A Prospective Observational Study Analyzing the Diagnostic Value of Hepcidin-25 for Anemia in Patients with Inflammatory Bowel Diseases

Iron deficiency (IDA) and chronic disease (ACD) anemia are complications of inflammatory bowel diseases (IBDs). Therapeutic modalities in remission and active IBD depend on the type of anemia. This study evaluated the link between hepcidin-25, proinflammatory cytokines, and platelet activation markers as biomarkers of anemia and inflammation in active IBD and remission. This prospective observational study included 62 patients with IBD (49 with ulcerative colitis and 13 with Crohn's) and anemia. Patients were divided into Group I (no or minimal endoscopic signs of disease activity and IDA), Group II (moderate and major endoscopic signs of disease activity and mild ACD), and Control group (10 patients with IBD in remission, without anemia). We assessed the difference among groups in the levels of CRP, hemoglobin (Hgb), serum iron, ferritin, hepcidin-25, interleukins, TNF-α, IFN-γ, soluble CD40 ligand, and sP-selectin. Hepcidin-25 levels were significantly higher in Group II versus Group I (11.93 vs. 4.48 ng/mL, p < 0.001). Ferritin and CRP values showed similar patterns in IBD patients: significantly higher levels were observed in Group II (47.5 ng/mL and 13.68 mg/L) than in Group I (11.0 ng/mL and 3.39 mg/L) (p < 0.001). In Group II, hepcidin-25 was positively correlated with ferritin (ρ = 0.725, p < 0.001) and CRP (ρ = 0.502, p = 0.003). Ferritin was an independent variable influencing hepcidin-25 concentration in IBD patients, regardless of disease activity and severity of anemia. IBD hepcidin-25 best correlates with ferritin, and both parameters reflected inflammation extent and IBD activity.

Predictive value of admission glycemia in diabetics with pulmonary embolism compared to non-diabetic patients

AIMS

To examine the relationship between admission glucose (AG) level and short-term in-hospital mortality and to investigate the association between hyperglycemia and major bleeding in PE patients with and without DMT2.

METHODS

We evaluated 1165 patients with diagnosed acute PE with multi-detector computed tomography pulmonary angiography (MDCT-PA) enrolled in the Regional multicenter PE registry (REPER). The study population was classified to patients with diabetes mellitus type 2 (DMT2) and those without diabetes. According to quartiles of AG patients, both groups separately were categorized into four subgroups (DMT2 I: < 7.5 mmol/L; II: 7.5-10.0 mmol/L; III: 10.0-15.7 mmol/L; IV: > 15.7 mmol/L and (non-DMT2 I: < 5.5 mmol/L; II: 5.5-6.3 mmol/L; III: 6.3-7.9 mmol/L; IV: > 7.9 mmol/L).

RESULTS

All-cause mortality was higher in the DMT2 group (9.5% vs. 18.2%, p < 0.001), and PE-cause mortality was 6% for the patients without DMT2 and 12.4% for DMT2 patients (p = 0.02). The patients in the fourth AG quartiles in both groups, without DMT2 and with DMT2, had significantly higher all-cause and PE-cause in-hospital mortality compared with the first quartile. Rates of major bleeding were similar between the groups. On the multivariable analysis, after adjusting for age, gender and mortality risk, the adherence in the fourth AG quartile had an independent predictive value for all-cause death (HR 2.476, 95% CI 1.017-6.027) only in DM patients.

CONCLUSION

In our cohort of patients with acute PE, diabetes was associated with increased rates for all-cause and PE-cause mortality.

Impact of disease activity on impaired glucose metabolism in patients with rheumatoid arthritis

Objective

To explore glucose metabolism in rheumatoid arthritis (RA) and its association with insulin resistance (IR) risk factors and disease activity indicators, including matrix metalloproteinase-3 (MMP3).

