Introdução: Estudos iniciais sugeriram que o risco para tromboembolismo venoso (TV) era atribuído ao componente estrogênico dos contraceptivos de forma dose-dependente. Estudos epidemiológicos têm sugerido que o risco para TV é maior com contraceptivos combinados que contêm progestagênios de terceira geração (gestodeno, desogestrel) comparados com aqueles com progestagênios de segunda geração (levonorgestrel). Esses achados inesperados têm sido alvo de muitos debates sem uma explicação definitiva. Assim, a questão das diferenças nas propriedades de cada progestagênio sobre a hemostasia tem sido levantada. Apesar dos progestagênios não serem associados a alterações marcantes nos parâmetros hemostáticos, existem poucos estudos sobre os efeitos dessas drogas, especialmente os progestagênios de terceira geração, no sistema hemostático. Objetivo: Avaliar o efeito do implante subdérmico de etonogestrel sobre a agregação plaquetária de mulheres hígidas, em seis meses de tratamento. Casuística e Métodos: Vinte e quatro mulheres saudáveis e voluntárias foram selecionadas neste estudo longitudinal e prospectivo, para usar um implante contraceptivo subdérmico de etonogestrel (metabólito biologicamente ativo do desogestrel). A agregação plaquetária foi avaliada em todas as mulheres, exceto uma, no período pré-inserção e após um, três e seis meses da inserção do implante. A agregação plaquetária foi induzida com adrenalina 50 µM, colágeno 10 µg/ml, colágeno 5 µg/ml, ADP 35 µM e ADP 17,5 µM. A análise estatística foi feita com o teste de Wilcoxon para comparar a diferença entre cada período de tratamento com os valores pré-tratamento. Resultados: Houve uma redução transitória, estatisticamente significativa, na mediana do percentual máximo de agregação plaquetária de 27%, 14% e 11%, respectivamente, com colágeno 5 µg/ml, adrenalina 50 µM e colágeno 10 µg/ml, observada um mês após a inserção do implante comparado ao valor pré-inserção (p< 0,05). A agregação plaquetária com esses agonistas retornou ao seu valor basal, após seis meses da inserção. Com outros agonistas, como o ADP 35 µM e ADP 17,5 µM, não se observou o mesmo fenômeno. Conclusão: Os resultados deste estudo mostram, pela primeira vez, que o uso do implante de etonogestrel está associado à redução transitória, mas significativa, da agregação plaquetária, observada em um mês de uso do contraceptivo, a qual retorna a seus valores normais em seis meses da inserção do implante. / Introduction: Several studies have suggested that the risk of venous thromboembolism (VTE) is attributable to the estrogen component of a contraceptive in a dose-dependent manner. Recent epidemiological studies have suggested that the risk of VTE was higher with contraceptives containing third-generation progestagens (desogestrel, gestodene) when compared with second-generation progestagens (levonorgestrel). These unexpected findings have been the subject of many debates with no definitive explanation and the question of differences in hemostatic properties of each progestagen has been raised. Although progestagens are not associated with marked changes in hemostatic variables, there are few studies on the effects of these drugs, especially third-generation progestagens, on the hemostatic system. Objective: To evaluate the acute effect of a long-term contraceptive implant of etonogestrel on platelet aggregation in healthy women. Material and Methods: Twenty-four healthy volunteer women were enrolled in this prospective longitudinal study, to use a subdermal contraceptive implant of etonogestrel (the biologically active metabolite of desogestrel). Platelet aggregation was measured in all users, except one, at baseline and after 1, 3 and 6 months of treatment. Platelet aggregation was induced with 50 µM adrenalin, 10 µg/ml collagen, 5µg/ml collagen, 35 µM ADP and 17,5 µM ADP. Statistical analysis included the Wilcoxon test to compare differences between each period of treatment from baseline. Results: Statistically significant 27%, 14% and 11% reductions of platelet aggregation with 5 µg/ml collagen, 50 µM adrenalin e 10 µg/ml collagen, respectively, were observed at 1 month of treatment (p < 0,05). Platelet aggregation returned to baseline values at 6 months of treatment with these reagents. Platelet aggregation did not show any statistic difference with ADP. Conclusions: The result of this study shows for the first time that an etonogestrel implant is associated with a transitory, but significant, reduction in platelet aggregation after the first month of treatment, which returns to normal values by 6 months of therapy.

