It is generally accepted that coagulation, fibrinolysis and prostaglandins (PGS) may be involved in ovulation, fertilization and implantation machanisms. However, the details of the relationship are still unknown.
The present study was designed to inventigate the involvement of: 1) PGS and fibrinolysis in ovulation, 2) the acrosin activity of sperm heads in the process of fertilization, 3) the fibrinolysis in the development of fertilized ova, 4) the fibrinolysis activity in fertilized ova and endometrium during implantation, using various models: delayed implantation in mice, hemilateral tubal ligation, etc.
We concluded as follows:
1) PGS and fibrinolytic activity in the ovaries are necessary for ovulation. The addition of antifibrinolytic agents significantly suppresses ovulation.
2) The secretion of acrosin from sperm heads is necessary for the sperm to pass through the zona pellucida.
The amount of acrosin present is significantry correlated with sperm concentration and sperm activity.
3) Fibrinolysis plays a significant role in the development and maturation of fertilized ova.
4) The interaction between the fibrinolysis of the fertilized ova and of the endometrium greatly influences the early stage of implantation, the position of ova in the endometrium and the subsequent development of implanted ova.

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The influence of factors of coagulation and fibrinolysis on the placental attachment mechanism to the uterus and the anti-thrombotic mechanism in intervillous space was examined, and the following results were obtained.
1) The localization of XIII-A and XIII-S in placenta in a case of congenital factor XIII deficient pregnant woman (6 week 4 days) was examined immunohistochemically.
In this case XIII-A could not be found in the placental tissue.
2) Plasminogen activator inhibitor complex (PPAI) was obtained from placenta, which had no fibrinolytic activity, but had strong UK inhibiting activity. However the fibrinolytic activity of this complex on the standard fibrin plate appeared after the treatment of 2M hydroxylamine and APC (activated protein C) prepared by activation of human protein C with human thrombin and thrombomodulin. After the incubation of PPAI with APC, UK inhibiting activity of PPAI was decreased. This fact suggests that APC and PPAI play an important role in the inhibition of thrombosis formation in intervillous space.

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1) Term and preterm newborn infants have normal levels of fibrinogen, factor V and factor VIII procoagulant activity when compared to older children and adults, although the range of values is greater in the small premature infants. On the other hand, the levels of contact phase clotting factors (XII, XI, prekalikrein and high molecular weight kininogen), vitamin K dependent clotting factors (II, VII, IX and X), factor XIII and coagulant inhibitors (antithrombin III, protein C and protein S) of the newborn infants are uniformly decreased to the levels of 20∼60% of normal adult values. These levels are dependent on gestational age with lower levels seen in normal preterm infants than in normal term infants.
2) The overall fibrinolytic activity of newborn infants within a few days of birth is increased when compared to adults. In preterm infants, plasminogen levels range from 25 to 40% of normal adults. These levels increase with gestational age and the plasminogen levels of term infants approach the 40∼60% of normal adults. The α₂-plasmin inhibitor levels of term newborn infants are slightly decreased to levels of 80% of normal adults.
3) Term and preterm newborn infants at gestational ages of 27 to 40 weeks have platelet counts in the same range as normal older children and adults. Platelet aggregation in platelet rich plasma of newborn infants within a few days of birth is diminished to ADP, collagen and epinephrine. However, whole blood platelet aggregation and platelet retention to glass beads are normal in newborn infants.
4) Above mentioned findings indicate that the hemostatic and antithrombotic balance is unstable in newborn infants. Therefore, the incidences of both thrombotic disorders and hemorrhagic disorders are higher in newborn infants than in older children and adults.
5) Our recent study indicates that many infants dying from intracranial hemorrhage had evidence of hemostatic failure compatible with disseminated intravascular coagulation or vitamin K dependent coagulant factor deficiency.
The coagulation abnormality is suggested to be the major factor of deterioration and, in some cases, the etiologic factor of intracranial hemorrhage in newborn infants.
6) Therapy of gabexate mesilate (FOY) for newborn infants with disseminated intravascular coagulation was more effective than heparin therapy.

