. With the exception of emergency situations when clotting assay results are not available on time, a clinically relevant coagulopathy must be verified before plasma is administered. The rapid infusion of at least 10 ml of plasma per kg of body weight is required to increase the respective clotting factor or inhibitor levels significantly. Therapeutic plasma exchange with 40 ml of plasma per kg of body weight is the treatment of first choice in acute thrombotic-thrombocytopenic purpura (TTP) or adult hemolytic uremic syndrome (HUS). Rare indications are congenital factor V or FXI deficiency, plasma exchange in neonates with severe hemolysis or hyperbilirubinemia, and filling of the oxygenator in extracorporeal membrane oxygenation in neonates. Prothrombin complex concentrates should be preferred to plasma for the rapid reversal of oral anticoagulation, since plasma is less efficient in this setting. Side effects resulting from the administration of plasma are rare but have to be considered.

ZusammenfassungVor allen operativen oder anderen invasiven Eingriffen, die mit gefährlichen Blutungen einhergehen können, muss eine hämorrhagische Diathese anamnestisch, ggf. anhand der klinischen Symptomatik und laboranalytisch ausgeschlossen werden. Auf keine dieser Maßnahmen kann verzichtet werden. Die Blutungsanamnese wird mit einem standardisierten Fragebogen unter Verwendung eines Scores und unter ärztlicher Anleitung erhoben. Falsch positive und falsch negative Blutungsanamnesen kommen häufig vor. Das laboranalytische Minimalprogramm besteht aus Thrombozytenzahl, aktivierter partieller Thrombo plastinzeit (aPTT) und Quick-Wert in % der Norm. Eine Ergänzung durch die Bestimmung des Fibrinogens ist sinnvoll. Ein zuverlässiges Screening für häufige Thrombozytopathien und das von-Willebrand-Syndrom steht nicht zur Verfügung. Ergeben Anamnese oder Symptomatik oder Labor-Screening den Verdacht auf eine hämorrhagische Diathese, muss eine präoperative Abklärung in einem hämo staseologischen Labor erfolgen.

Three types of therapeutic plasma are available that differ in their manufacturing processes, composition, clinical efficacy, and side effects. Quarantine-stored, not pathogen-reduced fresh-frozen plasma (QFFP) is prepared from single whole blood or plasma donations. The manufacture of pathogen-reduced single-donor plasmas such as methylene blue-light treated (MLP) or amotosalen-ultraviolet light treated plasma (ALP) involves the addition of a chemical followed by irradiation and subsequent removal of the chemical. Both plasma types show substantial fluctuation of clotting factor and inhibitor levels according to interindividual variations, and both carry the risk of inducing transfusion-associated lung injury (TRALI). Photo-oxidation in pathogen-reduced single-donor plasmas reduces clottable fibrinogen and other clotting factors markedly, and there is a lack of clear evidence showing whether this is harmful or not. MLP also appears to be less effective clinically than QFFP. Like clotting factor or inhibitor concentrates, solvent/detergent-treated plasmas (SDP) are bio-pharmaceutical preparations derived from large plasma pools, and variations in plasma protein levels from batch-to-batch are for that reason low. The SD manufacturing process inevitably involves a considerable reduction of plasmin inhibitor (PI), and moderate reduction of all other clotting factors and inhibitors in the final plasma bags. Clinical studies and broad clinical use have however shown that this does not significantly reduce clinical efficacy or increase adverse events. SDPs obviously do not induce TRALI and the risk of allergic reactions is significantly lower than for QFFP. Common to all three plasma types is that the time between donation and freezing the plasma, and whether plasma from whole blood or apheresis plasma is used as starting material, are decisive determinants for the clotting factor and inhibitor potencies in the final bags. Plasma frozen 3-6h after donation, and apheresis plasma, contain markedly greater amounts of clotting factors and inhibitors than plasma frozen 15-24h after collection or plasma from whole blood. Lyophilisation and the pooling of single-donor plasma units with ABO blood group in suitable proportions (Uniplas) facilitate SDP handling and logistics without loss of clinical efficacy. SDP is obviously at least as cost-effective as QFFP if non-infectious adverse events including TRALI are taken into account, at least in younger patients and patients with good prognosis.

In five patients with von Willebrand's disease the haemostatic effect of heat-treated factor VIII concentrates was examined. For comparison, small-pool cryoprecipitate was used. All three preparations (Factor VIII-HT Hyland, Factor VIII HS Behringwerke, Kryobulin SP) were shown to improve abnormal laboratory findings, especially bleeding time, and at times even normalize them. It was possible to prevent bleedings during operative procedures, and effectively treat spontaneous bleedings. Factor VIII-HT and Factor VIII HS could be used in dosages comparable to cryoprecipitate (20-40 U/kg); in patients undergoing surgery a dose interval of eight hours is recommended. Two of four patients suffering of chronic liver disease had raised transaminase activities after receiving Factor VIII-HT. Although the risk of hepatitis cannot be conclusively assessed, the preparations used provide, owing to their good blood-clotting effect, an advance in the treatment and prevention of serious complications in patients with von Willebrand's disease.

SUMMARY: TWO PREPARATIONS ARE AVAILABLE FOR PLATELET TRANSFUSION: single-donor apheresis platelet concentrates (APC) and pooled platelet concentrates (PPC) prepared from 4-6 whole blood units. Clear advantages of APC over PPC are a markedly reduced donor exposure of recipients, and easier logistics when attempting a complete supply with ABO-identical and Rh-compatible platelet concentrates. Regulations should aim at complete ABO-identical platelet transfusions because major and minor ABO-incompatible platelet transfusions are probably associated with significantly increased morbidity and mortality. The main advantage of PPC is lower costs. Preparation of PPC is however inevitably accompanied by substantial wastage of plasma and red cells. Only major supraregional blood transfusion centers can guarantee full-coverage supply with ABO-identical and Rh-compatible PPC. Whether APC are more effective than PPC and associated with fewer septic platelet transfusion reactions as shown in some but not all studies, has to be examined in future prospective controlled trials.