Orientadores: Sergio Marangoni, Luis Alberto Ponce Soto / Dissertação ( mestrado) - Universidade Estadual de Campinas, Instituto de Biologia / Made available in DSpace on 2018-08-19T23:07:57Z (GMT). No. of bitstreams: 1 Minaya_MagalyAlejandraBrousett_M.pdf: 1843449 bytes, checksum: 708051f59ddc90ca5b185a088f8d589d (MD5) Previous issue date: 2012 / Resumo: Os venenos de serpentes contêm uma variedade de proteínas que são estudadas no mundo pela importância biológica e farmacológica. Dentro de sua complexa composição, o veneno apresenta enzimas proteases, como as metaloproteases e serinoproteases que estão envolvidas em distúrbios hemostáticos e coagulantes, interferindo na agregação plaquetária. O presente trabalho teve como objetivo purificar, caracterizar bioquimicamente e avaliar as atividades farmacológicas de uma serinoprotease com atividade coagulante, do veneno de Bothrops barnetti nomeada TLBbar. A purificação envolveu dois passos cromatográficos, exclusão molecular em Sephadex G-75 e HPLC de fase reversa em coluna analítica Supelco C8, obtendo-se um alto grau de pureza e homogeneidade, revelado com SDSPAGE e com Mr ~ 28,5 kDa. TLBbar mostrou homlogia sequêncial com outras serinoproteases de veneno de serpentes, evidenciado através de espectrometria de massas MS/MS, como a trombina-like denominada Calobin, isolada e caracterizada a partir de Agkistrodon caliginosus (Korean Viper), Crotalase (Crotalus adamanteus), flavoxobin (Trimeresurus flavoviridis) entre outras. Observa-se na homologia que as serinoproteases, com as quais foi comparada a TLBbar, apresentam os aminoácidos conservados do sítio catalítico (His57, Asp102, Ser195), já na sequencia da TLBbar demonstra-se a presença do aminoácido histidina na posição 57 da tríada catalítica. Este resultado em conjunto com as atividades enzimáticas e biológicas, confirmam que TLBbar pertence ao grupo de enzimas serinoproteases com atividade trombina-like. A enzima apresenta sua maior atividade proteolítica a 37oC e em pH 8, sendo essa alterada na presença de íons divalentes por interações eletrostáticas entre enzima e substrato. TLBbar apresenta um comportamento michaeliano segundo os estudos cinéticos realizados com o substrato BApNA, revelando um Vmax e Km de 0,42nmol/min e 0,433mM, respectivamente. Em presença de heparina mantem 80% de sua atividade, e apresenta relativa estabilidade frente a SBT-I e agentes quelantes como EDTA e EGTA. TLBbar tem atividade coagulante sobre fibrinogênio bovino (atividade fibrigenolítica), formando um coágulo semi-rígido, pois não ativa o fator XIII da cascata de coagulação como faz a trombina que resulta na formação de um coágulo consistente. Sua atividade fibrigenolítica foi evidenciada pela liberação dos fibrinopeptídios A, pela degradação da cadeia A? do fibrinogênio, a qual foi inibida por PMSF e Leupeptina, confirmando sua classificação no grupo das serinoproteases. A eficiência desta atividade fibrigenolítica foi observada entre 30 oC e 40oC durante 2 horas de incubação e alterada em presença de íons divalentes como cálcio, magnésio e bário, ressaltando a maior atividade fibrigenolítica com o cálcio. A enzima purificada TLBbar foi capaz de agregar plaquetas e em concentração de 2,5?g evidenciou comportamento semelhante à trombina. Interessante que TLBbar estimula a agregação plaquetária assim como também retarda dita atividade no tempo quando comparado com o controle (trombina). Este fato é devido a sua mudança de conformação estrutural que corresponde à ativação plaquetaria a qual ocorre com mais lentidão (nos primeiros minutos), em comparação a transformação causada pela trombina, tendo como conseqüência a liberação mais lenta de agentes como ADP e tromboxanos A2, necessários para alcançar a adesão plaquetária. A serinoprotease TLBbar não apresenta toxicidade, pois não possui atividades edematogênica, hemorrágica e miotóxica in vivo. Por outro lado, TLBbar evidencia capacidade de dissolver o coágulo de fibrina gerado pela trombina após 36 horas de incubação a 37oC, esta atividade foi inibida com PMSF nas mesmas condições, estes dados sugerem a presença de atividade fibrinolítica / Abstract: The snake venoms contain variety of proteins and are studied in the world for biological and pharmacological importance, within their complex composition of the venom protease enzymes present, as metalloproteases and serineproteases that cause hemostatic disorders, coagulantes and platelet aggregation. The present dissertation aimed to purify, biochemically characterize and evaluate the pharmacological activities of a serine protease with coagulant activity named TLBbar from Bothrops barnetti. Its purification involved two chromatographic steps, molecular exclusion in Sephadex G-75 and reversedphase HPLC with a Supelco C8 analytical column, obtaining high purity and homogeneity revealed by SDS-PAGE with Mr ~ 28.5 