230
Letters to the Editor Blood Coagulation and Fibrinolysis 2015, 26:230–234
Confounding factors should be considered in the evaluation of mean platelet volume in nonvalvular atrial fibrillation Ercan Varol and Mehmet Ozaydin Department of Cardiology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey Correspondence to Ercan Varol, MD, Professor, Department of Cardiology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey Tel: +90 5323468258; fax: +90 2462324510; e-mail: [email protected] Received 10 December 2013 Revised 16 June 2014 Accepted 27 July 2014
We read the article by Tekin et al. with great interest [1]. They investigated whether mean platelet volume (MPV) is elevated in patients with nonvalvular atrial fibrillation, compared with healthy controls. They found that MPV and white blood cell count is significantly higher in patients with nonvalvular atrial fibrillation compared with the control group. We believe that the findings of this study will act as a guide for further studies about the effect of nonvalvular atrial fibrillation on platelet indices. However, we want to make minor criticism about this study from the methodological aspect. Firstly, they did not mention about the tube that the blood sample was collected for platelet indices and the time interval between blood sampling and analysis. This is very important. It is clear that platelets exhibit a time-dependent swelling when blood samples are anticoagulated with EDTA, whereas this swelling may be less with acid citrate-based anticoagulation [2]. With impedance counting, the MPV increases over time as platelets swell in EDTA, with increases of 7.9% within 30 min. Although an overall increase of 13.4% occurs over 24 h, the majority of this increase occurs within the first 6 h [2]. The recommended optimal measuring time of MPV with EDTA is 120 min after venipuncture [3]. For reliable MPV measurement, the potential influence of anticoagulant on the MPV must be carefully controlled, either using an alternative anticoagulant (such as citrate) or standardizing the time delay between sampling and analysis ( T, Cys227Phe) who showed spontaneous intracerebral bleeding. Cys227 is located in the conserved fibrinogen beta globular C-ter domain and is involved in the formation of a disulfide bridge with Cys161 in the gamma-chain. In this case, the complete fibrinogen
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
232 Blood Coagulation and Fibrinolysis 2015, Vol 26 No 2
deficiency can be explained by an abnormal three-dimensional structure of the beta-chain C-ter domain, which does not allow hexamer assembly and secretion as previously mentioned [7]. Our patient, a heterozygous carrier of 680delG with dysfibrinogenaemia, had an abnormal bleeding score. Her first bleeding event was a postpartum haemorrhage after a difficult vaginal delivery, a situation also occurring in normal subjects. Moreover, it is worth noticing that her two following vaginal deliveries were not complicated by bleeding. Referring to the literature [10], women with dysfibrinogenaemia and a history of recurrent poor pregnancy outcome were treated with prophylactic fibrinogen concentrate infusions as soon as pregnancy was confirmed using a target trough fibrinogen level of 1 g/l. In afibrinogenaemic/hypofibrinogenaemic patients, fibrinogen levels are maintained over 1 g/l during pregnancy and for delivery. According to these guidelines, our patient would not have received a prophylactic substitution during her first pregnancy and delivery. Indeed, her baseline level was above 1 g/l, so no further measures would have been undertaken. Knowing the diagnosis, when the postpartum haemorrhage occurred, a substitution might have achieved an earlier haemostatic efficacy and thereby a reduced overall bleeding. Both bleeding after hysterectomy and local bleeding after a fine needle aspiration in a breast lump can be considered standard complications after such procedures. According to the UK guidelines [11], patients with dysfibrinogenaemia with a bleeding phenotype should be treated with fibrinogen concentrate preoperatively to raise and maintain the fibrinogen level to 1 g/l above their baseline level until haemostasis is secure and 0.5 g/l until wound healing is complete. Knowing the diagnosis, our patient would have been prophylactically substituted, which could have prevented the bleeding. In conclusion, we have identified a novel heterozygous frame shift mutation in FGB exon 4: c.680delG. This mutation is associated with dysfibrinogenaemia and a mild history of bleeding but no thrombosis.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 2
3 4
Doolittle RF. Fibrinogen and fibrin. Annu Rev Biochem 1984; 53: 195–229. Redman CM, Xia H. Fibrinogen biosynthesis. Assembly, intracellular degradation, and association with lipid synthesis and secretion. Ann N Y Acad Sci 2001; 936:480–495. Matsuda M, Sugo T. Hereditary disorders of fibrinogen. Ann N Y Acad Sci 2001; 936:65–88. Neerman-Arbez M, de Moerloose P, Bridel C, Honsberger A, Schonborner A, Rossier C, et al. Mutations in the fibrinogen aalpha gene account for the majority of cases of congenital afibrinogenemia. Blood 2000; 96: 149–152.
