The aim of the present study was to compare the effect on swelling after bilateral osteotomies of the mandible of treatment with organo-heparinoid (Hirudoid) cream and that of a placebo cream. 12 patients (7 female, 5 male), median age of 29.5 years, were included in the study. 5 patients received bilateral sagittal-split procedures for symmetrical mandibular advancement, and 7 patients received bilateral mandibular osteotomies for symmetrical mandibular set-back. Each of the 2 operated sides were randomized for treatment with active medication or placebo; 1.5 g of the active- or placebo cream were carefully rubbed into the skin above the masseteric muscle 4 times a day for 4 days. Periodic identical CT-scans were performed to evaluate swelling; patients were CT-scanned preoperatively and once or twice postoperatively. 3 variables were used to assess the swelling: (1) thickness of the subcutis; (2) maximum thickness of the masseteric muscle; (3) cross-sectional area of the soft tissues facial to the ramus of the mandible. No significant differences in postoperative swelling could be demonstrated between the 2 treatments. There were no detectable systemic effects of the treatment with organo-heparinoid.

We studied a female child with mild classical haemophilia A, presenting with a F VIII deficiency similar to that detected in her maternal grandfather. Investigations on several occasions showed that the obligate carrier mother of the proposita had normal VIII:C activity, whereas her likewise obligate carrier sister had a typical carrier VIII:C/vWf:Ag pattern. The child was a phenotypically normal female with normal karyotype. Her father had no clinical or biochemical signs of haemophilia A. RFLP‐analysis using DX13 and St14 probes each elicited one allele (5.8 and 3.4 kb, respectively) segregating along with the affected F VIII gene from the hemizygous grandfather to both his daughters and further to the haemophilic female child. The paternity of the child was analyzed using various red cell and HLA antigens and RFLP by p29C, a probe detecting polymorphic hypervariable TaqI and PstI fragments in the pseu‐doautosomal areas of the X‐ and Y‐chromosomes. All results obtained were concordant with the declared paternity. RFLP‐analysis, using single (Pst I) and double digestion (Pst I/Hha I) of DNA and a PGK probe, revealed a remarkable difference in hybridization fragments, strongly suggesting hypermethylation, and in consequence, preferential X‐chromosome inactivation in the proposita. This points to extreme lyonization as the most plausible explanation for haemophilia A in this female child. A familial tendency to abnormal premature X‐chromosome inactivation is speculated.

The present communication describes the production of a new series of murine Mabs against von Willebrand factor (vWf) in which specificity was tested using immunoperoxidase techniques. Seven Mabs showed specific reactivity with native and disaggregated vWf, whereas no binding was found to material from patients with severe homozygous (or doubly heterozygous) von Willebrand's disease (vWd) or factor VIII coagulant antigen (VIII: Ag). These Mabs are thought to carry separate specificities as only slight or no competitive activity was detected. Four Mabs partially inhibited the ristocetin-induced platelet agglutination and three interacted with vWf-binding to type I collagen. All antibodies bound to the complete range of vWf multimers of normal plasma. Excellent binding and detection properties of Mabs were found in asymmetrical two-site enzyme linked immunosorbent assays (ELISA) for quantitation of vWf antigen (vWmg). One particular antibody (Mab vWf-33) discriminated vWf material from a number of subtype II vWd plasmas tested.

The aim of the present investigation was to evaluate the effect of mouthrinsing with tranexamic acid on the demand for replacement therapy in hemophilic patients demonstrating spontaneous gingival bleeding or bleeding following subgingival scaling. The study included one retrospectively studied group (I) of hemophilic patients treated with oral antifibrinolytics, replacement therapy and local hemostatics, and a prospectively studied group (II) in whom no replacement therapy but systemic and/or local antifibrinolytic treatment with tranexamic acid was employed. Six of the patients in group T received replacement therapy to control bleeding, while none of the patients in group II experienced bleeding episodes demanding replacement therapy. The difference in the frequency of demand for replacement therapy between the two groups was statistically significant (p<0.02). Based on the present findings, it is advocated that treatment of gingival bleeding in hemophilic patients should include local antifibrinolytic treatment.