Methods

This single-center study included 127 non-diabetic subjects: 90 RA patients and 37 matched controls. IR-related risk factors, disease activity (DAS28-ESR/CRP), concentrations of inflammation markers, MMP3, glucose, specific insulin, and C-peptide (a marker of β-cell secretion) were determined. Homeostasis Model Assessment was used to establish insulin resistance (HOMA2-IR) and sensitivity (HOMA2-%S). Associations of HOMA2 indices with IR-related risk factors, inflammation markers, and RA activity were tested using multiple regression analyses.

Results

RA patients had significantly increased HOMA2-IR index than controls. In the RA group, multivariate analysis revealed DAS28-ESR, DAS28-CRP, tender joint counts, patient’s global assessment, and MMP3 level as significant positive predictors for HOMA2-IR (β = 0.206, P = 0.014; β = 0.192, P = 0.009; β = 0.121, P = 0.005; β = 0.148, P = 0.007; β = 0.075, P = 0.025, respectively), and reciprocal negative for HOMA2-%S index. According to the value of the coefficient of determination (R²), DAS28-ESR ≥ 5.1 has the largest proportion of variation in both HOMA2-IR indices. DAS28-ESR ≥ 5.1 and ESR were independent predictors for increased C-peptide concentration (β = 0.090, P = 0.022; β = 0.133, P = 0.022). Despite comparability regarding all IR-related risk factors, patients with DAS28-ESR ≥ 5.1 had higher HOMA2-IR than controls [1.7 (1.2–2.5) vs. 1.2 (0.8–1.4), P = 0.000]. There was no difference between patients with DAS28-ESR < 5.1 and controls [1.3 (0.9–1.9) vs. 1.2 (0.8–1.4), P = 0.375].

Conclusions

RA activity is an independent risk factor for impaired glucose metabolism. DAS28-ESR ≥ 5.1 was the main contributor to this metabolic disturbance, followed by MMP3 concentration, outweighing the impact of classic IR-related risk factors.

Association of PC and AT levels in the early phase of STEMI treated with pPCI with LV systolic function and 6-month MACE

OBJECTIVES

To examine a relationship between protein C (PC) and antithrombin III (AT III) activities with ejection fraction of left ventricle (EFLV), in the early phase of acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI), and to investigate whether PC and AT III are associated with major adverse cardiovascular events (MACE) within 6 months following from pPCI.

PATIENTS AND METHODS

The research had a prospective character and included 357 patients who had, following the diagnosis of the STEMI, undergone pPCI at the Clinic of Cardiology and Emergency Internal Medicine, Military Medical Academy, Belgrade, Serbia, from January 2010 until April 2019.

RESULTS

The EFLV positively correlated with PC values (rho = 0.229). There was a statistically significant increase in the PC values between patients with MACE compared with those without MACE at 6 months' follow-up evaluation (p < 0.0001). Also, significant difference in PC values between patients who died in hospital and those who were alive at 6 months' follow-up (p < 0.01) was observed. PC values were different across different EFLV groups (p < 0.001), increasing from the 1st to the 4th EFLV quartiles: the median and the interquartile values for the 1st, 2nd, 3rd and 4th quartiles were 1.0400IU/l ± 0.15, 1.1400IU/l ± 0.15, 1.1350IU/l ± 0.16 and 1.2200IU/l ± 0.14, respectively.

CONCLUSION

Increased PC activity in the early phase of STEMI is associated with higher EFLV 5 days after the pPCI as well as with MACE at 6 months after the pPCI.