5
Roy SN, Mukhopadhyay G, Redman CM. Regulation of fibrinogen assembly. Transfection of Hep G2 cells with B beta cDNA specifically enhances synthesis of the three component chains of fibrinogen. J Biol Chem 1990; 265:6389–6393. 6 Shapiro SE, Phillips E, Manning RA, Morse CV, Murden SL, Laffan MA, et al. Clinical phenotype, laboratory features and genotype of 35 patients with heritable dysfibrinogenaemia. Br J Haematol 2013; 160:220–227. 7 Vu D, Di Sanza C, Caille D, de Moerloose P, Scheib H, Meda P, et al. Quality control of fibrinogen secretion in the molecular pathogenesis of congenital afibrinogenemia. Hum Mol Genet 2005; 14:3271–3280. 8 Zhang JZ, Redman CM. Identification of B beta chain domains involved in human fibrinogen assembly. J Biol Chem 1992; 267:21727– 21732. 9 Grandone E, Tiscia G, Cappucci F, Favuzzi G, Santacroce R, Pisanelli D, et al. Clinical histories and molecular characterization of two afibrinogenemic patients: insights into clinical management. Haemophilia 2012; 18:e16–e18. 10 Bornikova L, Peyvandi F, Allen G, Bernstein J, Manco-Johnson MJ. Fibrinogen replacement therapy for congenital fibrinogen deficiency. J Thromb Haemost 2011; 9:1687–1704. 11 Bolton-Maggs PHP, Perry DJ, Chalmers EA, Parapia LA, Wilde JT, Williams MD, et al. The rare coagulation disorders–review with guidelines for management from the United Kingdom Haemophilia Centre Doctors’ Organisation. Haemophilia 2004; 10:593–628. DOI:10.1097/MBC.0000000000000196
Coagulation profile, H1N1 influenza A infection and hematological malignancies Viroj Wiwanitkita,b,c,d a Faculty of Medicine, University of Nis, Nis, Serbia, bHainan Medical University, Haikou, Hainan Province, PR China, cJoseph Ayobabalola University, Ikeji-Arakeji, Nigeria and dSurin Rajabhat University, Surin, Thailand
Correspondence to Viroj Wiwanitkit, MD, Faculty of Medicine, University of Nis, Nis, Serbia E-mail: [email protected]
The recent report on ‘coagulation profile in patients with H1N1 influenza A infection undergoing treatment for haematological malignancies’ is very interesting [1]. Rupa-Matysek et al. [1] observed that ‘the association between coagulation activation and poor outcome pH1N1 infection was found in the analyzed group’. In fact, the coagulation disorder in the patient with H1N1 influenza A infection is an interesting topic. This problem can be seen in both typical and atypical H1N1 influenza A infection [2]. In the present report, the problem in the patient with H1N1 influenza A infection is possible. However, an important concern is the concomitant hematological malignancies. The remaining question is how we can assure that the coagulation is the result of H1N1 influenza infection, hematological malignancies or combination of both disorders. For sure, the problem is of concern for the hematologist. Some leukemic patients infected with H1N1 influenza virus can further develop serious complications such as hemophagocytic lymphohistiocytosis that can be fatal [3]. The coagulation disorder is an important presentation of such complications [3].
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Letters to the Editor 233
Acknowledgements
role in the vital eythroid aggregation because of ABS via acting on fibrinogen gamma.
Conflicts of interest
There are no conflicts of interest.
References 1
Rupa-Matysek J, Gil L, Wojtasin´ska E, Zajdel K, Ciepłuch K, Komarnicki M. Coagulation profile in patients with H1N1 influenza A infection undergoing treatment for haematological malignancies. Blood Coagul Fibrinolysis 2014; [Epub ahead of print].
2
Wiwanitkit V. Swine flu: any effect on the platelets? Blood Coagul Fibrinolysis 2010; 21:778.