kDa. The enzyme has its highest proteolytic activity at 37 °C and at pH 8, which is altered in the presence of divalent ions by electrostatic interactions between enzyme and substrate. TLBbar presents a Michaelis-Menten behavior according the kinetic studies revealing a Km and Vmax of 0.433 mM and 0.42 nmol/min, respectively. TLBbar in the presence of heparin maintains its activity around 80%, although has relative stability compared with SBT-I and chelating agents such as EDTA and EGTA. TLBbar has coagulant activity on bovine fibrinogen, forming a clot semi-rigid, different the action of thrombin that results in the formation of a clot consistent. Its fibrigenolytic activity was evidenced by the release of fibrinopeptides A, by degradation of fibrinogen A? chain, which was inhibited by PMSF and Leupeptin, confirming its classification in the group of serineproteases. The efficiency of this activity was observed between 30 and 40 °C during 2 hours of incubation and changed in the presence of divalents ions such as calcium, magnesium and barium, brings out the greatest fibrigenolytic activity with calcium. The purified enzyme TLBbar was capable of aggregating platelets; 2.5?g of concentration evidence similar behavior to thrombin, TLBbar interesting stimulates platelet aggregation as well as delay time in such activity when compared with control (thrombin). We suggest that structural process of platelet activation occurs over a longer period of time with TLBbar as a result of release of ADP and thromboxane A2 agents that happen that occur with less speed to achieve platelet adhesion compared with thrombin. This enzyme not showed edematogenic-activity when compared with the activity caused by B. Barnetti snake venom, did not induce hemorrhagic nor myotoxic effect in vivo. On the other hand, TLBbar had proteolytic activity similar to thrombin, proven in the fibrigenolytic activity on bovine fibrinogen as measured in the release of fibrinopeptides in times of release similar to the control, the proteolytic activity was also evidenced by the ability to dissolve fibrin clot generated by Thrombin after 36 hours of incubation at 37 °C, the activity was inhibited with PMSF under the same conditions, these data suggest the presence of fibrinolytic activity / Mestrado / Bioquimica / Mestre em Biologia Funcional e Molecular

Haemostasis is maintained by a dynamic balance between pro- and anti-thrombotic mediators. Its dysregulation can lead to bleeding or thrombosis, and is a major cause of morbidity and mortality. Thus, elucidation of the mechanisms involved in maintaining or disrupting this balance have important implications in health and disease. Investigative tools enable characterization of the haemostatic system, but are often associated with limitations. For instance, haemostasis in animal models is often investigated by assessing bleeding responses in one particular vessel or tissue without a complete understanding of how the results translate to the regulation of haemostasis in other vascular beds. As a second example, microparticles (MPs) are a heterogeneous population of submicron-sized vesicles that may be important in thrombosis. With the exception of a few subtypes, MPs cannot be reliably characterized using widely accessible techniques. Finally, the thrombin generation assay (TGA), which measures ex vivo activation and inhibition of thrombin, is a promising tool for clinical assessment of thrombosis and haemostasis. However, characterization of thrombin generation in the general population, and the development of point of care testing are in their infancies. As a result, the TGA remains largely a research tool. The works described in this thesis specifically seek to address these three limitations in thrombosis and haemostasis research. The first isolated murine arterial bleeding model is presented and its characterization with respect to bleeding in other vascular tissues is described. In addition, a solid-phase capture assay for evaluating procoagulant, P-selectin-binding MPs, which are postulated to be mediators of thrombosis, was developed in order to determine whether these MPs associate with risk of recurrent venous thromboembolism. Lastly, a 25 x 20 mm chip that performs four individual thrombin generation assays using ~10 µl of capillary blood was developed as a proof of concept for point of care thrombin generation testing. / Thesis / Doctor of Philosophy (PhD)