Lower plasma protein C activity is associated with early myocardial necrosis and no-reflow phenomenon in patients with ST elevation myocardial infarction

Background: Activity of protein C has important role in the development of early necrosis and no-reflow phenomenon in patients with ST-segment elevation myocardial infarction (STEMI) after successful primary percutaneous coronary intervention (pPCI). Methods: We examined association between plasma activity of protein C, antithrombin, coagulation factors II, VII, VIII and fibrinogen to early formation of new Q-waves (myocardial necrosis) before pPCI and early ST-segment resolution (microcirculatory reperfusion) after pPCI in patients with acute STEMI. According to ischaemic time, patients were considered as early or late presenters. 12-lead ECG was analysed for the presence of new Q-wave at admission and for significant ST-segment resolution 60 minutes after primary PCI. Results: In early presenters' group, protein C activity was significantly lower in patients who did not achieve significant ST-segment resolution after pPCI compared to patients who did (1.11 IU/L vs. 0.99 IU/L, p = .006) and in patients who had new Q-waves compared to group who had not (1.04 UI/l vs. 1.11 IU/L, p = .038). There was significant negative correlation between protein C activity and maximal CK-MB levels (R² = 0.06, p = .009) and BNP levels (R² = 0.109, p = .003) and significant positive correlation between protein C activity with LVEF (R² = 0.065, constant = 33.940, b = 11.968, p = .007) in early STEMI presenters. There were no differences between the activity of other examined haemostasis factors. Conclusion: Therefore we concluded that STEMI patients with early myocardial necrosis and no-reflow phenomenon after pPCI have lower activity of plasma protein C levels.

Effects of warfarin on biological processes other than haemostasis: A review

Warfarin is the world's most widely used anticoagulant drug. Its anticoagulant activity is based on the inhibition of the vitamin K-dependent (VKD) step in the complete synthesis of a number of blood coagulation factors that are required for normal blood coagulation. Warfarin also affects synthesis of VKD proteins not related to haemostasis including those involved in bone growth and vascular calcification. Antithrombotic activity of warfarin is considered responsible for some aspects of its anti-tumour activity of warfarin. Some aspects of activities against tumours seem not to be related to haemostasis and included effects of warfarin on non-haemostatic VKD proteins as well as those not related to VKD proteins. Inflammatory/immunomodulatory effects of warfarin indicate much broader potential of action of this drug both in physiological and pathological processes. This review provides an overview of the published data dealing with the effects of warfarin on biological processes other than haemostasis.

Oral warfarin affects some aspects of systemic immunomodulation with topical dinitrochlorobenzene (DNCB) in rats

PURPOSE

The efficacy of topical dinitrochlorobenzene (DNCB) in the treatment of some skin dermatoses is based both on local and systemic effects. It is not known, however, whether it can be applied to patients receiving some other therapy associated with systemic immunomodulation. The aim of the present paper using a rat model was to examine whether oral warfarin (WF) intake, as shown by others and by us, had an immunomodulatory potential to interfere with effects of topical DNCB as systemic immunotherapy.

MATERIALS AND METHODS

Rats received 3.5 mg/l of WF sodium in drinking water for 30 days and were thereafter skin-sensitized with 0.4% DNCB. Changes in the oxidative activity (myeloperoxidase/MPO, reduction of nitroblue tetrazolium/NBT and nitric oxide/NO production) as well as tumor necrosis factor (TNF) production by peripheral blood polymorphonuclear cells (PMN) were measured and compared with PMN from sensitized unexposed to WF rats.

RESULTS

WF intake enhanced some aspects of PMN activity (intracellular MPO activity and unstimulated NO production) as well as their responsiveness to exogenous stimulation (NBT reduction and TNF production from sensitized animals). However, WF also decreased PMN responsiveness of NO production to stimulation. WF affected NO and TNF production solely by PMN, as no effect on these activities of peripheral blood mononuclear cells was seen.

CONCLUSION

Having in mind that polymorphonuclear leukocytes are the most abundant cell type in peripheral blood in humans, increase of basic aspects of PMN activity described in the present paper might be relevant for consideration of using WF as therapeutic modality in patients topically treated with DNCB.