The Bernard-Soulier syndrome is an autosomal recessive trait characterized by deficient synthesis of platelet surface glycoprotein Ib (GP Ib) resulting in impaired platelet function and bleeding tendency [1]. GP Ib is a link protein for assembly of platelet and von Willebrand factor [2] during haemostasis. The development of a monoclonal antibody specific for GP Ib, denoted AN51, was reported by McMichael and coworkers [3]. The antibody is now commercially available. Employing this antibody and using a previously reported ELISA method for detection of platelet surface proteins [4], we developed a simple technique for direct detection of GP Ib.

This report describes the surgical treatment of advanced periodontitis in a haemophilic patient with inhibitors to Factor VIII. The treatment was performed after substitution therapy with Factor VIII-concentrate, supported by local and systemic antifibrinolytic treatment with tranexamic acid. No complications developed postoperatively, and after 9 months, the patient did not show recurrence of periodontal disease. Although the present case shows, that even severe periodontitis can be treated surgically in haemophilic patients with inhibitors to Factor VIII, this should not be done unless it is absolutely necessary. The treatment of periodontal disease in such patients should be instituted as early as possible in order to prevent the need for extensive surgery or dental extractions.

Eleven severely affected haemophilia A patients (aged 6-42 y) with F VIII:C inhibitor (high responders) were treated with high-dose F VIII in order to eliminate the inhibitors. The patients comprise Danish high responder patients treated during the period 1977-1985. In all patients the inhibitors decreased significantly. In six, the inhibitor apparently disappeared (detection limit 0.4 Bethesda Units per ml) (BU/ml), in four patients a low level inhibitor of 0.4-1.4 BU/ml persisted. One patient is still on high-dose schedule. The duration of high-dose treatments ranged from less than one month up to 18 months. In all patients the tendency to spontaneous bleedings vanished when a measurable VIII:C level appeared in the post-infusion sample. The inhibitor suppression has allowed for extensive physical training and rehabilitation orthopaedic surgery. The patients are now able to conduct a normal haemophilic life on self-administered prophylactic doses of F VIII.

The Bernard‐Soulier syndrome is characterized by low platelet counts, abnormally large (giant) platelets, and impaired or absent platelet aggregation by the inducer antibiotic ristocetin. The recent discovery of the inherited biochemical defect and the deficient synthesis of platelet glycoprotein Ib (GP‐Ib), has contributed greatly to the understanding of the disease. We report a case of the Bernard‐Soulier syndrome presenting with bleeding from the pharynx after adenotomy. The patient and nearest family members were studied by a novel immunoperoxidase method for quantification of platelet glycoprotein Ib using a specific monoclonal antibody (AN51).

Fibrinogen Aarhus is an abnormal fibrinogen for which the clotting time with thrombin is greatly prolonged both in plasma and in the isolated fibrinogen. The whole blood clotting time is only slightly prolonged. The patient with this fibrinogen has no bleeding tendency. In this report we have investigated fibrinogen Aarhus in two alternative, thrombin independent polymerization and gelation pathways. These pathways are the factor XIII dependent oligomerization and gelation of fibrinogen, and heteropolymer (fibrinogen-fibronectin) formation which also is catalysed by factor XIII. Both of these reactions are qualitatively the same in fibrinogen Aarhus as in normal fibrinogen, but the rate of oligomerization is somewhat slower in fibrinogen Aarhus. This may depend on impaired association between factor XIII and fibrinogen Aarhus.

Among patients with hemophilia A, approximately 15% develop inhibitors to Factor (F) VIII, and management of bleeding becomes a major problem.' The management of hemophiliacs with inhibitors has recently been reviewed by Lusher, t Eyster et al.,2 and Penner.' Penner proposed that hemophilic patients with low inhibitor levels «40 Bethesda Units (BU) of inhibitor per ml of plasma) who are to undergo surgery should be treated by plasmapheresis until the inhibitor level is below IO BUlml of plasma and then receive infusion of FVIII concentrate for six days followed by infusion of activated prothrombin complex concentrates (PCC). In patients with inhibitor levels above 40 BUlml of plasma who require surgery, 75-100 units of activated PCC per kg bodyweight at four to eight hour intervals is advocated.' Dental extractions performed in hemophiliacs with inhibitors have previously been reported. Nilsson et al. described the use of cyclophosphamide, F-IX concentrate, and tranexamic acid for dental extractions in two hemophilia B patients with inhibitors to F-IX. Several case reports of dental extractions in patients treated with a combination of activated PCC and systematically administered antifibrinolytics (epsilon-arninocaproic acid (EACA) or tranexamic acid (AMCA» have been presented [Agrestini et al.,5 four patients), Hanna et al.,6 three patients), Scharrer. (one patient),