Haemostasis is a complex physiological process involving cellular and plasma protein components that interact to keep the blood fluid under normal conditions and prevent blood loss after vessel injury by promoting clot formation. Primary haemostasis encompasses the activation and aggregation of platelets and is supported by secondary haemostasis, in which the coagulation factors of the plasma interact in a complex series of reactions. Secondary haemostasis is initiated by the exposure of tissue factor (TF) to the blood after vessel injury. TF forms a complex with activated factor VII (FVIIa), which in turn activates factor X (FXa) and ultimately results in fibrin formation. The TF-FVIIa complex and FXa are tightly regulated by tissue factor pathway inhibitor (TFPI), a trivalent Kunitz-type protease inhibitor. The endothelium, consisting of endothelial cells (ECs), constitutes the inner lining of all blood vessels. As such, it is in constant contact with the blood and plays a major role in haemostasis by synthesising and storing both pro- and anti- coagulant substances, including TF and TFPI. Release of TFPI from ECs is increased after exposure to both unfractionated and low molecular weight heparins, though the mechanisms are not clearly defined. TFPI circulates in plasma, predominantly bound to lipoproteins, though the effect of the three major lipoproteins [low density (LDL), very low density (VLDL) and high density (HDL)] on the release of TFPI from ECs is not well established. Furthermore, previous studies have not systematically investigated the effect of these lipoproteins on both TF and TFPI. The initial aim of this project was to establish assays for the measurement of TF activity and TFPI antigen to supplement the TFPI activity assay that is well established in our laboratory. / These assays were then used to determine the effects of heparin and the major lipoproteins on the expression of TF and the release of TFPI on/from ECs. Human umbilical vein endothelial cells (HUVECs) were used as the EC model because their collection and isolation is well established and they have biochemical and physiological properties representative of in vivo conditions. A TF activity assay, based on a previously published method, was successfully modified and validated for the measurement of cell surface TF (standard curve R2 = 0.997). Despite exhaustive attempts, adaptation of this assay for plasma TF was unsuccessful, raising doubts regarding the plasma fractionation procedure of the originally published assay [Fukuda, C., Iijima, K. and Nakamura, K. (1989). "Measuring tissue factor (factor III) activity in plasma." Clinical Chemistry 35(9): 1897‐1900]. A novel insect cell expression system was used to produce well defined recombinant TFPI standards for use in TFPI activity and antigen assays. For the first time, truncated TFPI variants, containing the first Kunitz domain only, the first and second Kunitz domains only, and the first through third Kunitz domains minus the carboxyl terminus, were successfully produced in insect cells, though the full length molecule was not. Possible reasons for this include codon bias, protein instability and/or the signal peptide used. An ELISA to measure TFPI antigen was designed using a monoclonal anti‐TFPI antibody directed against the N‐terminus for protein capture and a polyclonal anti‐ TFPI antibody for detection. The assay was successfully optimised (standard curve R2 = 0.978, intra‐assay CV = 4.8%), however it produced inaccurate results (normal range = 498.7 ± 156.3 ng/mL), probably due to the antibody combination used. / TF and TFPI activity assays were used to determine the effect of both unfractionated and low molecular weight heparins (UFH and LMWH, respectively) on the release of TFPI and the expression of TF from/on ECs. A significant increase in the secretion of functional TFPI from ECs due to heparin (0 U/ml vs 1 and 10 U/mL) was demonstrated only in the presence of serum (UFH: 9.0 mU/mL vs 18.3 and 18.4 mU/mL, p < 0.0001; LMWH: 8.8 mU/mL vs 13.3 and 21.4 mU/mL, p < 0.05), suggesting, for the first time, that a component of serum is required for the heparin‐dependent release of TFPI. The effect of LDL, VLDL and HDL on the release of TFPI and the expression of TF from/on ECs was also investigated. All three lipoprotein fractions increased the secretion of functional TFPI after one hour incubation (LDL: 12.5 μg/mL, p < 0.01; 25 μg/mL, p < 0.05; VLDL: 50 μg/mL, p < 0.01; HDL: 50 μg/mL, p < 0.05). This is the first data to demonstrate a HDL‐dependent increase in released TFPI. After 24 hours, both LDL and VLDL decreased levels of secreted functional TFPI (LDL: 25 μg/mL, p < 0.01; 50 μg/mL, p < 0.01; VLDL: 12.5 μg/mL, p < 0.01), probably due to the oxidation and subsequent association of both lipoprotein species with TFPI. Surprisingly, both LDL and VLDL decreased cell surface TF, though this effect was not dose dependent. These results suggest that the major lipoproteins have a short term anticoagulant effect which is reversed in the longer term due to lipid oxidation. In summary, this thesis describes the successful adaptation of a chromogenic assay for the measurement of cell surface TF activity and the production of truncated TFPI variants. / Both will be used for the measurement of TF