Background and Objectives Hydroxyethyl starches (HES) may have the potential to impact negatively on haemostasis. Recent findings suggest that side-effects on haemostasis stem not only from the physicochemical differences between HES, but also from the composition of the solvent. We compared the effects of a newly developed medium molecular weight (MW) and low molar substitution (MS) HES dissolved in a physiologically balanced electrolyte solution (MW 130, MS 0·42; B-HES) with a commercially available non-balanced HES (MW 130, MS 0·4; NB-HES), and with Ringer's lactate (RL) solution in vitro. Materials and Methods Activated partial thromboplastin time (APTT), factor VIII clotting activity (F VIII:C) and von Willebrand factor (vWF) activity were investigated in 48 healthy individuals. Platelet function as measured by turbidimetric platelet aggregometry and whole blood impedance aggregometry induced by adenosine diphosphate (ADP), collagen and thrombin receptor activating peptide (TRAP), and by ADP and TRAP-induced expression of activated platelet fibrinogen receptor glycoprotein (GP) IIb/IIIa was determined in 24 participants. Haemodilution (25% and 50%, v/v for blood coagulation analyses and 20% and 40%, v/v for platelet function studies) was performed using the two HES preparations and RL. Results APTT was significantly longer and F VIII and vWF significantly lower at 25% and 50% dilutions with NB-HES compared to B-HES and RL. At 20% and 40% dilutions, ADP and TRAP-induced expression of activated platelet surface GP IIb/IIIa was significantly increased by B-HES compared to NB-HES and RL. Percentages of platelet GP IIb/IIIa expression were also significantly greater in samples diluted with B-HES than in undiluted blood. Neither the diluent (B-HES, NB-HES and RL) nor the degree of dilution (undiluted, 20% and 40% dilution) had any significant influence on ADP, collagen or TRAP-induced turbidimetric platelet aggregation or impedance platelet aggregation. Conclusions In contrast to a non-balanced 130 kDa, MS 0·4 HES (NB-HES), a 130 kDa, MS 0·42 HES preparation dissolved in a physiologically balanced electrolyte solution (B-HES) does not affect APTT, F VIII:C and vWF in vitro. Both types of HES do not affect platelet aggregation induced by ADP, collagen or TRAP. B-HES but not NB-HES increases the expression of activated platelet GP IIb/IIIa induced by ADP or TRAP.

Background and Objectives The safety of chronic intensive donor plasmapheresis has not been determined in large prospective studies examining dropout rates, dropout reasons and predictors of withdrawals. Materials and Methods Twenty-one plasma centres recruited 3783 donors who were switched from a moderate to an intensive plasmapheresis programme and observed over a 3-year period. Individuals weighing < 70 kg and ≥ 70 kg donated 750 ml and 850 ml of plasma per session, respectively. The maximum of annual donations was limited to 60. Total serum protein (TSP) and haemoglobin (Hb) or haematocrit (Hct) were determined at each donation, and immunoglobulin G (IgG) at every fifth donation. Dropout rates, dropout reasons and potential predictors of withdrawal were analysed. Results Dropouts were predominantly due to socioeconomic (49·2% of all donors) or medical reasons not related to plasma donations (10·4% of all donors). Sixteen per cent of donors dropped out when IgG, TSP or Hb levels fell below threshold values. Severe clinical adverse events related to plasmapheresis were observed in five subjects. The incidence in severe cardiovascular diseases was lower in donors than in the general population. The risk factors that led to dropping out as a result of low IgG, TSP or Hb levels included younger age, female gender, low initial IgG levels and a high donation frequency. Neither body weight nor the amounts of plasma donated per kilogram of body weight per session were associated with ceasing due to medical reasons, whether related or unrelated to plasma donations. Females and males within the respective lowest body weight category were not at higher risk of dropping out. Conclusion Long-term intensive donor plasmapheresis under conditions investigated in this study is safe. All donors weighing ≥ 70 kg are safely able to donate 850 ml of plasma in each session up to 60 times per year, provided that they are carefully monitored.

Summary We investigated the relationship between platelet function analyzer (PFA-100TM) closure times (CT) and bleeding time (BT), platelet aggregation (PA) induced by ADP, arachidonic acid, and collagen, blood cell counts, and von Willebrand factor (VWF) in 120 well-characterised healthy individuals. Pre-analytical and analytical conditions were standardised comprehensively. In a substantial number of cases the differences between duplicate measurements exceeded 15%. The reference range (5th and 95th percentiles) for CT with the collagen/epinephrine (CEPI) and the collagen/ADP (CADP) cartridge was 93–223 s and 64–117 s respectively. Re-examination of 11 individuals with CEPI-CT above the 95th percentile revealed considerable batch-to-batch variation of CEPI-CT. Males had significantly longer CADP than females (P = 0·002). CEPI and CADP-CT measured pm were significantly longer than corresponding values determined am (P = 0·003 and P

"Aspirin resistance" and "aspirin nonresponsiveness" are terms used both to describe both the failure of aspirin to protect subgroups of individuals from severe vascular events and to evoke an appropriate inhibition of platelet function. Several studies utilizing a broad range of platelet function tests have shown that some subgroups of individuals exhibit a reduced or completely missing antiplatelet response to aspirin. The clinical significance of aspirin nonresponsiveness for the prediction of clinical endpoints remains, however, to be determined. Thus far, only three prospective clinical trials have demonstrated a possible relationship between aspirin nonresponsiveness and subsequent vascular events. Most platelet function tests used in respective clinical studies cannot be reliably performed in clinical routine and are not interchangeable for monitoring antiplatelet treatment. There is a need for a simple and reliable assay for predicting the clinical efficacy of antiplatelet therapy. Recent data demonstrate that none of the currently developed assays, including the PFA-100 system, are presently able to accomplish these objectives.