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It is well known that vessel walls show arteriosclerotic changes progressively with the presence of ageing. On the other side, there are few reports on changes in platelets by ageing. In males, platelet sensitivity to ADP-aggregation increased by ageing, while the increase was not observed in females. The result suggests an enhancement of platelet function by estrogen. We identified such an effect of estrogen on the following subects: 1. Enhancement of platelet aggregability in follicular phase in young females with normal menstrual cycle. 2. Decrease in platelet aggregability in females after bilateral ovariectomy. 3. Enhancement of platelet aggregability in males with prostatic cancer under estrogen treatment. However, we could not find an enhancement of platelet function induced by estrogen directly in vitro and in vivo experiments. Also platelet aggregability is enhanced in the presence of arteriosclerosis in their circulation. The above two factors, estrogen in circulating blood and arteriosclerotic vessel walls, may influence mainly on changes in platelets with the progress of ageing.

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Changes in coagulability, fibrinolytic activity and viscosity of blood, related to age were investigated in healthy subjects. The results were as follows: Factor VIII activity and plasma fibrinogen content increased with age, however factor V activity were lower in aged subjects. Activities of factors X and VIII, and levels of fibrinogen, antithrombin III and plasminogen in plasma were higer in the young male than in the age-matched female, although those were lower in the aged male than in the female with corresponding age. Von Willebrand factor in plasma were assayed in the aged subjects and was higher in male than in female. Hematcrit values and blood viscosity were higher in the male than in the female, in general. Hematcrit values tended to decline with age, although blood viscosity were higher in the aged subjects. From these results, it seems to be reasonable to conclude that aged male is Slightly thrombotic than age-matched female. This may contribute to longevity of female.

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Two major heparin dependent protease inhibitors in plasma ie antithrombin III (AT III) and heparin cofactor II (HC II) contribute to maintaine the blood fluidity through their interactions with endotherial cell surface glycosaminoglycans (GAG). ATIII and HCII possess many biochemical similarities but they differ in some respect. While ATIII can inhibit most of the serine proteases in coagulation cascade, neutralizing activity of HCII is restricted to thrombin. Protease neutralizing activity of HCII could be activated not only by heparin and chondroitin polysulfate but by dermatan sulfate. On the other hand Histidine-rich glycoprotein and platelet factor 4 regulate the interactions between these GAG and the protease inhibitors through their neutralizing activities toward GAG. Any disturbance in the precise mechanism of interactions between these substances may lead either to the thrombus formation or to the bleeding tendency. Thrombotic episode in ATIII Toyama could be explained as one of the example of this kind of disorder.

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Thrombomodulin (TM) is a newly described endothelial cell-associated protein that functions as a potent natural anticoagulant by converting thrombin from a procoagulant protease to an anticoagulant. Vessels in the brain were characterized with immunoperoxidase staining using a polyclonal anti-TM IgG. The staining patterns of TM were compared with those of von Willebrand factor (vWF) and Ulex europaeus agglutinin (UEA-1). The results showed that the staining of TM in the small vessels and capillaries in brain was faint compared to the staining of vWF and UEA-1. On the contrary, staining of TM was strongly positive in the capillaries in chroid plexus, however that of vWF was weak. It was suggested that the decreased distribution of TM in the brain vasculature may have a role for the pathogenesis of cerbrovascular occlusive diseases.
Next we assayed bradykinin in cerebrospinal fluid (CSF) by radioimmunoassay. Content of kinin in the CSF from non-neurological diseases was less than 30 pg/ml, however it was markedly increased up to 1-2 ng/ml in CSF from subarachnoid hemorrhage, meningitis and tumors. The level of kinin showed good correlation to the severity of headache or meningeal irritation. Based on these findings we propose that once coagulation factors are leaked into CSF-space through damaged blood-CSF barrier, factor XII will be activated resulting the release of kinin. The increased kinin in CSF may have effect on CSF-circulation and cause meningeal irritation with intracranial hypertension.

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The distribution of fibronectin (FN) and the deposition of fibrin and fibrinoltic components in human renal glomeruli with a variety of pathologic disorbers were examined on biopsy specimens by immunofluorescence and immunoperoxidase methods. In normal glomeruli, staining of FN was noted in the mesangial area. However, in a majority of the cases with thickening of capillary walls and or with fibrin deposits in the capillary walls, staining for FN along the walls of the capillary loops was noted in addition to the staining in the mesangial area. In the cases with intraglomerular fibrin deposits of (α₂-plasmin inhibitor (α₂-PL) and plasmin (ogen), which are major components of fibrinolytic system, were also seen along the capillary walls with a high frequency of occurence. Sice α₂-PI is known to be cross-linked to fibrin by activated factor XIII, α₂-PI deposits associated with deposits of fibrin may also be interpreted as indicating the presence of the cross-linked complex of α₂-PI and fibrin. Since factor XIII can be activated only by thrombin, the activation of factor XIII in turn inbicates that thrombin was generated at the loci by the blood coagulation process. In the cases of membranous nephropathy, heavy staining of FN was observed at the subendothelial space and patchy staining in the lamina rara interna. In the cases of membranoproliferative glomerulonephritis, staining of FN was observed in the position of mesangial interposition.