Strain differences in intestinal toxicity of warfarin in rats

Intestinal hemorrhage characterizes effectiveness of warfarin (WF) as rodenticide and is among adverse effects of therapy in humans. Having in mind genetic variations in the effectiveness of WF in wild rats and in the doses required for therapeutic effect, strain differences in the intestinal toxicity of oral warfarin in rats were examined in this study. High WF dose (3.5mg/l) led to mortality in Albino Oxford (AO) rats, with no lethality in Dark Agouti (DA) rats. Higher values of prothrombin time were noted at low WF dose (0.35mg/l) in the former strain. Leukocyte infiltration in intestine noted at this dose in both strains was associated with oxidative injury and more pronounced anti-oxidative response in AO rats. Suppression of mesenteric lymph node cell proliferation and IFN-γ and IL-10 production in AO rats and lack of these effects in DA rats, represent different strategies to protect vulnerable intestine from harmful immune responses.

Intestinal toxicity of oral warfarin intake in rats

Though warfarin is extensively used in the prevention and treatment of thromboembolic processes in humans, adverse effects of warfarin therapy have been recognized. Intestinal hemorrhage is one of the hazards of anticoagulant therapy, but the mechanisms of warfarin toxicity are virtually unknown. In this work, the effects of 30 days oral warfarin (0.35 mg/l and 3.5 mg/l) intake on rat's gut were examined. Both doses resulted in prolongation of prothrombin time. Systemic effects of higher warfarin dose (increases in plasma AST, proteinuria, hematuria, changes in peripheral blood hematological parameters) were seen. Warfarin intake resulted in histologically evident tissue damage, leukocyte infiltration and intestinal inflammation [increases in myeloperoxidase activity, malondialdehyde content, superoxide dismutase and catalase activity, proinflammatory cytokine (IFN-γ, IL-17) concentrations in intestinal homogenates]. In contrast, suppression of gut-draining mesenteric lymph node (MLN) cell activity [proliferation responsiveness, production of IFN-γ and IL-17 to T lymphocyte mitogen Concanavalin A stimulation] was noted. Inhibition of regulatory cytokine IL-10 production by MLN cells, suggests commitment of MLN to the suppression of all inflammatory activities and creation of the microenvironment which is non-permissive for induction of potentially harmful immune response. These novel findings indicate the need of staying alert for (adverse) effects of warfarin therapy.

Transdermal toxicity of topically applied anticoagulant rodenticide warfarin in rats

Occupational/accidental exposure data have showed hemorrhage as a result of transdermal exposure to warfarin, however, other effects are not known. In the present study, the impact of epicutaneous application of 10 μg or 100 μg of warfarin (three times, once a day) on peripheral blood polymorphonuclear (PMN) and mononuclear cells (PBMC) was examined in rats. Both doses resulted in prolongation of prothrombin time and changes in hematologic parameters. Increases in PMN intracellular myeloperoxidase (MPO) activity were seen at higher warfarin dose and both doses resulted in higher percentages of granular CD11b(+) cells. In contrast, a decrease in PMN TNF and IL-6 production (ELISA) and gene expression (RT-PCR) was observed. Epicutaneous application of warfarin resulted in decreased numbers of PBMC, higher numbers of mononuclear CD11b(+) cells, but without effect on PMBC cytokine production. The data obtained showed differential effects of transdermal exposure to warfarin depending on leukocyte type and activity.

Plasma constituent integrity in pre-storage vs. post-storage riboflavin and UV-light treatment--a comparative study

