The adapter protein SLP-76 is expressed in T lymphocytes and hematopoietic cells of the myeloid lineage, and is known to be a substrate of the protein tyrosine kinases that are activated after ligation of the T-cell antigen receptor. Transient overexpression of SLP-76 in a T-cell line potentiates transcriptional activation after T-cell receptor ligation, while loss of SLP-76 expression abrogates several T-cell receptor-dependent signaling pathways. Mutant mice that lack SLP-76 manifest a severe block at an early stage of thymocyte development, implicating SLP-76 in signaling events that promote thymocyte maturation. While it is clear that SLP-76 plays a key role in development and activation of T lymphocytes, relatively little is understood regarding its role in transducing signals initiated after receptor ligation in other hematopoietic cell types. In this report, we describe fetal hemorrhage and perinatal mortality in SLP-76-deficient mice. Although megakaryocyte and platelet development proceeds normally in the absence of SLP-76, collagen-induced platelet aggregation and granule release is markedly impaired. Furthermore, treatment of SLP-76-deficient platelets with collagen fails to elicit tyrosine phosphorylation of phospholipase C-gamma2 (PLC-gamma2), suggesting that SLP-76 functions upstream of PLC-gamma2 activation. These data provide one potential mechanism for the fetal hemorrhage observed in SLP-76-deficient mice and reveal that SLP-76 expression is required for optimal receptor-mediated signal transduction in platelets as well as T lymphocytes.

BACKGROUND: Interhospital differences in blood transfusion practice during coronary artery bypass graft (CABG) surgery have been noted, but the underlying issues have not been identified. STUDY DESIGN AND METHODS: Records of 3217 consecutive CABG cases in five university teaching hospitals in 1992 and 1993 were stratified by hospital, type of revascularization conduit, patients' sex, and other factors. Statistical methods were used to compare patient characteristics, transfusion outcomes, and hospital outcomes. RESULTS: Forward two‐step logistic regression using patient likelihood of red cell transfusion factors in the first step and the specific hospital in the second step revealed a significant effect of hospital on the delta odds ratios for red cell transfusion. This finding was confirmed by analyses of a highly stratified subset of cases, males in diagnosis‐related group 107 (primary cases of coronary bypass without coronary catheterization) who underwent revascularization with venous and internal mammary artery grafts, revealing variations among hospitals from 109 to 457 units of red cells transfused per hundred cases. Corresponding variations in transfusions of all blood components were from 324 to 1019 units by hospital. Variation in red cell transfusion practice among surgeons in the same hospital was not responsible for these interhospital differences. CONCLUSION: The effect of the specific hospital on transfusion practice is attributed to institutional differences that, through reasons of training or hierarchy, become ingrained in hospitals.

BACKGROUND: Red cell use in patients undergoing Diagnosis Related Group (DRG) 209 procedures (major joint and limb reconstruction procedures of the lower extremities) has been shown to have large, unexplained interhospital variations.STUDY DESIGN AND METHODS: Abstracted records of 2590 consecutive DRG 209 patients at five university hospitals from January 1992 to December 1993 were stratified by procedure and preoperative blood deposit status. Patient characteristics and transfusion and in-hospital outcomes were compared across hospitals.RESULTS: Blood use among patients who did not preoperatively deposit blood was similar across hospitals. Significant differences were found across hospitals for total hip replacement patients in the percentage of patients preoperatively depositing blood (59-80%), percentage of patients receiving transfusion(s) (51 to >99%), the mean number of units collected per patient (1.6-2.9), and the mean number of unused autologous units per 100 patients (1-185). No significant differences were found in the percentage of those who deposited blood and then required allogeneic units. There was little variability in length of hospital stay or in last hematocrits. Findings were similar for total knee replacement patients.CONCLUSIONS: Interhospital variations in red cell use for primary total hip and knee reconstruction are primarily due to hospital-specific differences in autologous blood collection and transfusion.