Background and Objectives There are still concerns about the safety of long-term intensive donor plasmapheresis, because the reasons that donors drop out of plasmapheresis programmes have not been determined in prospective studies. Materials and Methods Seventy-two donors were switched from a moderate plasmapheresis programme to an intensive plasmapheresis programme and observed over a 3-year period. In addition to measuring total serum protein (TSP), albumin, immunoglobulin G (IgG) and haemoglobin (Hb) levels, parameters of iron metabolism and blood coagulation, and biochemical cardiovascular risk markers, were determined at baseline and at every 15th donation. We also collected statements from donors who dropped out of the plasmapheresis programme about their reasons for withdrawal. Results Dropouts were predominantly related to socioeconomic (n = 34) or medical reasons not related to plasma donations (n = 8). Three donors had to drop out when their TSP levels fell below threshold for the third time within a 5-week period. At baseline, donors had significantly lower TSP, albumin, IgG, Hb and ferritin levels than gender-matched and age-matched non-donor controls. However, subsequent intensive plasmapheresis over 3 years did not impair the individuals’ ability to donate plasma. TSP, IgG, Hb, ferritin, transferrin, cardiovascular risk markers and parameters of blood coagulation did not change significantly during the observation period. Conclusions The reasons why donors cease to participate in intensive plasmapheresis programmes are predominantly not directly related to the plasma donation itself.

Background and Objectives There exists a current lack of information about the impact of different inline filters, used for the leucoreduction of whole blood (WB), on the levels of clotting factors and markers of coagulation, complement and cell activation in plasma. Only a few small comparisons of different types of WB inline filters have been published to date. Materials and Methods This study compared two plasma types of 200 units each. Both study groups were derived from WB, inline-filtered and held for 2 h at 20° between donation and filtration. Then, 200 units (Group A) were filtered using a positively charged polyester filter (Baxter RZ2000) and the other 200 units (Group B) were filtered using an uncharged polyester filter (Fresenius). After filtration, both groups were analysed for fibrinogen, factors V and VIII:C (FV and FVIII:C, respectively), immunoglobulin G (IgG), residual leucocytes and platelets, and markers of coagulation, complement and cell activation. Predonation plasma samples from CPDA1-anticoagulated blood were obtained from 100 different individuals and served as controls. Results WB inline filtration did not influence fibrinogen, FV, FVIII:C or IgG levels. Neither filter induced thrombin or fibrin formation. The charged filter caused substantial complement activation and neutrophil elastase and platelet factor 4 release. In contrast, the plasma filtered through the uncharged filter showed markedly lower levels of C3a-desArg, C5a, neutrophil elastase and platelet factor 4, and moderately reduced levels of prothrombin fragments 1+2 and d-dimer, compared with controls. Conclusions Filter type has a significant impact on the quality of plasma derived from WB filtered through inline filtration systems. Some filters produce substantial coagulation and complement activation and cell release, while others appear to reduce the plasma levels of activation markers. The clinical significance of these findings remains to be determined.

Recent reports on adverse events associated with solvent/detergent-treated plasma have raised concerns about the efficacy and safety of this type of therapeutic plasma. Comparisons of various brands of solvent/detergent-treated plasma have revealed substantial differences in their composition.Retrospective analyses and case reports suggest an association between the low protein S activity levels found in solvent/detergent-treated plasma and venous thromboembolism when solvent/detergent-treated plasma is given for thrombotic thrombocytopenic purpura or transfused massively during liver transplantation surgery. Augmented bleeding caused by hyperfibrinolysis, possibly caused by the low plasmin inhibitor (also termed alpha2-antiplasmin) activity of solvent/detergent-treated plasma, has also been a matter of concern. The efficacy and safety of various types of solvent/detergent-treated plasma have been studied intensively for all indications for therapeutic plasma by at least five prospective trials, four observational studies, and post-licensure monitoring. A review of the literature shows that the clinical significance of transient protein S and plasmin inhibitor deficiency has been considerably overstated, even when such deficiency might be aggravated by the administration of large amounts of solvent/detergent-treated plasma. However, different brands of solvent/detergent-treated plasma differ substantially with respect to their composition and hemostatic balance. It cannot be completely excluded that the very low citrate and protein S concentrations versus higher clotting factor concentrations found in a given brand of solvent/detergent-treated plasma could contribute to coagulation activation in the settings of thrombotic thrombocytopenic purpura and liver transplantation.Future research should seek to optimize the composition of solvent/detergent-treated plasma. Prospective trials and prospective hemovigilance studies are required to determine the rate of adverse events occurring after treatment with solvent/detergent-treated plasma and other types of therapeutic plasma.