and TFPI, their association with thrombus formation and propagation, and investigations into potential therapeutic applications of TFPI. The results presented in this thesis extend the current knowledge on the expression and release of TF and TFPI on/from ECs by heparin, highlighting the importance of serum in the heparin dependent release of TFPI in vitro. Furthermore, it describes for the first time the effects of the major lipoprotein fractions on TFPI release and TF expression. The data support novel mechanisms by which LDL and VLDL are procoagulant, and HDL anticoagulant. This study provides a foundation for future research of the TF pathway in cellular models, which is critical in increasing the understanding of the pathogenesis and treatment of thrombotic disease. vitro. Furthermore, it describes for the first time the effects of the major lipoprotein fractions on TFPI release and TF expression. The data support novel mechanisms by which LDL and VLDL are procoagulant, and HDL anticoagulant. This study provides a foundation for future research of the TF pathway in cellular models, which is critical in increasing the understanding of the pathogenesis and treatment of thrombotic disease.

Introduction: Endoscopic sinus surgery (ESS) is at present the gold standard therapeutic modality for chronic rhinosinusitis (CRS) resistant to medical therapy. Whilst results from ESS for CRS are generally good, postoperative bleeding and impaired wound healing with adhesion formation remains a concern. Due to patient discomfort and the detrimental effects on wound healing caused by most packing materials, many surgeons no longer routinely use nasal packing. Surgeons have in the past sought agents which would provide post-operative haemostasis without detrimentally affecting wound healing. Antifibrinolytics have been available for many years, however, their topical application has only been explored in the last few years. Recently different forms of chitosan have separately shown significant promise as powerful haemostatic and anti-adhesion agents. The aim of this thesis was to explore the progressive understanding of the interaction between haemostasis and wound healing with possible development of a novel agent. Methods: The first step to scientifically assess bleeding after sinus surgery was to develop a standardised method of video endoscopy and grading the surgical field during ESS. This was done as a multinational collaborative trial. Once this assessment tool was validated a randomised controlled trial evaluating the effect of two antifibrinolytics (epsilon aminocaproic acid and tranexamic acid) was conducted. Further evaluation was then conducted on other possible hemostatic and antiadhesion substances. This included various combinations of a novel chitosan gel. These gels were trialled in vitro to determine their effect on human nasal fibroblasts derived from CRS patients. Fibroblast adhesion and proliferation as well as closure of standardised wounds were studied. The most promising of these gels was then used in an in vivo sheep model. Once effectiveness of the chitosan-dextran gel was shown in the laboratory, this was evaluated against a number of currently available hemostatic and anti-adhesion substances in a standardised model of wound healing in sheep with CRS. This model had been previously extensively validated in our department. Full thickness mucosal injuries were created on the lateral nasal wall and ethmoids of twenty sheep and recombinant tissue factor (rTF), SprayGel or Chitosan-Dextran derivative gel applied topically in a randomized fashion. Adhesion formation and severity as well as microscopic wound healing and ciliary function were analysed at day 28, 56, 84 and 112 post initial surgery. A further sheep study was conducted applying chitosan dextran gel to standardised mucosal injuries and comparing its effect on the control of bleeding to control. Bleeding time and grade were recorded and wound healing monitored via serial videoendoscopy over two weeks and objectively measured. Results: a) Assessment of the bleeding scales showed that inter and intra observer reliability for both scales tested were significantly improved by employing a standardized video-endoscopy technique. The Wormald scale proved to be more reliable and sensitive to changes in the most common surgical fields encountered in ESS. b) Tranexamic acid showed a modest but clinically significant improvement in the surgical field at 2, 4 and 6 minutes after application. Epsilon aminocaproic acid did not effectively improve the surgical field. c) Nasal fibroblast adhesion and proliferation were significantly impaired with dextran and chitosan. The most effective ratio that delayed but did not prevent wound closure were 5 % chitosan: 5 % dextran gel. d) In a standardised sheep model of mucosal wound healing the chitosan