3
Lai S, Merritt BY, Chen L, Zhou X, Green LK. Hemophagocytic lymphohistiocytosis associated with influenza A (H1N1) infection in a patient with chronic lymphocytic leukemia: an autopsy case report and review of the literature. Ann Diagn Pathol 2012; 16:477–484. DOI:10.1097/MBC.0000000000000222
High iron content of Ankaferd hemostat as a clue for its hemostatic action of red blood cell origin ¨ ktemb, Nejat Akara, Yasemin Ardıc¸og˘lua, Zeki O b Nuran Erduran and Ibrahim C. Haznedarogluc a
b
TOBB-ETU Hospital, Ankara, Department of Chemistry, Faculty of Arts and Sciences, Kirikkale University, Kirikkale and cDepartment of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey Correspondence to Nejat Akar, MD, Professor, TOBB ETU Hospital, Pediatrics Department, So¨gu¨to¨zu¨/Ankara, Turkey E-mail: [email protected]
We have read with great interest the article by Sacak et al. [1], investigating the long-term histopathological effects of Ankaferd hemostat (ABS) on the vascular tissues in Blood Coagulation and Fibrinolysis [1]. ABS (http:// www.ncbi. nlm.nih.gov/pubmed/?term=ankaferd) is the first topical hemostatic agent regarding the red blood cell (RBC)–fibrinogen interactions tested in the clinical trials [2]. RBCs take part in the genesis of blood coagulation via making an almost impermeable seal in a clot [3]. The role of RBCs in the clot formation is very important for the development of hemostatic agents in the management of bleeding disorders. We have previously suggested that the ABS-induced pharmacological modulation of essential erythroid proteins (ankyrin, spectrin, and actin) can cause vital eythroid aggregation via acting on fibrinogen gamma [2]. Likewise, RBCs bind to the fibrinogen via a beta3-containing integrin, with almost similar affinity as platelets [3]. More importantly, human fibrinogen also directly recognizes iron, although the mechanism of binding with fibrinogen–iron and heme has not been elucidated in detail [4]. Thus, iron can play a significant role in the ABS-induced cellular hemostasis located in the crossroads of RBC–fibrinogen interactions [1,2]. The iron and trace element content of ABS has not been previously investigated. The aim of this study is to search iron inside ABS in order to set the hypothesis that iron could have a
Atomic absorption and UV–Vis spectrophotometric methods were used for the analysis of iron inside ABS. The concentrations of metal ions were determined first using a GBC model 933AA atomic absorption spectrophotometer (AAS), at wavelengths of 372.0 nm for Fe(III), 324.7 nm for Cu(II), 213.9 nm for Zn(II), and 328.1 nm for Ag(I). Air-acetylene type flame was used. ABS was diluted with distilled water in 1 : 500 ratio for Fe(III). Secondly, Fe(III) content of Ankaferd was determined using a Shimadzu 1800 UV–Vis spectrophotometer. For the UV–Vis measurements, 1 ml of ABS was diluted to 1000 ml. Then, 5.0 ml 2.0 mol\l HCl and 4.0 ml 1.5 mol/l potassium thiocyanate were added to 1 ml of this solution, and the absorbance of the obtained red solution, because of the formation of blood-red [Fe(SCN)6]3- complex, was measured at lmax ¼ 470 nm. Analytical grade iron(III)nitrate nonahydrate, FeN3O9 9H2O, and potassium thiocyanate were purchased from Merck (Rahway, New Jersey, USA), and AAS standards were the product of Merck Millipore (Darmstadt, Germany). Both methods indicated an iron ion concentration higher than 2000 ppm (Table 1). As Fe(II) does not react with SCN ions, the obtained amount is almost equal to Fe(III) ions in Ankaferd. Further, our analysis revealed the presence of Cu(II), Zn(II), and Ag(I) ions in ABS, but with much lower concentrations than Fe(III) ions. Concentrations were 2.56, 9.2, and 45.0 ppm, respectively. Also, AAS measurements indicated the absence of Pb(II), Ni(II), Cr(IV), Co(II), and Cd(II) ions in ABS. Our data revealed for the first time the presence of Fe(III) ions and also at very low concentration some other trace elements inside ABS. Next-generation RBC-related hemostatics, such as ABS nanohemostat, has been designated in the essential treatment of life-threatening bleedings by restoring physiological hemostasis via acting on RBCs [5]. High iron content of ABS should be further considered that the iron ion can play a significant role in the ABS-induced cellular hemostasis located in the crossroads of RBC–fibrinogen interactions. Therefore, the long-term histopathological alterations already reported by Sacak et al. [1] could be further evaluated by the tissue staining for iron, in order to test the hypothesis that tissue changes of ABS might be related to the iron content of the tissues upon exposure to ABS. The proteomics of iron (the
Table 1
Fe(III) concentration of Ankaferd hemostat
Analysis method
Fe(III) concentration (ppm)