Treatment of fresh frozen plasma (FFP) by riboflavin (RB) and ultraviolet (UV) light inhibits nucleic acid replication, leading to inactivation of white blood cells (WBCs) and pathogens. The goal of this study was to compare the effects of pathogen reduction technology (PRT) treatment on the plasma protein content based on biochemical, immune and hemostatic characteristics in "typical" pre-storage vs. post-storage PRT-treatment setting. Following whole blood centrifugation, separated plasma units were: (a) inactivated and frozen (pre-storage setting or control group [CG]) or (b) immediately frozen (post-storage setting or study group [SG]) afterward thawed, inactivated and stored at -40 ± 5°C (cryostorage). Plasma units were inactivated by the Mirasol PRT system (TerumoBCT, USA). Using multi-laboratory techniques and equipments, biochemistry (Advia 1800; Siemens, Germany), IgM, IgG and IgA, complement components C3 and C4 (BNA II nefelometer analyzer; Siemens, Germany), as well as CH50 activity (Behring coagulation timer; Siemens, Germany) were investigated. Procoagulant and inhibitor factors, such as antithrombin-III (AT-III), and protein C (PC) were determined by BCS XP Coagulation system (Siemens, Germany). There were neither significant changes in final protein levels, nor any differences in plasma immunoglobulin levels investigated. In the final samples CH50 activity was reduced in both investigated groups. The plasma concentration of the complement C3 following post-storage treatment was significantly (p<0.05) higher than in pre-storage setting. There was a trend of depletion of procoagulant activities in both, pre-storage and post-storage PRT-treatment (initial vs. final values), but there were no significant differences between two groups. Results confirmed that AT-III was significantly higher after post-storage inactivation. In conclusion, this study confirmed that there were not clinically relevant intergroup (pre-storage vs. post-storage PRT-treatment) differences in plasma constituent levels. Post-storage treated FFP remains, protein quantity, and activity well, and therefore can be used in clinical practice. Previously cryostored or quarantine FFP units (despite the reduced quarantine period after NAT/PCR testing) could be safely and effectively inactivated, directly prior to clinical application.

Oral warfarin affects peripheral blood leukocyte IL-6 and TNFα production in rats

Warfarin is a Vitamin K (VK) antagonist that affects Vitamin K-dependent (VKD) processes, including blood coagulation, as well as processes unrelated to hemostasis such as bone growth, calcification, and growth of some cell types. In addition, warfarin exerts influence on some non-VKD-related activities, including anti-tumor and immunomodulating activity. With respect to the latter, both immune stimulating and suppressive effects have been noted in different experimental systems. To explore the in vivo immunomodulatory potential of warfarin on one type of activity (i.e., cytokine production) in two different immune cell populations (i.e., mononuclear or polymorphonuclear cells), effects of subchronic oral warfarin intake in rats on pro-inflammatory cytokine (i.e., TNFα, IL-6) production by peripheral blood mononuclear and polymorphonuclear cells (granulocytes) was examined. Differential effects of warfarin intake on TNFα and IL-6 were noted, depending on the type of peripheral blood leukocytes and on the cytokine examined. Specifically, a lack of effect on TNFα and a priming of IL-6 production by mononuclear cells along with a decrease in TNFα and a lack of effect on IL-6 in polymorphonuclear cells were seen in warfarin-exposed hosts. The cell- and cytokine-dependent effects from subchronic oral warfarin intake on peripheral blood leukocytes demonstrated in this study could, possibly, differentially affect reactions mediated by these cells. Ultimately, the observed effects in rats might have implications for those humans who are on long-term/prolonged warfarin therapy.

Usefulness of soluble transferrin receptor and ferritin in iron deficiency and chronic disease

Soluble transferrin receptor (sTfR) is a biochemical parameter used for the detection of iron deficiency in situations where ferritin has limited diagnostic value owing to the present chronic disease. The sTfR concentration was determined in 118 patients divided according to their inflammatory status and underlying disease into groups of patients with iron-deficiency anemia (IDA), anemia of chronic disease (ACD) and patients with a coexisting state of iron deficiency and anemia of chronic disease (ID+ACD). All patients with iron deficiency had elevated sTfR levels, but ferritin concentrations were normal or increased in patients with inflammatory characteristics. Diagnostic efficiencies of sTfR, sTfR/log ferritin index (sTfR/F) and ferritin were evaluated by receiver operating characteristic curve (ROC) analysis. According to the results obtained, the best diagnostic efficiency for differential diagnosis of anemic patients with iron deficiency compared to the control group had a sTfR concentration (0.884) that was significantly higher than ferritin (0.638), but not higher than the calculated ratio sTfR/F (0.820). The cut-off value of the sTfR/F index differentiating the best control group from the IDA and ID+ACD groups was 1.30, and for differentiation of ACD from IDA and ID+ACD, the value was 0.90. Soluble transferrin receptor is an additional parameter to ferritin for the diagnosis of IDA and differential diagnosis of ID+ACD, but calculation of the sTfR/F index did not improve the diagnostic value of determining sTfR alone.