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Placental circulation, especially circulation in choriodecidual space in normal and toxemia of pregnancy was investigated from the view point of coagulation and fibrinolysis. Main results obtained were as follows:
1) No endothelial cells could be observed at least on the surface of villi.
2) Antithrombin III (AT-III) and α₂ plasmin inhibitor (α₂-PI) were decreased in plasma obtained from uterine vein during cesarean section.
3) Two potent proteins which inhibited platelet aggregation (placental platelet aggregation inhibitor: PPAI) and prolonged blood coagulation time (placental coagulation inhibitor: PCI) were found in microsomal fraction of placental homogenate.
4) PCI was purified by several steps of column chromatography. Molecular weight and pI of PCI were estimated to be 29,000 daltons and 4.2-4.4, respectively.
5) Histochemical study of PCI revealed that it was distributed syncytiotrophoblast in the placenta.
6) In the coagulation cascade, thrombin and factor Xa formation were inhibited by PCI when reacted with phospholipid and Ca²⁺, but essentially no inhibition was observed without phospholipid.
7) In toxemia of pregnancy, AT-III was decreased and α₂-PI plasmin complax was increased as severity increased.
8) The amount of PCI in the placenta of toxemia was significantly increased but thrombomodulin activity was almost similar to that of normal pregnancy.

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The skin which consists of avascular epidermal tissue and vascular-rich dermal connective tissue represented a model for the study of extravascular roles of fibrinolytic enzyme system. 1) In the normal epidermis PA inhibitor was dominantly shown and this was purified to a homogenous protein. However, in hyperproliferative psoriatic epidermis, the epidermal PA inhibitor was lost, while urokinase-type PA was demonstrated. PA-PA inhibitor system is suggested to regulate proliferation, movement, attachment-detachment, and differentiation of epidermal cells. 2) In the dermal tissue, we investigated experimental granulomatous inflammation in mice. During the early stage of inflammation fibrin was deposited, which served as matrix for mononuclear cell infiltration. However PA activity which was secreted by activated macrophages was demonstrated in correlation with immunologic stimulation and organization of hypersenstivity-type granulomas. Both coagulation and fibrinolysis were shown to play a role during the development of granulomatous tissue remodellings.

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Incubation of porcine aortic endothelial cell cultures with β-D-xyloside resulted in a reduction of ¹²⁵I-antithrombin III binding to cells in parallel with the decrease in biosynthesis of radiolabeled heparan sulfate on the cell surface. Characterization of heparan sulfate revealed that neither a size nor a charge density of the molecule was altered by β-D-xyloside treatment. In the medium from xyloside-treated cultures, free chondroitin sulfate chains were markedly increased. On the other hand, incubation of endothelial cells with n-butyrate caused a significant increase in the amount of antithrombin bound to cells, while growth and morphological appearances of cells were influenced by this treatment. Incorporation of radiolabeled sulfate into glycosaminoglycans in the medium and cells from n-butyrate-treated cultures was not different from that in control. These results suggest that β-D-xyloside treatment of endothelial cells caused a dose-depandent decrease in production of cell surface heparan sulfate, which could serve as antithrombin binding sites on endothelial cells, and that n-butyrate treatment led to a qualitative rather than quantitative change in heparan sulfate, resulting in a increase in antithrombin binding to cells. Thus, altered synthesis of cell surface heparan sulfate could affect interactions of antithrombin III with endothelium.

