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It is safe to withhold anticoagulation in outpatients suspected of having first-episode deep venous thrombosis if results of simplified compression ultrasonography are normal at presentation and on a single repeated test done 5 to 7 days later.

Purpose: Fibroblast Activation Protein (FAP) is a tumor fibroblast protease that has been shown to potentiate colorectal cancer growth. The clinical impact of FAP inhibition was tested using Val-boroPro (Talabostat), the first clinical inhibitor of FAP enzymatic activity, in a phase II study of patients with metastatic colorectal cancer.Methods: Patients with metastatic colorectal cancer who had previously received systemic chemotherapies were treated with single agent Val-boroPro 200 μg p.o. BID continuously. Eligibility included measurable disease, performance status of 0 to 2, and adequate organ function. Laboratory correlates evaluated the pharmacodynamic effects of Val-boroPro on FAP enzymatic function in the peripheral blood.Results: Twenty-eight patients (median age 62; 12 males, 16 females) were enrolled in this study. There were no objective responses. Six of 28 (21%) patients had stable disease for a median of 25 weeks (range 11-38 weeks). Laboratory analysis demonstrated significant, although incomplete inhibition of FAP enzymatic activity in the peripheral blood.Conclusion: This phase II trial of Val-boroPro demonstrated minimal clinical activity in patients with previously treated metastatic colorectal cancer. However it provides the initial proof-of-concept that physiologic inhibition of FAP activity can be accomplished in patients with colorectal cancer, and lays the groundwork for future studies targeting the tumor stroma.

Human ␣ 2 -antiplasmin (␣ 2 AP), also known as ␣ 2 -plasmin inhibitor, is the major inhibitor of the proteolytic enzyme plasmin that digests fibrin. There are 2 N-terminal forms of ␣ 2 AP that circulate in human plasma: a 464-residue protein with Met as the N-terminus, Met-␣ 2 AP, and a 452-residue version with Asn as the N-terminus, Asn-␣ 2 AP. We have discovered and purified a proteinase from human plasma that cleaves the Pro12-Asn13 bond of Met-␣ 2 AP to yield Asn-␣ 2 AP and have named it antiplasmin-cleaving enzyme (APCE). APCE is similar in primary structure and catalytic properties to membranebound fibroblast activation protein/seprase for which a physiologic substrate has not been clearly defined. We found that Asn-␣ 2 AP becomes cross-linked to fibrin by activated factor XIII approximately 13 times faster than native Met-␣ 2 AP during clot formation and that clot lysis rates are slowed in direct proportion to the ratio of Asn-␣ 2 AP to Met-␣ 2 AP in human plasma. We conclude that APCE cleaves Met-␣ 2 AP to the derivative Asn-␣ 2 AP, which is more efficiently incorporated into fibrin and consequently makes it strikingly resistant to plasmin digestion. APCE may represent a new target for pharmacologic inhibition, since less generation and incorporation of Asn-␣ 2 AP could result in a more rapid removal of fibrin by plasmin during atherogenesis, thrombosis, and inflammatory states. IntroductionHuman ␣ 2 -antiplasmin (␣ 2 AP), also known as ␣ 2 -plasmin inhibitor, is the main inhibitor of plasmin. 1 Plasmin plays a critical role in fibrin proteolysis and tissue remodeling. The physiologic relevance of plasmin inhibition by ␣ 2 AP to blood clotting and fibrinolytic homeostasis is supported by the following observations: (1) the rate of free plasmin inactivation by circulating ␣ 2 AP is much faster than fibrin(ogen) digestion by plasmin, 2 thereby eliminating the possibility of a systemic lytic state and consequent bleeding; (2) ␣ 2 AP is cross-linked to forming fibrin by activated blood clotting factor XIII (FXIIIa) and inhibits plasmin-mediated lysis in direct proportion to the amount incorporated 3-5 ; and (3) patients with homozygous ␣ 2 AP deficiency manifest serious hemorrhagic tendencies, while heterozygotes tend to bleed only after major trauma or surgery. 6 Human ␣ 2 AP is synthesized primarily in the liver, and during circulation in plasma, the secreted precursive Met-␣ 2 AP form, a 464-residue protein having Met as the N-terminus, undergoes proteolytic cleavage between Pro12 and Asn13 to yield Asn-␣ 2 AP, a 452-residue version with Asn as the N-terminus. 7 Met-␣ 2 AP accounts for approximately 30% of circulating ␣ 2 AP, and Asn-␣ 2 AP, approximately 70%. 7,8 While 3-fold more Asn-␣ 2 AP than recombinant Met-␣ 2 AP was shown to cross-link to fibrin, 9 no data have been reported for native circulating Met-␣ 2 AP. Moreover, the effect of different ratios of the 2 ␣ 2 AP forms on clot lysis has not been reported. Finally, the enzyme responsible for converting Met-␣ 2 AP to Asn-␣ 2 AP has not been ident...

Using electron microscopy, we have visualized the substructure of human von Willebrand factor (vWf) purified by two different approaches. vWf multimers, which appear as flexible strands varying in length up to 2 £m, consist of dimeric units (protomers) polymerized linearly in an end-to-end fashion through disulfide bonds. Examination of small multimers (erg., one-mers, two-mers, and three-niers) suggests that each protomer consists of two large globular end domains (22 X 6.5 nm) connected to a small central node (6.4 X 3.4 nm) by two flexible rod domains each -34 nm long and -2 nm in diameter. The protomer is 120 nm in length when fully extended. These same structural features are seen both in vWf molecules that were rapidly purified from fresh plasma by a new two-step procedure and in those purified from lyophilized intermediate-purity Factor VIII/vWf concentrates. The 240,000-mol wt subunit observed by gel electrophoresis upon complete reduction of vWf apparently contains both a rod domain and a globular domain and corresponds to one half of the protomer. Two subunits are disulfide-linked, probably near their carboxyl termini, to form the protomer, disulfide bonds in the amino-terminal globular ends link protomers to form vWf multimers. The vWf multimer strands have at least two morphologically distinct types of ends, which may result from proteolytic cleavage in the globular domains after formation of large linear polymers. In addition to releasing fragments that were similar in size and shape to the repeating protomeric unit, plasmic degradation of either preparation of vWf reduced the size of multimers, but had no detectable effect on the substructure of internal protomers.