Background and Objectives Major studies are still lacking on the impact of differing intensities of long-term donor plasmapheresis, not only on total serum protein, albumin and immunoglobulin G (IgG), but also on humoral and cellular immunity, red cell and iron metabolism, and biochemical cardiovascular risk markers. Materials and Methods Three groups of donors, comprising 483 individuals undergoing differing intensities of long-term serial plasmapheresis, were entered into a cross-sectional study. A fourth control group consisted of 100 non-donors. In addition to measuring total protein, albumin and IgG levels, we determined parameters of humoral and cellular immunity, red cell and iron metabolism and recognized biochemical cardiovascular risk factors. Results The median annual net amount of plasma donated by the three donor groups was 37, 16 and 10 l, respectively (P

5 Assessment According to current knowledge, HIV-1 has been transmitted via blood and blood products in Germany since 1979. With the introduction of antibody testing of blood and plasma donations in 1985, transmission of infections via blood, blood components and plasma products has been dramatically reduced. The residual risk of transmission of HIV with red cell, granulocyte and platelet concentrates, which are not currently subject to virus inactivation/removal procedures, is already very low at approximately 1 per 1.5 million donations. In the case of fresh-frozen plasma, which is subject to quarantine rules, there have been no known cases of transmission of HIV. Plasma products that have correctly undergone virus inactivation/ removal procedures during manufacture currently pose no residual risk of HIV transmission. The introduction of NAT for HIV-1 genome will bring about a further reduction in the residual risks for cellular blood components. The window period for antibody formation of approximately 21–45 days will be reduced as a result to approximately 11 days, as even incipient HIV infection is detectable with NAT. The spread of HIV amongst the German population in around 1978 is an example of how rapidly an established level of safety can collapse even in the blood services sector. The measures introduced for donor selection, inactivation of plasma products and selective use of blood and blood components should prevent a repeat of transmission of an enveloped virus on such a scale in the future. ...

ZusammenfassungMehrere Studien mit verschiedenen Plättchenfunktionstests (PFT) zeigten, dass Subgruppen von Patienten unter Azetylsalizylsäure(ASS)-Therapie den erwarteten plättchenfunktionshemmenden Effekt vermissen lassen. Dieses Phänomen wird ebenso wie das klinische Versagen einer ASS-Prophylaxe als ASS-Resistenz (AR) oder Nichtansprechen (nonresponsiveness) auf ASS bezeichnet. Mithilfe von PFT lassen sich mehrere Subtypen unterscheiden. Zur Charakterisierung einer AR wurden bislang folgende PFT herangezogen: optische Aggregometrie, Vollblut-Aggregometrie, Plättchenfunktionsanalyzer PFA-100, Plättchenreaktivitätsindex, Durchflusszytometrie und die Ausscheidung von Metaboliten des Thromboxans B2 im Urin oder die Thromboxan-B2-Generation in plättchenreichem Plasma. Eine komplizierte Präanalytik und Analytik sowie unspezifische Störeinflüsse und schlechte Reproduzierbarkeit schränken ihre Anwendung in der klinischen Routine erheblich ein. Darüber hinaus sind unterschiedliche PFT offenbar nicht austauschbar im Hinblick auf die Beurteilung einer AR. Drei prospektive klinische Studien wiesen eine Assoziation zwischen einer vermeintlichen, laboranalytisch festgestellten AR und kardiovaskulären Ereignissen nach. Daher besteht dringender Bedarf an einem einfachen und reproduzierbaren Test, der zuverlässig die individuelle klinische Wirksamkeit einer Therapie mit Plättchenfunktionshemmern anzeigt. Keiner der aktuell verfügbaren PFT einschließlich des PFA-100-Systems wird gegenwärtig diesem Anspruch gerecht.

Die „activated clotting time“ (ACT) ist der Standard zur patientennahen Kontrolle der Gerinnungssituation wahrend der perkutanen transluminalen koronaren Ballonangioplastie (PTCA). Die Auswirkungen einer kombinierten Gabe von Heparin und dem Glykoprotein-IIb/IIIa-Antagonisten Abciximab auf die ACT ist jedoch nur unzureichend untersucht. 30 Patienten, bei denen eine PTCA durchgefuhrt wurde, erhielten 100 IU Heparin/kg Korpergewicht als Bolus. Weitere 30 Patienten erhielten einen initialen Bolus von 70 IU Heparin/kg + Abciximab. Wir bestimmten die ACT im Katheterlabor, die aktivierte partielle Thromboplastinzeit (APTT) im Labor und als „point-of-care“-Messung sowie die Plasmaheparinspiegel. Trotz der unterschiedlichen prainterventionellen Heparindosen war die maximale ACT statistisch nicht unterschiedlich zwischen den Gruppen. Nach der PTCA war die mediane ACT beider Gruppen fast identisch (267 vs. 272 Sekunden; p = 0,79). Der mediane ACT-verlangernde Effekt von Abciximab entsprach etwa 0,68 IU/ml Heparin. Beide APTT-Assays waren auf Grund ihrer hohen Sensitivitat nicht geeignet die Gerinnungseffekte der Medikamente wahrend der PTCA zu messen. Im Gegensatz dazu gelang dies mit der Bestimmung der Plasmaheparinspiegel sehr gut. Die schwache Korrelation (r=0.23) zwischen der ACT und dem Heparinspiegel bei Patienten, die eine Kombination von Heparin und Abciximab erhielten, konnte auf exzessiv verlangerte ACT-Werte (540–1245 s) bei sechs Patienten zuruckgefuhrt werden, was durch ein ungewohnlich starkes Ansprechen auf Abciximab zuruckzufuhren war. Im Gegensatz dazu korrelierte die ACT bei den nur mit Heparin behandelten Patienten gut mit den Heparinspiegeln. Wahrend die ACT sowohl die Heparin- als auch die Abciximab-Therapie widerspiegelt, zeigen die Heparinspiegel lediglich den Heparineffekt an. Die APTT-Assays sind nicht geeignet, die Gerinnungssituation von Patienten wahrend einer PTCA zu kontrollieren.