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Coagulation-fibrinolytic and clinico-pathological investigations were performed on the autopsy cases of the acute cerebrovascular diseases. Results were as follows.
1. Thirteen cases were internal carotid (IC) occlusion treated with urokinase (UK). 1). Marked hemorrhages in the infarct with marked secondary brain stem hemorrhages were found in 2 cases which showed partial recanalization during UK administration (initial dose: 74×10⁴ IU). 2). Brain edema following infarct was marked not only in 6 out of the 7 recanalized cases, but also in 5 out of the 6 unrecanalized cases. 3). Poor collateral circulation to the occluded IC through the circle of Willis was indicated in 5 out of the 6 unrecanalized cases.
2. Forty cases were aneurysmal rupture. 1). Thirty six cases (90%) were hypertensive. 2). Coagulation studies at the time of admission revealed coagulation disorders resulting from hepatic injury in 8 cases (alcoholic: 7, hepatitis B: 1 case). 3). Disseminated intravascular coagulopathy (DIC) were found in 6 cases after severe subarachnoid hemorrhage.
3. Thirty five cases were hypertensive cerebral hemorrhage. 1). Coagulation disorders due to alcoholic hepatic injury were found most frequently in cases with brain stem hemorrhage (5 out of the 6 cases). The pathogenesis was discussed.

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Twenty-six patients with multiple myeloma, who had not recieved any previous chemotherapy, were treated with a VCAP regimen consisting of vincristine, cyclophosphamide, Adriamycin and prednisolone. This regimen was used not only for remission induction chemotherapy, but for maintenance therapy as well.
The response rate, evaluated by 50% or more reduction of M-protein, was 69% (18 of 26 patients). The median survival time was 44 months, which was longer than that reported by Alexanian. The patients in stage II survived longer than those in stage III, but the difference was not significant (p>0.05). The median survival times of the patients in stage IIIB and IIIA were 8.5 months and more than 49 months, respectively. Side effects, including leukopenia, gastrointestinal discomforts, peripheral neuropathy, and alopecia, were not serious.
These results suggest that the VCAP regimen is a useful combination chemotherapy for patients with multiple myeloma and that a maintenance therapy employing this regimen may prolong patients' survival time.

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A 70-year-old man who had T-CLL with cytotoxic phenotype accompanied by gastric cancer and thrombocytopenia was reported. The laboratory data on admission revealed leukocytosis (2.07×10⁴/mm³) with an increase in relatively mature lymphocytes (76%) and thrombocytopenia (1.9×10⁴/mm³). A surface marker analysis of peripheral lymphocytes using monoclonal antibodies demonstrated to be T cells with cytotoxic phenotype. They had no in vitro suppressor activity to immunoglobulin synthesis of normal lymphocytes nor ADCC and NK activities.
CLL has been known to have a high incidence of malignant diseases and autoimmuse ones. In our cases, CLL, gastric cancer and thrombocytopenia were simultaneously found. The reason for this may be speculated that the disturbance of the immunosurveillance due to CLL, directly or indirectly, plays a role in an increased incidence of malignant and/or autoimmune diseases.

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Four cases having acute myelomonocytic leukemia with bone marrow eosinophilia (M₄E₀) are reported.
Chromosomal analyses revealed an inversion of chromosome 16, inv (16) (p13q22), in all bone marrow cells examined. Cytologic study showed an increased percentage of eosinophils in the bone marrow with several abnormalities such as nuclear hyposegmentation, a mixture of eosinophilic and basophilic staining granules in the cytoplasm, and positivity of their granules to naphthol AS-D chloroacetate esterase and periodic acid-Schiff reactions. As inv (16) is observed in metaphases of eosinophilis, it is suggested that marrow eosinophils of M₄E₀ are part of the neoplastic process.
Eighty-two out of 93 (88%) patients with M₄E₀ in the literature, including our 4 cases, entered complete remission after treatment. It is likely that M₄E₀ is sensitive to chemotherapy. However, we suggest that much longer follow-up should be conducted to investigate for long-term survival based on the data of patients in the literature.

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A case of pure red cell aplasia (PRCA) with T-cell lymphocytosis was reported.
A 33-year-old man was admitted to our hospital, because of anemia.
Peripheral blood examination showed RBC 262×10⁴/cmm, Hb 8.6g/dl, WBC 10,700/cmm with lymphocyte 86.0%, and platelet 57.4×10⁴/cmm. Bone marrow examination revealed severe erythroid hypoplasia and 60.0% lymphocytes. The lymphocytes had large granules in cytoplasm and surface phenotypes of cytotoxic/suppressor T-cell (Tγ-cell), (E (+), T3 (+), T4 (-), T8 (+), Ia (+), Leu7 (+), IgG Fc receptor (+)).
By functional analysis, these lymphocytes displayed natural killer (NK) activity and antibody-dependent cell-mediated cytotoxicity (ADCC) activity. The diagnosis of PRCA with T-cell lymphocytosis was made.
He was successfully treated with cyclophosphamide and metenolone.
These findings suggest that T-cell-mediated inhibition of erythropoiesis is the pathogenetic mechanism of PRCA in this case.