gel significantly decreased lateral nasal wall and ethmoidal adhesions at all time points. The chitosan group had a significantly greater percentage of re-epithelialisation and reciliation than control and rTF. In addition the mean cilial grade in the chitosan group was significantly better than control. e) The chitosan dextran gel was significantly more haemostatic at 2,4, and 6 minutes after injury with no significant difference noted in wound healing. Conclusions: Standardised methods of videoendoscopy and grading the surgical field in ESS are valuable tools for further research. Tranexamic acid significantly improved the surgical field to a moderate degree in ESS compared to control. Chitosan gel is a promising new powerful haemostatic bio-polymer which has a mild inhibitory effect on fibroblast attachment and proliferation. This may partially explain the significant improvement in microscopic wound healing and reduction in adhesion formation seen in a sheep model of chronic sinusitis. Future work evaluating this gel in the setting of a human trial is currently underway. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1375402 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2009

<p>The present thesis addresses various means of reducing inflammatory responses associated with cardiopulmonary bypass (CPB) and retransfusion of pericardial suction blood (PSB) during cardiac surgery.</p><p>Four (I-IV) prospective randomised controlled clinical trials comprising 475 patients were performed in the following areas: effects of heparin coating on measures of clinical outcome and memory function (I, II), inflammatory reactions in PSB and its systemic effects after retransfusion using cardiotomy suction or cell salvage (III) and effects of retransfusion of PSB on memory function and release patterns of protein S100B (IV).</p><p>The use of heparin coated CPB-circuits was associated with a decrease of postoperative blood loss (I, II), transfusion requirements (II), shorter stay in hospital (I) decreased postoperative ventilator time (I), lower incidences of atrial fibrillation (II) and neurological deviations (I), reduction in releases of protein S100B (I, II) and lower postoperative creatinine elevation (I, II).</p><p>PSB contained high concentrations of cytokines, complements, myeloperoxidase, free plasma haemoglobin and protein S100B (III, IV). Retransfusion using cardiotomy suction increased the systemic concentrations of free plasma haemoglobin and protein S100B, whereas retransfusion using cell salvage caused no detectable systemic effects (III, IV). CPB was associated with a small but significant release of protein S100B, despite elimination of PSB-contained protein S100B using cell salvage (IV).</p><p>Subtle signs of impaired memory function were identified that were not associated with the use of heparin coated CPB-circuits (I, II) or retransfusion of PSB (IV).</p><p>Key words: cardiopulmonary bypass, oxygenators, heparin, S100 proteins, blood loss, haemostasis, memory, outcome and process assessment.</p>

The present thesis addresses various means of reducing inflammatory responses associated with cardiopulmonary bypass (CPB) and retransfusion of pericardial suction blood (PSB) during cardiac surgery. Four (I-IV) prospective randomised controlled clinical trials comprising 475 patients were performed in the following areas: effects of heparin coating on measures of clinical outcome and memory function (I, II), inflammatory reactions in PSB and its systemic effects after retransfusion using cardiotomy suction or cell salvage (III) and effects of retransfusion of PSB on memory function and release patterns of protein S100B (IV). The use of heparin coated CPB-circuits was associated with a decrease of postoperative blood loss (I, II), transfusion requirements (II), shorter stay in hospital (I) decreased postoperative ventilator time (I), lower incidences of atrial fibrillation (II) and neurological deviations (I), reduction in releases of protein S100B (I, II) and lower postoperative creatinine elevation (I, II). PSB contained high concentrations of cytokines, complements, myeloperoxidase, free plasma haemoglobin and protein S100B (III, IV). Retransfusion using cardiotomy suction increased the systemic concentrations of free plasma haemoglobin and protein S100B, whereas retransfusion using cell salvage caused no detectable systemic effects (III, IV). CPB was associated with a small but significant release of protein S100B, despite elimination of PSB-contained protein S100B using cell salvage (IV). Subtle signs of impaired memory function were identified that were not associated with the use of heparin coated CPB-circuits (I, II) or retransfusion of PSB (IV). Key words: cardiopulmonary bypass, oxygenators, heparin, S100 proteins, blood loss, haemostasis, memory, outcome and process assessment.