BACKGROUND : Iron (Fe) depletion is common among regular whole-blood donors, but can be prevented through regular oral Fe supplementation. Little is known, however, about the Fe metabolism of donors undergoing intensive plasmapheresis. These donors lose considerable amounts of blood drawn for laboratory analyses and remaining in the disposable plastic sets. STUDY DESIGN AND METHODS : Menstruating women were enrolled in a prospective placebo- controlled double-blind study. One hundred women were randomly allocated to receive either 100 mg of elemental Fe per day or placebo over 24 weeks and asked to donate plasma at 1-week intervals. Hb was determined before each plasmapheresis. Ferritin, transferrin, and Fe concentration and reticulocyte count were measured every 4 weeks. RESULTS : Thirty donors in the placebo group and 29 receiving Fe completed the study. The total mean blood loss was 526 mL in the placebo group and 546 mL in the Fe arm (p = 0.271). The number of donations with Hb values lower than 12.5 g per dL requiring prolongation of the time interval until the next plasmapheresis was significantly greater in the placebo arm. In the placebo group (n = 30), ferritin levels began to decline significantly 4 weeks after entry. When the study was completed, Hb concentration and reticulocyte count also were found to be significantly lower in the placebo group than in the Fe study arm (p = 0.028 and p = 0.036, respectively). Hb, ferritin, and transferrin levels and reticulocyte counts did not change significantly in the Fe group during the observation period. CONCLUSION : Menstruating women undergoing regular plasmapheresis at short intervals are prone to develop Fe depletion. This can be prevented by regular Fe intake. Laboratory analyses in product plasma instead of serum gained from whole-blood samples could be an alternative to reduce blood loss.

Thrombophilic disorders and hypofibrinolysis were demonstrated to be risk factors in a majority of women with recurrent pregnancy loss (RPL) and infertility. We investigated the association of FV G1691A mutation, F II G20210A gene polymorphism (PM), 4G/5G PAI-1 and Alu I/D tPA PM in 32 women with infertility and 49 women with at least 2 unexplained early abortions. FV Leiden mutation was significantly more common in women with RPL (10%, p = 0.02) and infertility (19%, p = 0.0005) compared with controls (2%). PAI-1 4G PM and t-PA Alu I PM, alone or in combination, were not associated with RPL or infertility. 9/49 women with RPL showed coagulation disorders with heterozygous FV Leiden mutation (5), FXII (1), protein C (1) or protein S (2) deficiency. However, due to the small number of patients studied, no definite conclusion can be drawn.

Many hereditary factors have been implicated in the development of arterial and/or venous thromboembolic diseases. A number of these risk factors can be identified by the amplification refractory mutation system (ARMS). However, the underlying technical conditions for performing ARMS are highly variable, and depend on which risk factors are being analyzed. We have now developed a novel ARMS-based system to simultaneously screen for multiple hypercoagulability factors under identical PCR conditions. This can greatly simplify the process of screening for hereditary hypercoagulability.

Plasma exchange (PE) is the most important treatment in thrombotic microangiopathies (TMAs) mainly encompassing thrombotic thrombocytopenic purpura (TTP) and adult hemolytic syndrome (HUS). This therapeutic measure has substantially improved clinical outcome. One plasma volume corresponding to 40 ml/kg of body weight is exchanged daily until the platelet count is above 150×10 9 /l or 100×10 9 /l and continues to rise or remains constantly after cessation of treatment. Exacerbations and late recurrences demand reapplication of daily PE. Twice daily PEs are initiated if the response to initial treatment is poor. The importance of additional or alternate measures including glucocorticoids, antiplatelet agents, splenectomy, intravenous immunoglobulins, protein A columns, vincristine, cyclosporine, and cyclophosphamide is uncertain. Whether cryosupernatant plasma (CSP) or solvent/detergent-treated (SDP) plasma is superior to standard fresh frozen plasma (FFP) remains to be determined. Methylene blue-treated plasma (MBP) seems to be less effective than standard FFP.

The aim of our study was to compare a systemic and a local aprotinin application in patients during coronary artery bypass graft (CABG) surgery. The advantage of a topical aprotinin application is seen in the fact that this may not lead to systemic side effects. A prospective, randomized study comprising 97 patients was conducted. A dose of 5 106KIU aprotinin was given systemically to 49 patients and four doses of 1.25 106KIU aprotinin were applied topically to 48 patients by spraying the substance on the target area (A. mammaria interna region and pericardium). We determined markers for the inflammatory response, coagulation system, standard haematological markers and postoperative complications. Exclusion criteria were defined as surgical bleeding, redo operations, neurological, haematological, liver and kidney disorders. Sex, age, perfusion times, mortality, renal failure and strokes were identical in both groups. Biochemical markers and clinical outcome demonstrated no significant differences between the systemic and local applications. Interleukin 6 and elastase were tendentially higher ( p= 0.1) in the local group, but with a high standard deviation in each patient. Our results suggest that there is no difference between the perioperative application of 5 106KIU systemically given aprotinin and 1.25 106KIU locally applied aprotinin.

Background and Objectives Solvent/detergent-treated plasma (SDP) contains markedly lower protein S (PS) and plasmin inhibitor (PI) activity than standard fresh-frozen plasma (FFP). It has also been reported that SDP contains no α1-antitrypsin. Despite the lack of clinical data, it is suspected that SDP may be less effective than FFP in the treatment of complex coagulopathies. We therefore conducted a prospective trial to study the impact of SDP and FFP on haemostasis and fibrinolysis in complex coagulopathy after open-heart surgery. Materials and Methods Patients received either 600 ml of SDP (n = 36) or 600 ml of FFP (n = 31) at an infusion rate of 30 ml/min. The following parameters were measured before treatment and 60 min after termination of plasma infusion: prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen, factor VIII, antithrombin, protein C (PC), free PS and PS activity, prothrombin fragments F1+2 (F1+2), d-dimers (DD), fibrinogen degradation products (FDP), plasmin–plasmin inhibitor complexes (PPI), plasminogen, PI and α1-antitrypsin. Results The rise in fibrinogen, factor VIII, antithrombin, PC, free PS, α1-antitrypsin and plasminogen, and the decrease in PT and APTT, did not significantly differ between the two study arms. However, PS activity did not increase after SDP infusion but did show a significant elevation after infusion with FFP. PI declined significantly after SDP and remained uninfluenced by FFP. Neither SDP nor FFP had any significant influence on F1+2, DD or FDP. However, a significant decrease in PPI levels caused by both types of plasma indicated a reduction in hyperfibrinolysis. Clinical haemostasis evaluation revealed no significant difference between the two treatment regimens. No adverse reactions were observed. Conclusion With the exception of PS and PI, SDP and FFP improved haemostasis and fibrinolysis to a similar degree. The clinical significance of these findings has to be determined in patients with severe acquired PS and PI deficiency requiring plasma transfusions.

