Hemodynamic effects of double bolus reteplase versus alteplase infusion in massive pulmonary embolism.

BACKGROUND: Thrombolytic agents are given in massive pulmonary embolism to dissolve or reduce the clot and normalize hemodynamics. Comparative clinical studies have shown that administration of a 2-hour infusion of alteplase is more effective than urokinase over a 12-hour period. Reteplase is a new generation thrombolytic with a longer half-life that can be administered more conveniently as a double bolus. We compared efficacy and safety of reteplase with the approved regimen of alteplase in massive pulmonary embolism. METHODS: Thirty-six patients were enrolled and randomly assigned: 23 received reteplase and 13 received alteplase along with intravenous heparin. Reteplase was administered as 2 intravenous bolus injections of 10 U 30 minutes apart, and alteplase was administered as an intravenous infusion of a total dose of 100 mg over a 2-hour period, including an initial 10-mg bolus. Diagnosis of pulmonary embolism was confirmed by selective pulmonary angiography. Hemodynamic monitoring was conducted during the first 24 hours after administration. The primary end point was change in total pulmonary resistance. Secondary variables were pulmonary pressure, cardiac index, clinical parameters, and adverse events. RESULTS: The primary parameter of total pulmonary resistance showed a significant decrease after just 0.5 hours in the reteplase group and after 2 hours in the alteplase group, with a further decrease persisting for up to 24 hours in both treatment groups. A similar pattern was seen in other directly measured hemodynamic parameters, especially mean pulmonary artery pressure and cardiac index; there was no significant difference between reteplase and alteplase. There was also no apparent difference between the treatment groups with respect to safety, and no stroke or intracranial hemorrhage occurred. The rate of bleedings and the incidence of nonhemorrhagic adverse events were as expected for patients with pulmonary embolism treated with a thrombolytic agent. CONCLUSIONS: Reteplase is suitable for treatment of massive pulmonary embolism with a standard double bolus 10 + 10 U. Efficacy of reteplase appeared to be at least as good at decreasing pulmonary vascular resistance as that of the approved alteplase regimen of 100 mg infusion over a 2-hour period.

Neurological and neuropsychiatric dysfunction in primary Sjögren's syndrome.

In a prospective clinical investigation of 20 patients with primary Sjögren's syndrome (SS), neurological complications, not attributable to other diseases were detected in 14 patients (= 70%). Dysfunction of the peripheral nervous system (PNS) was nearly twice as frequent as central nervous system (CNS) complications. PNS involvement was dominated by symmetric sensory neuropathies, carpal tunnel syndromes, cranial nerve palsies (above all trigeminal sensory neuropathy) and pupillary dysfunction. CNS impairment was represented by cortical atrophy (n = 4), hemiparesis (n = 1) and aseptic meningitis (n = 1). Though CNS complications were rare, psychometric testing revealed diminished cognitive capacity in 14 patients. In addition to the characteristic sicca syndrome patients suffered from musculoskeletal pain and recurring abnormal sensation which frequently lead to the misdiagnosis of functional disorders. Additionally the frequent occurrence of psychiatric symptoms such as nervosity and depression support the impression of a psychosomatic pattern with no organic basis.

[Intra-arterial DSA of the hand arteries in the diagnosis of inflammatory connective tissue diseases]. / Die intraarterielle DSA der Handarterien in der Diagnostik entzündlicher Bindegewebserkrankungen.

Seventy-five patients with suspected rheumatic diseases underwent intraarterial DSA of the hand arteries. In 81% of the patients we were able to establish the diagnosis of vasculitis according to angiographic criteria. Neither clinical nor chemical or immunological features allowed the diagnosis of an inflammatory disease of joint and perivascular tissue at this time. However, histological examination and immunofluorescence microscopy confirmed the angiographic findings and showed signs of an immune complex vasculitis. A strong predictor for an abnormal angiogram of the hand arteries is the presence of Sicca's and Raynaud's Syndrome in addition to rheumatoid joint pain.

Immunoglobulin substitution therapy in a patient with primary hypogammaglobulinaemia and anti-IgA antibodies.