When unfractionated heparin is used for therapeutic anticoagulation, the heparin effect must be monitored to avoid thrombotic or hemorrhagic complications. The ability of a factor Xa inhibition (XaI) assay was compared with that of a low-level heparin protamine titration (LLHPT) assay to measure the concentration of heparin after heparin was added in vitro to specimens of plasma and whole blood. Heparin effect on the activated partial thromboplastin time also was assessed in the same specimens. The XaI and LLHPT assays had comparable precision and provided linear results over a wide range of heparin concentrations. Both assays slightly underestimated the total amount of heparin added to the specimens. The most rapid test was the whole blood LLHPT assay; this test therefore may be useful for bedside monitoring of heparin. A significant disadvantage of the LLHPT assay was the large sample size required to perform it. These results provide in vitro evidence that the XaI and LLHPT assays can provide equally precise monitoring of heparin concentration.

Background: Very little is known about the determinants of blood transfusions in patients undergoing coronary artery bypass graft surgery.Study Design and Methods: To identify factors that influenced the transfusion of red cells, platelets, plasma, and cryoprecipitate, statistical methods were used to study 2476 consecutive diagnosis-related group 106 and 107 patients in five teaching hospitals who underwent coronary artery bypass surgery between January 1, 1992, and June 30, 1993.Results: The likelihood of red cell transfusion was significantly associated with 10 preoperative factors: 1) admission hematocrit, 2) the patient's age, 3) the patient's gender, 4) previous coronary artery bypass surgery, 5) active tobacco use, 6) catheterization during the same admission, 7) coagulation defects, 8) insulin-dependent diabetes with renal or circulatory manifestations, 9) first treatment of new episode of transmural myocardial infarction, and 10) severe clinical complications, Platelet and/or plasma transfusions were strongly associated with the dose of red cells transfused. Transfusion requirements and other in-hospital outcomes were associated with patient characteristics, surgical procedure (reoperation vs. primary procedure), and the conduits used for revascularization (venous graft only, venous and internal mammary artery graft, or internal mammary artery graft only). Blood resource use and donor exposures were evaluated with respect to the risk to patients of contracting hepatitis C virus and human immunodeficiency virus infections.Conclusion: The classification of coronary artery bypass graft patients on the basis of attributes known preoperatively and by conduits used yields subsets of patients with distinctly different transfusion requirements and in-hospital outcomes.

The purpose of this study was: 1) to define coagulation abnormalities in patients who receive red cell concentrates rather than whole blood for large volume blood loss (greater than 0.5 blood volume); and 2) to determine when coagulation abnormalities lead to increased bleeding in the massively transfused surgical patient. We studied 32 ASA physical status I or II patients (mean age 15.6 +/- 2.3 yr) who lost more than 50% of their blood volume during elective posterior spinal stabilization. Crystalloid solutions and packed red cell concentrates were used to replace blood and fluid losses. Invasive hemodynamic measures, urinary output, and serial hematocrit determinations were used to help maintain a constant intravascular volume and confirm the estimates of blood loss. The quality of hemostasis was assessed during operation. In 15 of the 32 patients, surgical hemostasis remained effective throughout posterior spinal fusion. A coagulation profile (prothrombin time [PT] and activated partial thromboplastin time [aPTT], platelet count, and fibrinogen) was measured at the conclusion of operation in these patients. In 17 patients, increased surgical bleeding as a result of decreased clot formation and increased bleeding from the wound was present. In these 17 patients at the time increased bleeding was diagnosed, hemostatic tests (PT, aPTT, fibrinogen, platelet count, and coagulation factor assays V, VIII, and IX) were obtained.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective study of the postoperative kinetics of coagulation factors was undertaken in 23 burn patients and in six non-burn patients. All procedures resulted in a large volume blood loss. Fibrinogen, platelets and factors V, VIII and IX were measured serially. Burn patients returned all parameters to preoperative levels by 48 h postoperation, while non-burn patients showed a slower rate of return of platelets and factor V. This study suggests that burn patients may safely undergo re-operation at 48 h intervals for successive wound debridements if clinically necessary.