AAS UV–Vis AAS, atomic absorption spectrometer; UV, ultra-violet.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
2163 7 2385 9
234 Blood Coagulation and Fibrinolysis 2015, Vol 26 No 2
structural and functional properties of the proteins related to the iron metabolism) should also be matched with the already established proteomics of ABS [2]. Protein-engineering techniques to produce recombinant proteins and their variants should be used to study the cellular and animal models with the aim to clarify, at molecular level, the mechanisms of interaction between the various iron proteins to understand and enhance ABS-induced hemostasis. Moreover, further basic, experimental, and clinical trials about ABS shall focus on the interrelationships between high iron content, fibrinogen gamma, and vital erythroid aggregation because of ABS.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
2
3 4 5
Sacak B, Akdeniz ZD, Sirinoglu H, Cilingir OT, Celebiler OB, Ercan F, Numanoglu A. Microvascular anastomosis using Ankaferd blood stopper: demonstration of long-term histopathologic effects on vascular tissue. Blood Coagul Fibrinolysis 2014; May 6 [Epub ahead of print]. Haznedaroglu BZ, Beyazit Y, Walker SL, Haznedaroglu IC. Pleiotropic cellular, hemostatic, and biological actions of Ankaferd hemostat. Crit Rev Oncol Hematol 2012; 83:21–34. Arie¨ns RAS. A new red cell shape helps the clot. Blood 2014; 123:1442– 1443. Orino K. Functional binding analysis of human fibrinogen as an iron- and heme-binding protein. Biometals 2013; 26:789–794. Huri E, Beyazit Y, Mammadov R, Toksoz S, Tekinay AB, Guler MO, et al. Generation of chimeric ‘ABS Nanohemostat’ complex and comparing its histomorphological in vivo effects to the traditional Ankaferd hemostat in controlled experimental partial nephrectomy model. Int J Biomater 2013; 2013:949460; doi: 10.1155/2013/949460-70. DOI:10.1097/MBC.0000000000000223
Thrombelastography will not predict bleeding if normal Evan G. Pivalizza, Sam D. Gumbert, Olga Pawelek and Nischal K. Gautam Department of Anesthesiology, University of Texas Medical School – Houston, Houston, Texas, USA Correspondence to Evan G. Pivalizza, MD, Professor, Department of Anesthesiology, University of Texas Medical School – Houston, MSB 5.020, 6431 Fannin Street, Houston, TX 77030, USA Tel: +1 713 500 6251; fax: +1 713 500 6270; e-mail: [email protected]
We read Sharma et al.’s [1] statistically elegant retrospective evaluation of the inability of the thrombelastograph (TEG) maximum amplitude and angle to predict bleeding when added to an existing model with interest. Therein, however, lies the dilemma – it is unlikely that a whole-blood viscoelastic coagulation measure obtained after arterial line placement in the operating room could predict bleeding per se, rather than a RESPONSE to any abnormal bleeding, including guiding transfusion or hemostatic product decisions.
The authors acknowledge several limitations in this retrospective study. (1) The absence of a transfusion protocol or algorithm may have led to unintentional bias, and the utility of the TEG has been most successful in cardiac surgery when incorporated into an algorithmic approach [2,3]. (2) Only a minority of patients in this cohort received an intraoperative (when the TEG was analyzed) transfusion of either red blood cells (20.3%) or platelets (12.5%), which suggests that any potential information from the TEG to guide therapy was diluted by 79–87% of the cohort, respectively, who were not transfused. (3) Despite the statistical significance in three of the four reported TEG parameters between baseline and warming and postprotamine, changes are not clinically significant (9% decrease in maximum amplitude and 11% increase in K time), especially as all fall within the anticipated normal ranges for this cohort. This is in sharp contrast to the dramatic changes in platelet count (54% decrease) and international normalized ratio (72% increase). Given the small number of patients actually receiving a platelet transfusion (fresh frozen plasma data not shown), it is tempting to conclude that changes in standard coagulation tests did NOT predict transfusion and that the very small changes in TEG parameters more closely reflect the conservative clinical transfusion practice in this particular cohort. Despite the statistical absence of effect of TEG parameters adding to a prediction of bleeding in this study, we wonder whether the TEG parameters may have been more closely linked to transfusion rather than the standard coagulation tests. We look forward to further data publication from Sharma’s group addressing this question in a prospective investigation.
Acknowledgements No financial support was provided for this submission apart from the department resources. Conflicts of interest
There are no conflicts of interest.