Die hamostaseologische Basisdiagnostik in der Intensivmedizin umfasst Thrombozytenzahlung, Quickwert (Q), aktivierte partielle Thromboplastinzeit (APTT), Fibrinogen, D-Dimere und Antithrombin. Mit Ausnahme der Thrombopathien, fur deren Nachweis bislang kein geeigneter Screeningtest zur Verfugung steht, kann dieses Basisprogramm nahezu alle klinisch relevanten Hamostasestorungen erfassen und im Verlauf kontrollieren. Der Intensivmediziner muss alle Ursachen einer Verminderung des Q oder einer verlangerten APTT kennen, um aufgrund von Fehlinterpretationen keine falschen Schlussfolgerungen zu ziehen. Hohe Heparindosen, das Lupus-Antikoagulanz und hohe Fibrin(ogen)-Spaltprodukt-Konzentrationen konnen den Q vermindern oder die APTT verlangern, ohne dass ein Gerinnungsfaktorenmangel zugrunde liegt. Die Differenzierung zwischen Faktorenmangel und anderen Ursachen gelingt mit einem modifizierten Q. Die Sensitivitat der Q- und APTT-Reagenzien gegenuber den verschiedenen Einflussgrosen schwankt von Reagenz zu Reagenz und von Charge zu Charge. Deshalb ist die APTT zum Monitoring einer hochdosierten Heparintherapie weniger gut geeignet als der Heptest, der spezifischer und besser reproduzierbar die antikoagulatorische Anti-Faktor-Xa-Aktivitat erfasst. Unter Streptokinasetherapie und beim primaren Hyperfibrinolysesyndrom werden falsch zu niedrige Fibrinogenspiegel gemessen, wenn die Clauss-Methode benutzt wird. Die Massivtransfusion erfordert Kenntnisse uber Storungen der Ergebnisse hamostaseologischer Laboruntersuchungen durch Hypothermie und durch Hydroxyethylstarken oder Dextrane. Bei der akuten disseminierten intravasalen Gerinnung mussen Gerinnungsanalysen engmaschig in 6-stundlichen Abstanden erfolgen. Wegen mangelhafter Vergleichbarkeit mit den Ergebnissen der Routinediagnostik und weiterer erheblicher Nachteile hat die Point-of-care-Gerinnungsdiagnostik bislang noch keine wesentliche Verbreitung gefunden.

Hamostasestorung sind an der Entstehung der koronaren Herzkrankheit (KHK) und der akuten Koronarsyndrome wesentlich beteiligt. Neben biochemischen Parametern wurden in den letzten Jahren zahlreiche Genpolymorphismen der Hamostase und ihre Assoziation zum koronaren Risiko untersucht. Hierzu gehoren Polymorphismen der Thrombozyten-Glykopriteine, der Gerinnungsfaktoren Fibrinogen, Prothrombin, Faktoren V, VIII und XIII sowie des Plasminogenaktivator-Inhibitors-1 und des Tissue-Type-Plasminogenaktivators. Obwohl vor allem retrospektive Fallkontrollstudien entsprechende Assoziationen aufzeigten, konnte bislang keiner der untersuchten Polymorphismen als eindeutiger Risikomarker der KHK identifiziert werden. Die Grunde liegen in der Komplexitat der KHK und deren Komplikationen sowie dem relativ geringen Einfluss eines einzelnen Genpolymorphismus auf das Gesamtrisiko. Diese Gegebenheiten wurden die bisherigen Studien uberwiegend nicht gerecht. Es werden daher Moglichkeiten diskutiert, wie kunftige Studien zum besseren Verstandnis der genetischen Basis der KHK und zu neuen Moglichkeiten der individuellen therapeutischen Intervention beitragen konnen.