Introduction: Endoscopic sinus surgery (ESS) is at present the gold standard therapeutic modality for chronic rhinosinusitis (CRS) resistant to medical therapy. Whilst results from ESS for CRS are generally good, postoperative bleeding and impaired wound healing with adhesion formation remains a concern. Due to patient discomfort and the detrimental effects on wound healing caused by most packing materials, many surgeons no longer routinely use nasal packing. Surgeons have in the past sought agents which would provide post-operative haemostasis without detrimentally affecting wound healing. Antifibrinolytics have been available for many years, however, their topical application has only been explored in the last few years. Recently different forms of chitosan have separately shown significant promise as powerful haemostatic and anti-adhesion agents. The aim of this thesis was to explore the progressive understanding of the interaction between haemostasis and wound healing with possible development of a novel agent. Methods: The first step to scientifically assess bleeding after sinus surgery was to develop a standardised method of video endoscopy and grading the surgical field during ESS. This was done as a multinational collaborative trial. Once this assessment tool was validated a randomised controlled trial evaluating the effect of two antifibrinolytics (epsilon aminocaproic acid and tranexamic acid) was conducted. Further evaluation was then conducted on other possible hemostatic and antiadhesion substances. This included various combinations of a novel chitosan gel. These gels were trialled in vitro to determine their effect on human nasal fibroblasts derived from CRS patients. Fibroblast adhesion and proliferation as well as closure of standardised wounds were studied. The most promising of these gels was then used in an in vivo sheep model. Once effectiveness of the chitosan-dextran gel was shown in the laboratory, this was evaluated against a number of currently available hemostatic and anti-adhesion substances in a standardised model of wound healing in sheep with CRS. This model had been previously extensively validated in our department. Full thickness mucosal injuries were created on the lateral nasal wall and ethmoids of twenty sheep and recombinant tissue factor (rTF), SprayGel or Chitosan-Dextran derivative gel applied topically in a randomized fashion. Adhesion formation and severity as well as microscopic wound healing and ciliary function were analysed at day 28, 56, 84 and 112 post initial surgery. A further sheep study was conducted applying chitosan dextran gel to standardised mucosal injuries and comparing its effect on the control of bleeding to control. Bleeding time and grade were recorded and wound healing monitored via serial videoendoscopy over two weeks and objectively measured. Results: a) Assessment of the bleeding scales showed that inter and intra observer reliability for both scales tested were significantly improved by employing a standardized video-endoscopy technique. The Wormald scale proved to be more reliable and sensitive to changes in the most common surgical fields encountered in ESS. b) Tranexamic acid showed a modest but clinically significant improvement in the surgical field at 2, 4 and 6 minutes after application. Epsilon aminocaproic acid did not effectively improve the surgical field. c) Nasal fibroblast adhesion and proliferation were significantly impaired with dextran and chitosan. The most effective ratio that delayed but did not prevent wound closure were 5 % chitosan: 5 % dextran gel. d) In a standardised sheep model of mucosal wound healing the chitosan gel significantly decreased lateral nasal wall and ethmoidal adhesions at all time points. The chitosan group had a significantly greater percentage of re-epithelialisation and reciliation than control and rTF. In addition the mean cilial grade in the chitosan group was significantly better than control. e) The chitosan dextran gel was significantly more haemostatic at 2,4, and 6 minutes after injury with no significant difference noted in wound healing. Conclusions: Standardised methods of videoendoscopy and grading the surgical field in ESS are valuable tools for further research. Tranexamic acid significantly improved the surgical field to a moderate degree in ESS compared to control. Chitosan gel is a promising new powerful haemostatic bio-polymer which has a mild inhibitory effect on fibroblast attachment and proliferation. This may partially explain the significant improvement in microscopic wound healing and reduction in adhesion formation seen in a sheep model of chronic sinusitis. Future work evaluating this gel in the setting of a human trial is currently underway. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1375402 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2009