References 1
2
3
Sharma AD, Al-Achi A, Seccombe JF, Hummel R, Preston M, Behrend D. Does incorporation of thromboelastography improve bleeding prediction following adult cardiac surgery? Blood Coagul Fibrinolysis 2014; 25:; [Epub ahead of print]. Shore-Lesserson L, Manspeizer HE, DePerio M, Francis S, Vela-Cantos F, Ergin MA. Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg 1999; 88:312–319. Royston D, von Kier S. Reduced hemostatic factor transfusion using heparinase-modified thrombelastography during cardiopulmonary bypass. Br J Anaesth 2001; 86:575–578. DOI:10.1097/MBC.0000000000000195
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Letters to the Editor Blood Coagulation and Fibrinolysis 2015, 26:230–234
Confounding factors should be considered in the evaluation of mean platelet volume in nonvalvular atrial fibrillation Ercan Varol and Mehmet Ozaydin Department of Cardiology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey Correspondence to Ercan Varol, MD, Professor, Department of Cardiology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey Tel: +90 5323468258; fax: +90 2462324510; e-mail: [email protected] Received 10 December 2013 Revised 16 June 2014 Accepted 27 July 2014
We read the article by Tekin et al. with great interest [1]. They investigated whether mean platelet volume (MPV) is elevated in patients with nonvalvular atrial fibrillation, compared with healthy controls. They found that MPV and white blood cell count is significantly higher in patients with nonvalvular atrial fibrillation compared with the control group. We believe that the findings of this study will act as a guide for further studies about the effect of nonvalvular atrial fibrillation on platelet indices. However, we want to make minor criticism about this study from the methodological aspect. Firstly, they did not mention about the tube that the blood sample was collected for platelet indices and the time interval between blood sampling and analysis. This is very important. It is clear that platelets exhibit a time-dependent swelling when blood samples are anticoagulated with EDTA, whereas this swelling may be less with acid citrate-based anticoagulation [2]. With impedance counting, the MPV increases over time as platelets swell in EDTA, with increases of 7.9% within 30 min. Although an overall increase of 13.4% occurs over 24 h, the majority of this increase occurs within the first 6 h [2]. The recommended optimal measuring time of MPV with EDTA is 120 min after venipuncture [3]. For reliable MPV measurement, the potential influence of anticoagulant on the MPV must be carefully controlled, either using an alternative anticoagulant (such as citrate) or standardizing the time delay between sampling and analysis ( T, Cys227Phe) who showed spontaneous intracerebral bleeding. Cys227 is located in the conserved fibrinogen beta globular C-ter domain and is involved in the formation of a disulfide bridge with Cys161 in the gamma-chain. In this case, the complete fibrinogen
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
232 Blood Coagulation and Fibrinolysis 2015, Vol 26 No 2
deficiency can be explained by an abnormal three-dimensional structure of the beta-chain C-ter domain, which does not allow hexamer assembly and secretion as previously mentioned [7]. Our patient, a heterozygous carrier of 680delG with dysfibrinogenaemia, had an abnormal bleeding score. Her first bleeding event was a postpartum haemorrhage after a difficult vaginal delivery, a situation also occurring in normal subjects. Moreover, it is worth noticing that her two following vaginal deliveries were not complicated by bleeding. Referring to the literature [10], women with dysfibrinogenaemia and a history of recurrent poor pregnancy outcome were treated with prophylactic fibrinogen concentrate infusions as soon as pregnancy was confirmed using a target trough fibrinogen level of 1 g/l. In afibrinogenaemic/hypofibrinogenaemic patients, fibrinogen levels are maintained over 1 g/l during pregnancy and for delivery. According to these guidelines, our patient would not have received a prophylactic substitution during her first pregnancy and delivery. Indeed, her baseline level was above 1 g/l, so no further measures would have been undertaken. Knowing the diagnosis, when the postpartum haemorrhage occurred, a substitution might have achieved an earlier haemostatic efficacy and thereby a reduced overall bleeding. Both bleeding after hysterectomy and local bleeding after a fine needle aspiration in a breast lump can be considered standard complications after such procedures. According to the UK guidelines [11], patients with dysfibrinogenaemia with a bleeding phenotype should be treated with fibrinogen concentrate preoperatively to raise and maintain the fibrinogen level to 1 g/l above their baseline level until haemostasis is secure and 0.5 g/l until wound healing is complete. Knowing the diagnosis, our patient would have been prophylactically substituted, which could have prevented the bleeding. In conclusion, we have identified a novel heterozygous frame shift mutation in FGB exon 4: c.680delG. This mutation is associated with dysfibrinogenaemia and a mild history of bleeding but no thrombosis.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 2
3 4
Doolittle RF. Fibrinogen and fibrin. Annu Rev Biochem 1984; 53: 195–229. Redman CM, Xia H. Fibrinogen biosynthesis. Assembly, intracellular degradation, and association with lipid synthesis and secretion. Ann N Y Acad Sci 2001; 936:480–495. Matsuda M, Sugo T. Hereditary disorders of fibrinogen. Ann N Y Acad Sci 2001; 936:65–88. Neerman-Arbez M, de Moerloose P, Bridel C, Honsberger A, Schonborner A, Rossier C, et al. Mutations in the fibrinogen aalpha gene account for the majority of cases of congenital afibrinogenemia. Blood 2000; 96: 149–152.