Human hepatocytes were isolated by the two-step collagenase technique applied on distal left liver lobe. Homogenous and large cells were isolated revealing hepatocyte characteristics by light-microscopy. Hepatocytes were washed repeatedly in albumine buffer (5%), resuspended in the same buffer and sonicated using a cell density of 0.75 × 106 cells/ml. In some cases cells were separated from non-viable cells by flotation on a linear Percoll gradient. Supernate material after sonication was subjected to ELISA for VIII:Ag using human antibodies and vWf:Ag by polyclonal antibodies. Freshly isolated cells contained at least 0.25 IU/ 0.75 × 106 hepatocytes, whereas the vWf:Ag was below 0.01 IU/ 0.75 × 106 cells. The material obtained from sonication was further studied using fast protein liquid chromatography by Mono-Q HR 5/5 revealing a single peak of VIII: Ag eluting in the same position as the high molecular weight polypeptides of VIII :Ag of high purity FVIII derived from the plasma source. Isolated hepatocytes also were cultivated at 37°C in medium RPMI 1640 supplemented with Ultroser G (4%), glutamine and antibiotics. Cells secreted increasing quantities of albumin, fitrinogpn and protease-inhibitors. The supernatants also contained VIII: Ag in quantities ranging from 0.04 - 0.17 IU/ml after 24 hours, but no further secretion was observed. No vWf: Ag could be detected. Cells harvested and sonicated after 30 hours of culture only contained 0.04 IU/ 0.75 × 106 cells. Our results shows, that VIII :Ag is present in freshly isolated human hepatocytes and that only traces of vWf:Ag is found. A hepatocyte site of production of VIII is speculated. These very preliminary findings do not permit conclusions concerning active synthesis of VIII in hepatocytes. Further studies are underway.

A recently developed new series of monoclonal antibodies (MAbs) against the von Willebrand factor (vWf) included antibodies strongly inhibiting ( Mab vWf-41) and partly inhibiting ( Mab vWf-33) the collagen binding of vWf. We also characterized two Mabs with interacting properties against the ristocetin induced platelet aggregation (MAbs vWf-21 and vWf-39). These antibodies were conjugated with horse-radish peroxidase (HRP) and examined in different constructions forming two-site MAb ELISA's for plasma vWf:Ag and compared with polyclonal antibody ELISA. Symmetrical MAb-ELISA ( i.e. same Mab for extraction and detection) gave practical no dose-response in the standard assay, whereas any different combination of Mabs gave favourable dose-response relationships in sensitive ELISA's for vWf:Ag. Two different sandwiches were chosen using MAb vWf-33 and Mab vWf-41 at either side of the ELISA. These two assay models gave results of plasma from normal persons almost identical to those obtained with polyclonal antibody ELISA. Also in type I von Willebrand's disease these three assays performed very uniformly. In subtypes II plasma ( IIA: n=7; IIB: n=3, IIC: n=l, IID: n=i) . the assay using vWf-33 for coating and vWf-41-HRP for detection measured considerably lower than the polyclonal ELISA and the Mab-ELISA based on the opposite combination. We believe, that our results are indicative of a molecular defect in the collagen binding domain of vWf in subtype II plasma.