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During the past fifteen years, we encounterd five of seventy patients with aplastic anemia who developed arterial thrombosis. The thrombotic complication in four of these patients ocurred when the platelet counts began to increase during long-term therapy with steroids or anabolic hormones. Furthermore, a retrospective study on coagulation and fibrinolysis in sixteen patients with aplastic anemia showed shortening of PTT and STT and a reduced level of ATIII. These therapies are known to induce a hypercoagulable state. Our cases suggest that arterial thrombosis develops even in patients with thrombocytopenia (2.7-7.6×10⁴/μl ) during treatment with seroids or anabolic hormones.

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We report a case of 46 year-old male of refactory anemia with excess of blasts who exhibited complex chromosomal aberrations. On admission, his hemoglobin was 6.0g/dl, platelet count 3.2×10⁴/μl and white blood cell 1.1×10³/μl with blast count of 4%. He had a normocellular bone marrow with marked dysmyelopoiesis and 11% blasts which were positive for peroxydase and naphthol ASD chloroacetate esterase and negative for α-naphtyl butylate esterase. Chromosome analysis of bone marrow revealed a mosaic pattern of normal karyotypes and abnormal ones with complex defects including 4; 11; 17 translocation and ring chromosome.

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The 3-month old boy having refractory anemia with excess of blasts (RAEB) as well as high percentage of ringed sideroblasts was reported as a possibly first child case of RAEB with ringed sideroblast in Japan.
Severe anemia (RBC 163×10⁴/μl, Hb 5.4 g/dl, Ht 16.1%, MCV 98.7 fl) and leukopenia (WBC 2,500/μl) were noticed but no erythroblasts, nor blast cells in peripheral blood smears were present. There were no hepatosplenomegaly and congenital malformations. Bone marrow smears were normocellular and its myelogram showed M/E ratio of 1.83 and 7% blasts without Auer bodies. Morphological features for myelodysplastic syndrome were apparent for granuloid (pseudo-Pelger Hüet anomaly, giant metamyelocyte, sparce specific granules), erythroid (megaloblastoid cells) and megakaryocytic (micro-megakaryocyte and giant platelet) series. Ninety nine percent of erythroblasts were sideroblasts and 23% of them were ringed sideroblasts. The patient was diagnosed to have RAEB with ringed sideroblasts (congenital form?) and received blood transfusion and vitamin B₆ treatment. The anemia was nonreactive to vitamin B₆ administration and required continued periodic red cell transfusion. Until one year-old age, his growth and development have been normal and there appears no sign of thansformation into acute leukemia.

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A 68 year-old house-wife, who had neither past nor family history of hemorrhagic diathesis, developed spontaneous bleeding of the palate in February, 1983, followed by swelling and pain in her ankle joints. She was hospitalized for this hemorrhagic diathesis in June, 1983. The laboratory data were as follows: activated partial thromboplastin time (APTT), 75 seconds; factor VIII procoaglant activity, 0%; factor VIII related antigen, 160%; von Willebrand's factor, 88%. The level of factor VIII inhibitor was remarkably high, 250 Bethesda units. A diagnosis of bleeding due to the presence of the factor VIII inhibitor was made. The inhibitor was an immunoglobulin of IgG type, which had both K and L light chain. Only 24 cases of hemorrhagic diathesis caused by spontaneous factor VIII inhibitor have been reported sofar, including this case, in Japan.
Bleeding of non-hemophilic patients with factor VIII inhibitor have usually been treated with corticosteroids, immunosuppresive agents, plasmapheresis and so on. These treatments were tried with no noticeable effect in our case. Therefore, prothrombin complex concentrages (PCC), Autoplex and Proplex, were administered to stop the bleeding. This resulted in the improvement of these symptoms, as shown by the TEG, APTT and PT values. It appears that PCC are effective in the treatment of bleeding due to a high spontaneous factor VIII inhibitor level.

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