Platelet membrane glycoproteins Ib (GPIb) and IIb/IIIa (GPIIb/IIIa) bind soluble von Willebrand factor (vWf) after stimulation with ristocetin (GPIb) or with thrombin or ADP (GPIIb/IIIa). In fluid-phase, vWf does not bind to these platelet receptors without stimulation. In contrast, platelets adhere to solid-phase vWf without stimulation by ristocetin, adenosine diphosphate (ADP), or thrombin, and adhesion increases after stimulation by these agonists. The effect of monoclonal antibodies specific for GPIb (6D1) and GPIIb/IIIa (10E5 and HP1-1D) on platelet adhesion to solid-phase vWF was studied. Adhesion of radiolabeled, washed platelets (with washed red blood cells) aspirated at a constant wall shear rate of 1000 sec-1 through glass capillary tubes coated with purified human vWf was quantified. Unstimulated platelet adhesion was decreased 80% to 90% by blocking either the GPIb site or the GPIIb/IIIa site with 6D1 or 10E5, respectively, or with 6D1 and 10E5 together. Adhesion was not reduced significantly by HP1-1D (anti-GPIIb/IIIa). After stimulation with ADP or thrombin, the platelet adhesion was reduced by prior incubation with saturating concentrations of either 6D1 (61% reduction) or 10E5 (80% reduction), as well as with both 6D1 and 10E5 (80% reduction). After stimulation with ristocetin, the adhesion was reduced with either 6D1 (90% reduction) or 10E5 (90% reduction) or both 6D1 and 10E5 (90% reduction). Prior incubation with HP1-1D had minimal effect on platelet adhesion to vWF after stimulation with thrombin, ADP, or ristocetin.(ABSTRACT TRUNCATED AT 250 WORDS)

Some thromboplastin manufacturers are currently supplying the instrument-specific international sensitivity index (ISI) values of their reagents, allowing clinical laboratories to calculate instrument-specific international normalized ratio (INR) values on plasma samples from patients receiving coumarin therapy. However, the assumption that systematic interinstrument variability in the INR would be eliminated if manufacturer-determined ISI values were used remains unsubstantiated. This assumption was evaluated by comparing INR values obtained on one instrument that measures a mechanical endpoint (fibrometer) with one that measures a photo-optical endpoint (MLA-700). Three thromboplastin reagents with instrument-specific ISI values supplied by the manufacturer (ISI range, 1.23-2.79) were used. For two of three reagents, the fibrometer INR values were significantly higher than the MLA-700 INR values (P < .01). Analysis of log prothrombin time ratio plots showed that this systematic variability was caused by inaccurate manufacturer ISI values. Of clinical significance is that the inaccurate ISI values produced a high number of discordant INR values between these two instruments (> 47% of plasma samples had one INR value within and one out of the recommended therapeutic range). The implication of these findings for laboratory monitoring of oral anticoagulation is discussed.

Background and Purpose Ensuring the reliability and validity of outcome measures used in clinical trials is essential to the success of the trial. The Trial of Org 10172 in Acute Stroke Treatment (TOAST) is a multicenter clinical trial that is recruiting patients with acute ischemic stroke seen at medical centers across the United States.Methods This paper describes an approach to train physicians to use three clinical measures: the National Institutes of Health (NIH) Stroke Scale, a supplemental motor examination, and the Glasgow Outcome Scale. The program included education, certification, remediation when needed, monitoring, and reliability assessment. The goal was to ensure that interrater assessments were as equivalent to one another as possible.Results Of the first 95 clinicians who began the certification process, 75 passed during the first evaluation. Eighteen of the other physicians were able to complete the process after remediation. The intraclass correlations of both the NIH Stroke Scale and supplemental motor examination exceeded 0.95. The kappa values for the Glasgow Outcome Scale were 0.61 and 0.62 for the first and second ratings of the videotape, respectively.Conclusions Our experience suggests that a program that includes educational and certification processes can be performed as part of the design of a multicenter clinical trial. The method of providing educational and testing videotapes to each site so that physicians can be trained and certified is an effective, inexpensive, and practical approach for enhancing and certifying the expertise of the large number of physicians involved in a multicenter study.