The known transmission of viral diseases, particularly AIDS (HIV, LAV, HTLV-III), has led to the mandatory use of virus-inactivated coagulation factor concentrates for treatment of bleeding disorders due to deficient or abnormal synthesis of the factor VIII/von Willebrand factor complex. The present investigation was undertaken to study the influence of heat-treatment on the von Willebrand factor (vWf). Using normal plasma as reference material, we studied the influence of low-purification steps in a simple cryo-plasma and a unrefined freeze-dried cryoprecipitate. For comparison, non-heated and heat-inactivated concentrates of different manufacture representing varying heat-treatment protocols were studied using quantitation of von Willebrand factor antigen (vWf:Ag) by electroimmunoassay and ELISA, and investigation of vWf multimeric composition. A locally produced factor VIII concentrate was studied before and after exposure to 68°C for 72 hours (dry state). Whenever possible, commercial preparations manufactured prior to the heat-treatment era were compared with the present product. The locally produced high purity concentrate elicited only minor changes in oligomeric satellite pattern, which did not change after dry heat exposure. In principle, no major differences were found between non-heated and pasteurized commercial concentrates of same manufactural origin.

The molecular sieving electrophoretic technique for the study of the von Willebrand protein was introduced by the group led by MEYER and ZIMMERMANN in 1980 [1].

The objectives of the present clinical investigation were to examine the effects in hemophiliacs of local antifibrinolytic treatment with tranexamic acid on the incidence of postoperative bleeding after oral surgery and on the amount of replacement therapy needed to control bleeding. The study compared three groups of patients. The patients in group A received high doses of factor concentrate and systemic antifibrinolytic treatment with tranexamic acid. In group B local antifibrinolytic treatment with tranexamic acid was added to the treatment received by group A. Group C received replacement therapy to raise factor levels to approximately 10% of the normal value perioperatively, combined with systemic and local antifibrinolytic treatment (mouth rinse) with tranexamic acid. The study demonstrated that local antifibrinolytic therapy with tranexamic acid as a supplement to the currently used systemic therapy significantly reduces the incidence of postoperative bleeding. The results of the study further suggest that replacement therapy can be reduced during oral surgery in the hemophilic patient provided that local and systemic inhibition of fibrinolysis is instituted.

Fibrinogen Aarhus was found in a woman with slightly prolonged whole blood clotting time. The thrombin induced clotting of plasma and purified fibrinogen was much prolonged. Kinetic analysis of FPA and FPB release revealed larger apparent Km and Vmax values for fibrinogen Aarhus than for normal fibrinogen. No clot formation of fibrinogen Aarhus was demonstrated in the presence of Batroxobin and the release of FPA was slower than normal. Upon addition of the clotting enzyme from Agkistrodon contortrix contortrix clotting did occur but the clotting time was much prolonged in comparison with normal fibrinogen. The turbidity of fibrin gels obtained from fibrinogen Aarhus was similar to normal fibrin gels at low thrombin concentrations. Increasing thrombin concentration resulted in appearance of degradation products in the fibrin gels from fibrinogen Aarhus and at the same time a relative increase in turbidity of the gels was observed. Possibly reasons for the slow release of fibrinopeptides, the delayed gelation, and susceptibility to degradation by thrombin are discussed.

A method for the quantitation of factor VIII clotting antigen (VIII:CAg) has been developed based on a micro enzyme linked immunosorbent assay (ELISA) principle employing antibodies from two polytransfused haemophilia A patients. Solid polystyrene support bound IgG fraction of inhibitor plasma extracted VIII:CAg from normal plasma and samples. Bound VIII:CAg was detected by peroxidase labelled F(ab')2 fragment of the IgG used for solid phase. Two assays, each based on its particular inhibitor antibody, were set up. The F VIII clotting antigen in plasma of 30 healthy persons was found identical with the two VIII:CAg assays (r=0.97) and closely correlating with clotting activity (VIII:C) (r=0.84). Serum VIII:CAg was 67% (+/-14.5%) of the corresponding plasma value. In severe haemophilia A, 17 out of 19 had VIII:CAg values less than 1 U/dl. Two patients with cross-reactive material (CRM+) were found. In some milder cases of haemophilia A, higher values of VIII:CAg than VIII:C was recorded. The sensitivity of the method was 0.08 U/dl. Inter assay coefficient of variation at the 100 U/dl level was 9.5% (CV%), at the 2 U/dl level 16.4% (CV%). Mainly due to the great stability of enzyme conjugated antibody compared to the natural decay of radioiodinated material and subsequent loss of detecting material, ELISA was found superior to immunoradiometric assay (IRMA).