5
Roy SN, Mukhopadhyay G, Redman CM. Regulation of fibrinogen assembly. Transfection of Hep G2 cells with B beta cDNA specifically enhances synthesis of the three component chains of fibrinogen. J Biol Chem 1990; 265:6389–6393. 6 Shapiro SE, Phillips E, Manning RA, Morse CV, Murden SL, Laffan MA, et al. Clinical phenotype, laboratory features and genotype of 35 patients with heritable dysfibrinogenaemia. Br J Haematol 2013; 160:220–227. 7 Vu D, Di Sanza C, Caille D, de Moerloose P, Scheib H, Meda P, et al. Quality control of fibrinogen secretion in the molecular pathogenesis of congenital afibrinogenemia. Hum Mol Genet 2005; 14:3271–3280. 8 Zhang JZ, Redman CM. Identification of B beta chain domains involved in human fibrinogen assembly. J Biol Chem 1992; 267:21727– 21732. 9 Grandone E, Tiscia G, Cappucci F, Favuzzi G, Santacroce R, Pisanelli D, et al. Clinical histories and molecular characterization of two afibrinogenemic patients: insights into clinical management. Haemophilia 2012; 18:e16–e18. 10 Bornikova L, Peyvandi F, Allen G, Bernstein J, Manco-Johnson MJ. Fibrinogen replacement therapy for congenital fibrinogen deficiency. J Thromb Haemost 2011; 9:1687–1704. 11 Bolton-Maggs PHP, Perry DJ, Chalmers EA, Parapia LA, Wilde JT, Williams MD, et al. The rare coagulation disorders–review with guidelines for management from the United Kingdom Haemophilia Centre Doctors’ Organisation. Haemophilia 2004; 10:593–628. DOI:10.1097/MBC.0000000000000196
Coagulation profile, H1N1 influenza A infection and hematological malignancies Viroj Wiwanitkita,b,c,d a Faculty of Medicine, University of Nis, Nis, Serbia, bHainan Medical University, Haikou, Hainan Province, PR China, cJoseph Ayobabalola University, Ikeji-Arakeji, Nigeria and dSurin Rajabhat University, Surin, Thailand
Correspondence to Viroj Wiwanitkit, MD, Faculty of Medicine, University of Nis, Nis, Serbia E-mail: [email protected]
The recent report on ‘coagulation profile in patients with H1N1 influenza A infection undergoing treatment for haematological malignancies’ is very interesting [1]. Rupa-Matysek et al. [1] observed that ‘the association between coagulation activation and poor outcome pH1N1 infection was found in the analyzed group’. In fact, the coagulation disorder in the patient with H1N1 influenza A infection is an interesting topic. This problem can be seen in both typical and atypical H1N1 influenza A infection [2]. In the present report, the problem in the patient with H1N1 influenza A infection is possible. However, an important concern is the concomitant hematological malignancies. The remaining question is how we can assure that the coagulation is the result of H1N1 influenza infection, hematological malignancies or combination of both disorders. For sure, the problem is of concern for the hematologist. Some leukemic patients infected with H1N1 influenza virus can further develop serious complications such as hemophagocytic lymphohistiocytosis that can be fatal [3]. The coagulation disorder is an important presentation of such complications [3].
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Letters to the Editor 233
Acknowledgements
role in the vital eythroid aggregation because of ABS via acting on fibrinogen gamma.
Conflicts of interest
There are no conflicts of interest.
References 1
Rupa-Matysek J, Gil L, Wojtasin´ska E, Zajdel K, Ciepłuch K, Komarnicki M. Coagulation profile in patients with H1N1 influenza A infection undergoing treatment for haematological malignancies. Blood Coagul Fibrinolysis 2014; [Epub ahead of print].
2
Wiwanitkit V. Swine flu: any effect on the platelets? Blood Coagul Fibrinolysis 2010; 21:778.