Background and aim: Coronary artery disease (CAD), arterial hypertension and Type 2 diabetes mellitus are common polygenetic disorders which have a major impact on public health. Disease prevalence and progression to cardiovascular complications, such as myocardial infarction (MI), stroke or heart failure, are the product of environment and gene interaction. The LUdwigshafen RIsk and Cardiovascular Health (LURIC) study aims to provide a well-defined resource for the study of environmental and genetic risk factors, and their interactions, and the study of functional relationships between gene variation and biochemical phenotype (functional genomics) or response to medication (pharmacogenomics). Long-term follow-up on clinical events will allow us to study the prognostic importance of common genetic variants (polymorphisms) and plasma biomarkers. Setting: Cardiology unit in tertiary care medical centre in south-west Germany. Study design: Prospective cohort study of individuals with and without cardiovascular disease at baseline. Patients and methods: LURIC is an ongoing prospective study of currently > 3300 individuals in whom the cardiovascular and metabolic phenotypes CAD, MI, dyslipidaemia, hypertension, metabolic syndrome and diabetes mellitus have been defined or ruled out using standardised methodologies in all study participants. Inclusion criteria for LURIC were: German ancestry (limitation of genetic heterogeneity), clinical stability (except for acute coronary syndromes [ACSs]) and availability of a coronary angiogram (this inclusion criterium was waived for family members provided that they met all other inclusion and exclusion criteria) Exclusion criteria were: any acute illness other than ACSs, any chronic disease where non-cardiac disease predominated & a history of malignancy within the past five years Exclusion criteria were pre-specified in order to minimise the impact of concomitant non-cardiovascular disease on intermediate biochemical phenotypes or on clinical prognosis (limitation of clinical heterogeneity). A standardised personal and family history questionnaire and an extensive laboratory work-up (including glucose tolerance testing in non-diabetics and objective assessment of smoking exposure by determination of cotinine plasma levels) was obtained from all individuals after informed consent. A total of 115 ml of fasting venous blood was sampled for the determination of a pre-specified wide range of intermediate biochemical phenotypes in serum, plasma or whole blood, for leukocyte DNA extraction and immortalisation of B-lymphocytes. Biochemical phenotypes measured included markers of endothelial dysfunction, inflammation, oxidative status, coagulation, lipid metabolism and flow cytometric surface receptor expression of lympho-, mono- and thrombocytes. In addition, multiple aliquots of blood samples were stored for future analyses. Results: A total of 3500 LURIC baseline measurements were performed in 3316 individuals between July 1997 and January 2000. The baseline examination was repeated within a median of 35 days in 5% of study participants (n = 166, including a third examination in 18 after a median of 69 days) for pharmacogenomic assessment of lipid-lowering therapy and for quality control purposes. A five-year follow-up on major clinical events (death, any cardiovascular event including MI, stroke and revascularisation, malignancy and any hospitalisation) is ongoing. The clinical phenotypes prevalent at baseline in the cohort of 2309 men (70%) with a mean age of 62 ± 11 years and 1007 women (30%), mean age 65 ± 10 years, were angiographically-documented CAD in 2567 (79%), MI in 1368 (41%), dyslipidaemia in 2050 (62%) with hypercholesterolaemia = 240 mg/dl (27%), hypertriglyceridaemia = 150 mg/dl (44%) and HDL-cholesterol = 35 mg/dl (38%) in individuals not treated with lipid-lowering agents, systemic hypertension in 1921 (58%), metabolic syndrome in 1591 (48%), Type 2 diabetes in 1063 (32%) and obesity defined by body mass index = 30 kg/m2 in 770 (23%). Control patients in whom CAD had been ruled out angiographically were five years younger than those with CAD (59 ± 12 and 64 ± 10 years, respectively; p < 0.001), twice as often females (48% compared to 25% females in the CAD group, p < 0.001) and had significantly less cardiovascular risk factors than individuals with CAD. The prevalence of specific cardiovascular risk subsets in LURIC, such as the elderly (= 75 years), was 375 (11%), while 213 (6%) were young adults (< 45 years) and 904 (27%) were postmenopausal women (90% of all females). A low risk status (= 1 out of the four traditional risk factors: dyslipidaemia, smoking, hypertension and diabetes mellitus) was identified in 314 (9%) individuals of the entire cohort (5% in CAD and 26% in controls, p < 0.001) and 97 (3%) carried none of the four risk factors (1% in CAD and 9% in controls, p < 0.001).A total of 35 aliquots (serum, plasma and red blood cells) were kept for long-term storage and future analyses at -80°C. Multiple stocks of whole blood and extracted DNA are available for ongoing and future genomic studies, including aliquots of B-cells frozen in liquid nitrogen for transformation into lymphoblastoid cell lines. All phenotypic data are stored in a database currently carrying 1710 variables on each individual. Conclusions: LURIC is a study to contribute to the identification and assessment of environmental and genetic factors for atherosclerosis and related metabolic diseases. Major efforts have been undertaken to establish reliable phenotypes for the cardiovascular and metabolic diseases CAD/MI, hypertension and diabetes mellitus. Phenotypic characterisation included a standardised clinical and an extensive laboratory work-up. DNA and plasma aliquots were stored for future use. Furthermore, immortalised cell lines offer a renewable source of DNA. The LURIC database and tissue bank is a resource to elucidate functional relationships between genetic variation and biochemical phenotype (functional genomics), to study genetically modified responses to medication (pharmacogenomics) and to study the prognostic importance of biomarkers of cardiovascular and metabolic disease.

Malignancy frequently is accompanied by activated coagulation and fibrinolysis indicating a hypercoagulable state. The purpose of our study was to estimate the contribution of local tumor-induced mechanisms to the activation of hemostasis and fibrinolysis. In a prospective study, we compared the plasma levels of thrombin-antithrombin complexes, prothrombin fragment 1+2, and D-dimers in blood samples that simultaneously were drawn from the superior vena cava and the pulmonary vein of a tumor-bearing pulmonary lobe. Samples from the superior vena cava were drawn before operation and served as controls. After thoracotomy, a second group of samples was simultaneously taken from the pulmonary veins of the tumor-bearing lobe and the superior vena cava. Forty-five patients with pulmonary malignancies were included (25 adenocarcinomas and 20 squamous cell carcinomas). There were no significant differences of thrombin-antithrombin complexes, prothrombin fragment 1+2, and D-dimers levels in patients suffering from adenocarcinoma and from squamous cell carcinoma. Intraoperatively, prothrombin fragment 1+2 and D-dimers levels were markedly increased when compared with the preoperative values (p

Four-factor PCCs are most frequently used for replacement of vitamin K-dependent clotting factors and inhibitors proteins C and S in patients bleeding after phenprocoumon or warfarin overdose, in vitamin K-deficient patients presenting life-threatening bleeding, and liver disease. Since many of these patients are prone to thromboembolic complications including DIC, all conceivable measures should be taken against the thrombogenic potential of PCC preparations. This thrombogenic potential of PCCs is obviously dependent on several factors including activated clotting factors, lack of inhibitors of blood coagulation, and coagulation factor overload, as well as predisposing factors referred to recipients and drug interactions. The composition of PCC should meet the following criteria: Antithrombin in addition to heparin for the neutralization of FIXa and FXa should be present in the preparations; no overloading with FII and FX; substantially lower FVII than FIX potencies in order to minimize contamination with or generation of FVIIa; and substantial protein C as well as protein S activities. Quality control should include determinations as recommended by the European Pharmacopoeia. Specific assays for quantification of FIXa and FXa are urgently required, and validity of these assays must be proven in surveys. All lots should also be tested for their FVIIa content. Furthermore, the safety of PCCs must be proven by suitable animal models. Whenever possible, patients receiving PCCs should be under low-dose heparin prophylaxis; simultaneous administration of heparin-neutralizing drugs or antifibrinolytic agents must be avoided.