Permanent immunoglobulin substitution therapy was performed in a 44-year-old patient with common variable immunodeficiency, recurrent respiratory tract infections, total absence of serum IgA and a high titre of class-specific anti-IgA antibodies. An IgA-depleted i.v. immunoglobulin (IG) preparation was used. Infusions were well tolerated by the patient although minor anaphylactoid symptoms regularly occurred. Anti-IgA antibody titres rose during the first 4 months of treatment and gradually fell during the following 8 months. Regular IG substitution therapy led to a substantial improvement in the patient's health and quality of life.

Disseminated mycobacterial histiocytosis due to M. Fortuitum associated with helper T-lymphocyte immune deficiency.

Mycobacterial histiocytosis is a rare disease usually associated with haematological or immunological disorders. We report a fatal case caused by M. fortuitum infection showing the typical disseminated histiocytosis. Immunological investigations revealed impaired cellular immunity demonstrated by negative skin tests with different "recall-antigens", and in vitro an isolated defect of helper T-lymphocytes in the peripheral blood which in combination with hypergammaglobulinemia suggests a "lymphocyte and distribution syndrome".

Immunologic properties of biosynthetic human insulin in vitro.

Some immunologic properties of biosynthetic human insulin (BHI) were examined in vitro. An identical behavior was found for BHI and pancreatic human insulin as standard preparation and for A14-mono-labeled BHI and pork insulin as tracer in the insulin radioimmunoassay. BHI proved to be free of human proinsulin and C-peptide. Insulin antibodies in serum of two diabetic patients showed a preferential binding of 125I-bovine insulin. However, the antibody titers were almost identical for A14-mono-labeled BHI and pork insulin. These studies did not reveal any characteristic immunologic properties of BHI compared with highly purified pancreatic human and pork insulin.

[Clinical results with a new intravenous immunoglobulin preparation (author's transl)]. / Klinische Erfahrungen mit einem neuen intravenös applizierbaren Immunglobulin-Präparat.

A new immunoglobulin preparation (Sandoglobulin) was administered to 20 patients, a total of 49 infusions at a dose averaging 12.6 gamma-globulin per infusion. Twelve patients had congenital or acquired immunoglobulin deficiency, in come of them very severe. A In-vivo recovery, on the basis of an estimated plasma volume, averaged 85% of expected values. Half-life on repeat substitutions was over 20 days. There were no severe side-effects or changes in important biochemical values. In one woman with an antibody deficiency syndrome fever regularly developed after several infusions, but it always fell to normal spontaneously after several hours. In two women followed for some time, both with severe antibody-deficiency syndrome, there was a definite decrease in severity and frequency of pulmonary infections.

[Antibody coated bacteria in the urine: a specific test for pyelonephritis (author's transl)]. / Untersuchungen zur Spezifität des Antibody-Coated-Bacteria-Testes bei der Diagnostik bakteriell bedingter interstitieller Nephritiden.

Three groups of subjects have been studied: the first group with sterile urine, the second with significant bacteriuria without antibody-coated bacteria and the third with significant bacteriuria with antibody-coated. IgG, IgA, IgM and transferrin were determined by immunological methods (partigen plates). The antibody coating was determined by immunofluorescence. Subcultures were prepared from the urine samples containing bacteria. The bacteria obtained from the subcultures were then incubated with the original urine which had been sterilised by passing through a filter. These were then treated with AH-IgG containing fluorescein. Serum was taken from several patients and incubated with the bacteria from the subcultures. These were also treated with AH-IgG fluorescein. In no case could specific antibodies against the infecting organisms be found, although IgG in the urine were elevated and specific antibodies were present in the serum. This leads to the conclusion that specific antibodies are formed by direct tissue contact of the bacteria and that coating is not established in the urine itself.

[Epidemiological study on hepatitis morbidity in dental personnel on the model of the Erlangen university dental clinic]. / Epidemiologische Studie zur Hepatitismorbidität des zahnärztlichen Personals am Modell der Erlanger Universitäts-Kieferklinik.

1. The dentist and staff are exposed to nearly double the risk of hepatitis than the population in general. The risk of infection rises with proved contact with hepatitis patients. 2. About 60% of dental personnel suffers subclinical infections. A subclinically infected person is a source of infection for his patients. 3. The chief source of infection is blood contact. In comparisons with the practitioner with mixed dental practice, the surgically active dentist is exposed to three or four times the infection risk. 4. Serological determination of hepatitis antibodies makes it possible to demonstrate subclinical infections. 5. Consistent prophylaxis against infection is required. After proved contact with a hepatitis patient, infection can be prevented by timely treatment with hyperimmune serum.