3
Lai S, Merritt BY, Chen L, Zhou X, Green LK. Hemophagocytic lymphohistiocytosis associated with influenza A (H1N1) infection in a patient with chronic lymphocytic leukemia: an autopsy case report and review of the literature. Ann Diagn Pathol 2012; 16:477–484. DOI:10.1097/MBC.0000000000000222
High iron content of Ankaferd hemostat as a clue for its hemostatic action of red blood cell origin ¨ ktemb, Nejat Akara, Yasemin Ardıc¸og˘lua, Zeki O b Nuran Erduran and Ibrahim C. Haznedarogluc a
b
TOBB-ETU Hospital, Ankara, Department of Chemistry, Faculty of Arts and Sciences, Kirikkale University, Kirikkale and cDepartment of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey Correspondence to Nejat Akar, MD, Professor, TOBB ETU Hospital, Pediatrics Department, So¨gu¨to¨zu¨/Ankara, Turkey E-mail: [email protected]
We have read with great interest the article by Sacak et al. [1], investigating the long-term histopathological effects of Ankaferd hemostat (ABS) on the vascular tissues in Blood Coagulation and Fibrinolysis [1]. ABS (http:// www.ncbi. nlm.nih.gov/pubmed/?term=ankaferd) is the first topical hemostatic agent regarding the red blood cell (RBC)–fibrinogen interactions tested in the clinical trials [2]. RBCs take part in the genesis of blood coagulation via making an almost impermeable seal in a clot [3]. The role of RBCs in the clot formation is very important for the development of hemostatic agents in the management of bleeding disorders. We have previously suggested that the ABS-induced pharmacological modulation of essential erythroid proteins (ankyrin, spectrin, and actin) can cause vital eythroid aggregation via acting on fibrinogen gamma [2]. Likewise, RBCs bind to the fibrinogen via a beta3-containing integrin, with almost similar affinity as platelets [3]. More importantly, human fibrinogen also directly recognizes iron, although the mechanism of binding with fibrinogen–iron and heme has not been elucidated in detail [4]. Thus, iron can play a significant role in the ABS-induced cellular hemostasis located in the crossroads of RBC–fibrinogen interactions [1,2]. The iron and trace element content of ABS has not been previously investigated. The aim of this study is to search iron inside ABS in order to set the hypothesis that iron could have a
Atomic absorption and UV–Vis spectrophotometric methods were used for the analysis of iron inside ABS. The concentrations of metal ions were determined first using a GBC model 933AA atomic absorption spectrophotometer (AAS), at wavelengths of 372.0 nm for Fe(III), 324.7 nm for Cu(II), 213.9 nm for Zn(II), and 328.1 nm for Ag(I). Air-acetylene type flame was used. ABS was diluted with distilled water in 1 : 500 ratio for Fe(III). Secondly, Fe(III) content of Ankaferd was determined using a Shimadzu 1800 UV–Vis spectrophotometer. For the UV–Vis measurements, 1 ml of ABS was diluted to 1000 ml. Then, 5.0 ml 2.0 mol\l HCl and 4.0 ml 1.5 mol/l potassium thiocyanate were added to 1 ml of this solution, and the absorbance of the obtained red solution, because of the formation of blood-red [Fe(SCN)6]3- complex, was measured at lmax ¼ 470 nm. Analytical grade iron(III)nitrate nonahydrate, FeN3O9 9H2O, and potassium thiocyanate were purchased from Merck (Rahway, New Jersey, USA), and AAS standards were the product of Merck Millipore (Darmstadt, Germany). Both methods indicated an iron ion concentration higher than 2000 ppm (Table 1). As Fe(II) does not react with SCN ions, the obtained amount is almost equal to Fe(III) ions in Ankaferd. Further, our analysis revealed the presence of Cu(II), Zn(II), and Ag(I) ions in ABS, but with much lower concentrations than Fe(III) ions. Concentrations were 2.56, 9.2, and 45.0 ppm, respectively. Also, AAS measurements indicated the absence of Pb(II), Ni(II), Cr(IV), Co(II), and Cd(II) ions in ABS. Our data revealed for the first time the presence of Fe(III) ions and also at very low concentration some other trace elements inside ABS. Next-generation RBC-related hemostatics, such as ABS nanohemostat, has been designated in the essential treatment of life-threatening bleedings by restoring physiological hemostasis via acting on RBCs [5]. High iron content of ABS should be further considered that the iron ion can play a significant role in the ABS-induced cellular hemostasis located in the crossroads of RBC–fibrinogen interactions. Therefore, the long-term histopathological alterations already reported by Sacak et al. [1] could be further evaluated by the tissue staining for iron, in order to test the hypothesis that tissue changes of ABS might be related to the iron content of the tissues upon exposure to ABS. The proteomics of iron (the
Table 1
Fe(III) concentration of Ankaferd hemostat
Analysis method
Fe(III) concentration (ppm)
AAS UV–Vis AAS, atomic absorption spectrometer; UV, ultra-violet.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
2163 7 2385 9
234 Blood Coagulation and Fibrinolysis 2015, Vol 26 No 2