Erythrocytotoxicity of tiazofurin in vivo and in vitro detected by scanning probe microscopy

Tiazofurin (TZF) is a cytostatic drug that leads to depletion of the GTP pool in tumor and normal cells via its active metabolite tiazofurin-adenine dinucleotide (TAD). TAD was detected in different cell lines, but not in erythrocytes, so the mechanism of erythrocytotoxicity of TZF remains unclear. The purpose of this study was to evaluate in vitro and in vivo action of tiazofurin on rat erythrocytes (RBC). After two decades of clinical trials the question of erythrocytotoxicity of TZF had remained unexplained making this study justified. Since we have previously demonstrated early erythrocytotoxic effects in male Wistar rats, we extend this finding on isolated RBC. Isolated erythrocytes from untreated animals were treated in buffered solution or plasma containing TZF. In addition, groups of 10 rats were treated with 200 and 1000 mg/kg of TZF and hematologic parameters were analyzed by flowcytometry and by the analysis of the peripheral blood smears. Early signs of hemolysis or aberrant structures were monitored by scanning probe microscopy (SPM). We suggest that correlation exists between early erythrocytotoxicity and irregularities in erythrocyte morphology and membrane integrity. We also found that TZF affects responsiveness to oxidative stress. This is in concordance with flowcytometric findings describing anisocytosis and anisochromosis of RBC.

Reticulocyte hemoglobin content in the diagnosis of iron deficiency anemia

The aim of the study was to examine the clinical utility of the reticulocyte hemoglobin content (CHr) in relation to the mean cell volume of the erythrocyte (MCV) and ferritin for the differential diagnosis of iron-deficient anemia (IDA). In 96 anemic patients classified according to morphology of erythrocytes, CHr indicated a high statistical difference between the non-anemic control group and microcytic (p < 0.001) and normocytic (p < 0.001) anemic groups, but was limited in patients with macrocytic anemia, for which reason they were excluded from the study. In the inflammatory disorders, ferritin concentration may be normal or increase due to acute phase response, which provides false information on a patient's iron status, but CHr indicated a high statistical difference between the control group and the non-inflammatory (p < 0.001) and inflammatory groups (p < 0.001). Receiver operator characteristic curve analysis demonstrates that CHr has a better overall sensitivity and specificity than MCV and ferritin in the diagnosis of iron deficiency compared to hemoglobin concentration.

Elevated plasma levels of transforming growth factor-beta 1 (TGF-beta 1) in patients with advanced breast cancer: association with disease progression

We examined the association between an elevated plasma TGF-beta 1 level and the disease progression of advanced breast cancer (BC) patients (n = 44). TGF-beta 1 levels were detected by an enzyme-linked immunosorbent assay (ELISA). Platelet carryover and in vitro platelet activation in our plasma samples was assessed and found to be insignificant. Plasma TGF-beta 1 values were significantly elevated (P < 0.05) in stage IIIB/IV patients (median value: 2.40 ng/ml, range: 0.13-8.48 ng/ml, n = 44) compared with healthy donors (median value: 1.30 ng/ml, range: 0.41-4.93 ng/ml, n = 36). Although pronounced in metastatic patients, especially those who had been newly diagnosed, TGF-beta 1 elevation was independent of tumour mass, site of distant metastases, histopathological type, steroid receptor (SR) content and age of the BC patients. Follow-up of 6 patients indicated a relationship between the plasma TGF-beta 1 and the patient's response. This suggests that TGF-beta 1, may be a promising prognostic marker for breast cancer patients with advanced disease. Confirmatory large-scale studies are needed, particularly given the overlap of values between our different subgroups analysed.