Introduction: Thrombotic events are among the most serious complications of sepsis and also the most frequent causes of morbidity and mortality in patients with sepsis. Currently, the administration of low molecular weight heparins (LMWH) is recommended in patients with severe sepsis for prophylaxis of these complications. However, this prophylaxis often fails. Objectives of the study: One of the objectives of our study was to examine changes in haemostasis in relation to the inflammatory response during 15 days of severe sepsis. The next objective was to determine whether a prophylactic inhibition of F Xa in the range from 0.2 to 0.4 IU/mL is achieved in these patients, if they receive the recommended prophylaxis with LMWH. We also recorded the dynamics of changes in the F Xa inhibition during the entire study period. Moreover, we tried to identify the factors that may affect the antithrombotic efficacy of the subcutaneously administered enoxaparin. Patient population and methods: A total of 35 ICU patients meeting the criteria of severe sepsis were enrolled in the study. Only 16 of these patients could be followed throughout the entire 15-day period. Patients were treated according to the current guidelines, including LMWH prophylaxis; enoxaparin (40 mg sc per day) was used in this study....

Patients with rheumatoid arthritis (RA) have a shorter life span than the general population. An increased death due to cardiovascular disease (CVD) has been reported. RA is characterized by synovitis and joint destruction accompanied by an acute phase reaction and systemic features. The present work investigates the epidemiology of CVD in patients with RA in the county of Västerbotten and the influence of inflammation on lipid metabolism and haemostasis. In a retrospective cohort study on 606 RA patients, the overall mortality was significantly higher than in the general population, with an excess death rate for CVD and for ishemic heart diseae (IHD) in both sexes. Multiple Cox regression, showed that male sex, higher age at disease onset and cardiovascular event increased the risk for death. Male sex, high age at disease onset and hypertension increased the risk for cardiovascular event. Diabetes mellitus, treatment with corticosteroids, disease modifying antirheumatic drugs and postmenopausal estrogen neither influenced survival nor the risk of cardiovascular event. In 93 patients with active RA, the levels of cholesterol, high density- (HDL) and low density (LDL) lipoprotein cholesterol were significantly lower, and Lipoprotein(a) was significantly higher compared to controls. In a follow-up on 53 patients, a relation between the change of Lp(a) and acute phase proteins was found only in patients with high levels of Lp(a). Preheparin lipoprotein lipase (LPL) activity and mass were significantly decreased in 17 postmenopausal women with active RA. Preheparin LPL mass correlated inversely to several acute phase proteins and interleukin-6. Low levels of LPL mass may implicate increased hepatic clearence but also increased macrophage ingestion of lipoproteins via the LDL receptor-related protein (LRP). Haemostasis of the circulation was investigated in 74 of the 93 patients with active RA. In patients with extraarticular disease, the release of tissue plasminogen activator (tPA) was significantly decreased, and its inhibitor (PAI-1) was significantly increased compared to patients with nonsystemic disease, implicating hypofibrinolysis. In a two year follow-up, patients with thromboembolic events had significantly elevated levels of von Willebrand factor, PAI-1, triglycerides and haptoglobin compared to event-free patients. In 29 RA patients and 18 spondylarthropathy patients with gonarthritis, radiological joint destruction correlated to PAI-1 antigen in synovial fluid and, inversely, to plasminogen. A relationship between activation of fibrin degrading proteolytic enzymes and joint destruction was implicated. In conclusion, several processes involved in lipid metabolism and haemostasis are influenced in active RA. In view of the increased death rate due to CVD, an efficient control of inflammation should be important, not only for reducing joint destruction, but also for reducing systemical atherogenic and thrombogenic effects. / <p>s. 1-54: sammanfattning, s. 55-133: 6 uppsatser</p> / digitalisering@umu.se