structural and functional properties of the proteins related to the iron metabolism) should also be matched with the already established proteomics of ABS [2]. Protein-engineering techniques to produce recombinant proteins and their variants should be used to study the cellular and animal models with the aim to clarify, at molecular level, the mechanisms of interaction between the various iron proteins to understand and enhance ABS-induced hemostasis. Moreover, further basic, experimental, and clinical trials about ABS shall focus on the interrelationships between high iron content, fibrinogen gamma, and vital erythroid aggregation because of ABS.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
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Sacak B, Akdeniz ZD, Sirinoglu H, Cilingir OT, Celebiler OB, Ercan F, Numanoglu A. Microvascular anastomosis using Ankaferd blood stopper: demonstration of long-term histopathologic effects on vascular tissue. Blood Coagul Fibrinolysis 2014; May 6 [Epub ahead of print]. Haznedaroglu BZ, Beyazit Y, Walker SL, Haznedaroglu IC. Pleiotropic cellular, hemostatic, and biological actions of Ankaferd hemostat. Crit Rev Oncol Hematol 2012; 83:21–34. Arie¨ns RAS. A new red cell shape helps the clot. Blood 2014; 123:1442– 1443. Orino K. Functional binding analysis of human fibrinogen as an iron- and heme-binding protein. Biometals 2013; 26:789–794. Huri E, Beyazit Y, Mammadov R, Toksoz S, Tekinay AB, Guler MO, et al. Generation of chimeric ‘ABS Nanohemostat’ complex and comparing its histomorphological in vivo effects to the traditional Ankaferd hemostat in controlled experimental partial nephrectomy model. Int J Biomater 2013; 2013:949460; doi: 10.1155/2013/949460-70. DOI:10.1097/MBC.0000000000000223
Thrombelastography will not predict bleeding if normal Evan G. Pivalizza, Sam D. Gumbert, Olga Pawelek and Nischal K. Gautam Department of Anesthesiology, University of Texas Medical School – Houston, Houston, Texas, USA Correspondence to Evan G. Pivalizza, MD, Professor, Department of Anesthesiology, University of Texas Medical School – Houston, MSB 5.020, 6431 Fannin Street, Houston, TX 77030, USA Tel: +1 713 500 6251; fax: +1 713 500 6270; e-mail: [email protected]
We read Sharma et al.’s [1] statistically elegant retrospective evaluation of the inability of the thrombelastograph (TEG) maximum amplitude and angle to predict bleeding when added to an existing model with interest. Therein, however, lies the dilemma – it is unlikely that a whole-blood viscoelastic coagulation measure obtained after arterial line placement in the operating room could predict bleeding per se, rather than a RESPONSE to any abnormal bleeding, including guiding transfusion or hemostatic product decisions.
The authors acknowledge several limitations in this retrospective study. (1) The absence of a transfusion protocol or algorithm may have led to unintentional bias, and the utility of the TEG has been most successful in cardiac surgery when incorporated into an algorithmic approach [2,3]. (2) Only a minority of patients in this cohort received an intraoperative (when the TEG was analyzed) transfusion of either red blood cells (20.3%) or platelets (12.5%), which suggests that any potential information from the TEG to guide therapy was diluted by 79–87% of the cohort, respectively, who were not transfused. (3) Despite the statistical significance in three of the four reported TEG parameters between baseline and warming and postprotamine, changes are not clinically significant (9% decrease in maximum amplitude and 11% increase in K time), especially as all fall within the anticipated normal ranges for this cohort. This is in sharp contrast to the dramatic changes in platelet count (54% decrease) and international normalized ratio (72% increase). Given the small number of patients actually receiving a platelet transfusion (fresh frozen plasma data not shown), it is tempting to conclude that changes in standard coagulation tests did NOT predict transfusion and that the very small changes in TEG parameters more closely reflect the conservative clinical transfusion practice in this particular cohort. Despite the statistical absence of effect of TEG parameters adding to a prediction of bleeding in this study, we wonder whether the TEG parameters may have been more closely linked to transfusion rather than the standard coagulation tests. We look forward to further data publication from Sharma’s group addressing this question in a prospective investigation.
Acknowledgements No financial support was provided for this submission apart from the department resources. Conflicts of interest
There are no conflicts of interest.
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Sharma AD, Al-Achi A, Seccombe JF, Hummel R, Preston M, Behrend D. Does incorporation of thromboelastography improve bleeding prediction following adult cardiac surgery? Blood Coagul Fibrinolysis 2014; 25:; [Epub ahead of print]. Shore-Lesserson L, Manspeizer HE, DePerio M, Francis S, Vela-Cantos F, Ergin MA. Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg 1999; 88:312–319. Royston D, von Kier S. Reduced hemostatic factor transfusion using heparinase-modified thrombelastography during cardiopulmonary bypass. Br J Anaesth 2001; 86:575–578. DOI:10.1097/MBC.0000000000000195
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