Die Empfehlungen zur Thrombozytentransfusion der Thrombozyten-Arbeitsgruppe der DGTI, GTH und DGHO [1] haben einen eklatanten logischen Widerspruch in unseren Sicherheitskonzepten zur Herstellung und Anwendung von Hamotherapeutika offen zutage treten lassen. Die Auswahl des Thrombozytenkonzentrats (TK) – Pool-TK aus 4–6 Vollbluteinheiten oder Apherese-TK von Einzelspendern – soll bei nichtimmunisierten Patienten allein von der Verfugbarkeit der Praparate abhangig gemacht werden. Diese Empfehlung wird mit einem Evidenzgrad 1B unterlegt, der weder durch die zitierten [2–4] noch durch eine neuere, nicht zitierte [5] Studie gestutzt wird. Es ist zumindest zweifelhaft, ob man aus einer einzigen randomisierten Studie an drei Gruppen von jeweils 17 Patienten mit hamatologischen malignen Erkrankungen [4] eine starke Empfehlung ableiten kann, Pool-TK und Apherese-TK als gleichermasen wirksam und vertraglich zu betrachten. Ist nun die Wahl des einen oder des anderen Thrombozytenpraparats bei nichtimmunisierten Patienten allein eine Frage der lokalen Versorgungslogistik? Mitnichten, wie eine genauere Analyse zeigt. Bei oberflachlicher Betrachtung ist die Spenderexposition bei Transfusion von Pool-TK gegenuber Apherese-TK um Faktor 4–6 erhoht. Dies wurde bereits den Sicherheitsgewinn durch NAT-Verfahren zunichte machen [6]. Die wahren Unterschiede in der Spenderexposition zwischen beiden Thrombozytenpraparaten sind jedoch erschreckend: Fur die zirka 150 000 jahrlich in Deutschland hergestellten Pool-TK werden 620 000 Vollblutspenden benotigt [7], die von durchschnittlich 485 500 Spendern (Bereich: 350 000 bei 1,8 Vollblutspenden pro Jahr bis 620 000 bei einer Vollblutspende pro Jahr) erbracht werden. Die tatsachliche Zahl an notwendigen Spendern durfte noch wesentlich hoher liegen, wenn die AB0-Blutgruppen, das Rh-Merkmal D sowie weitere spezielle Spendermerkmale wie der CMV-Antikorperstatus entsprechend der Normalverteilung in der Bevolkerung berucksichtigt werden. Derzeit spendet ein Thrombozytenspender zirka 8 Apherese-TK pro Jahr mit steigender Tendenz aufgrund von Doppel-Thrombozytapheresen (Statistik der StKB 2005). Wurden 150 000 Apherese-TK statt Pool-TK hergestellt, konnten diese von rund 18 750 Spendern erbracht werden, woraus sich fur die Patienten ein Unterschied in der Spenderexposition zwischen Apherese-TK und Pool-TK von durchschnittlich 1:26 ergibt (Bereich: 1:18 bis 1:33). Zielte man auf eine moglichst niedrige Spenderexposition ab, konnte ein Stamm von 4000 Thrombozytenspendern ausreichen, diese 150 000 Pool-TK durch Apherese-TK zu ersetzen. Die Spenderexposition wurde sich um nahezu zwei Log-Stufen (!) reduzieren. Abgesehen davon werden mit der Herstellung von 150 000 Pool-TK als Folge einer verminderten Ausbeute bei der Vollblut-Fraktionierung zirka 37 000 l Plasma «verfeuert», die fur die Herstellung knapper Plasmaderivate fehlen. Die Anwendung von Pool-TK begunstigt die AB0und Rh-inkompatible Thrombozytentransfusion, die wegen moglicher schwerer unerwunschter Wirkungen weitgehend vermieden werden muss. Will man einem Patienten mit Blutgruppe A Rh– zwei AB0und Rh-identische Pool-TK mit einem Thrombozytengehalt von jeweils mindestens 2,5 × 1011 verabreichen, wird eine Tagesserie von mindestens 142 Vollblutspenden benotigt. Sollen die Praparate anti-CMV-negativ sein, sind bereits 315 Vollblutspenden an einem Tag notwendig. Soll ein Patient mit Blutgruppe AB Rh– zwei AB0und Rh-gleiche und anti-CMV-negative Pool-TK erhalten, muss auf 3700 Vollblut-Einheiten eines Spendetages zuruckgegriffen werden konnen. Hieraus wird deutlich, dass AB0und Rh-identische Pool-TK nur von uberregionalen Spendediensten flachendeckend bereitgestellt werden konnten, die allerdings mit erheblicher, haufig nicht vertretbarer Zeitverzogerung am Krankenbett ankamen. In der klinischen Routine stellt daher die AB0und Rh-inkompatible Transfusion von Pool-TK wohl die Regel und nicht die Ausnahme dar. Demgegenuber kann Letter to the Editors · Brief an die Herausgeber