American Journal of HematologyVolume 45, Issue 1 p. 98-99 Letters and CorrespondenceFree Access Intracranial hemorrhage in an adult with factor-VII deficiency Barbara J. Seaborg, Barbara J. Seaborg Department of Medicine, The University of Iowa College of Medicine, Iowa City, IowaSearch for more papers by this authorC. Patrick Burns, C. Patrick Burns Department of Medicine, The University of Iowa College of Medicine, Iowa City, IowaSearch for more papers by this authorJohn D. Olson, John D. Olson Department of Pathology, The University of Iowa College of Medicine, Iowa City, IowaSearch for more papers by this authorBeverly J. Pennell, Beverly J. Pennell Department of Pathology, The University of Iowa College of Medicine, Iowa City, IowaSearch for more papers by this authorKenneth A. Follett, Kenneth A. Follett Department of Neurosurgery, The University of Iowa College of Medicine, Iowa City, IowaSearch for more papers by this author Barbara J. Seaborg, Barbara J. Seaborg Department of Medicine, The University of Iowa College of Medicine, Iowa City, IowaSearch for more papers by this authorC. Patrick Burns, C. Patrick Burns Department of Medicine, The University of Iowa College of Medicine, Iowa City, IowaSearch for more papers by this authorJohn D. Olson, John D. Olson Department of Pathology, The University of Iowa College of Medicine, Iowa City, IowaSearch for more papers by this authorBeverly J. Pennell, Beverly J. Pennell Department of Pathology, The University of Iowa College of Medicine, Iowa City, IowaSearch for more papers by this authorKenneth A. Follett, Kenneth A. Follett Department of Neurosurgery, The University of Iowa College of Medicine, Iowa City, IowaSearch for more papers by this author First published: January 1994 https://doi.org/10.1002/ajh.2830450122Citations: 6AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1 Gilgenkrantz S. Briquel ME, Andre E, Alexandre P, Jalbert P, Le Marec B, Pouzol P, Pommereuil M: Structural genes of coagulation factors VII and X located on 13q34. Ann Genet 29: 32–35, 1986. 2 Marder VJ, Shulman NR: Clinical aspects of congenital factor VII deficiency. Am J Med 37: 182–194, 1964. 3 Ragni MV, Lewis JH, Spero JA, Hasiba U: Factor VII deficiency. Am J Hematol 10: 79–88, 1981. 4 Owen CA Jr, Amundsen MA, Thompson JH Jr, Spittell JA Jr, Bowie EJW, Stilwell GG, Hewlett JS, Mills SD, Sauer WG, Gage RP: Congenital deficiency of factor VII (hyponvertinemia). Critical review of literature and report of three cases, with extensive pedigree study and effect of transfusions. Am J Med 37: 71–91, 1964. 5 Owren PA: Prothrombin and accessory factors. Clinical Significance. Am J Med 14: 201–215, 1953. Citing Literature Volume45, Issue1January 1994Pages 98-99 ReferencesRelatedInformation

Aspects of the mechanisms of hemostasis are reviewed with particular emphasis on the assembly of enzyme complexes on the membranes of cells. The way this membrane fixation of reactions accelerates coagulation, inhibition, and fibrinolytic systems is discussed. The complex nature of the hemostatic system and the multiple complications of its abnormalities present a difficult problem for the neurologist and neurosurgeon managing the patient with intracerebral hemorrhage. This is a situation in which close consultation and collaboration among the neurological and hematologic specialists are imperative to achieve the most favorable outcome for the patient with this life-threatening situation.

Multiple assays have been described which quantify von Willebrand Factor (vWF) in plasma or other specimens. An assay using a modification of the microtitre method(1) is described. Washed platelets fixed in formalin and frozen in dimethylsulfoxide are substrate for the reaction. Platelets, ristocetin and the specimen to be assayed are combined in the wells of a microtitre plate. The reaction is mixed for defined times and agglutination of platelets read visually. By adjusting the concentration of platelets, concentration of ristocetin and time, the sensitivity can be adjusted over a wide range.