Fibrinolytic therapy of acute cerebral infarct

On the basis of our upon own results of local intra-arterial fibrinolysis (LIF), this article gives a short overview of recently established thrombolytic therapy in acute ischemic stroke. Fifty patients with acute occlusions of vertebrobasilar arteries and 118 patients showing occlusions of branches of the internal carotid artery were treated with LIF. The Occlusion type, occlusion site and successful recanalization were associated with a favorable outcome: 92% of embolic occlusions in the vertebrobasilar territory were recanalized and resulted in 50% in a favorable outcome. In the carotid territory, optimal outcome was achieved in main stem and branch occlusions of the middle cerebral artery, due to recanalization rates of 49%-64%. In contrast, occlusions of the intracranial bifurcation of the carotid artery (carotid-"T") resulted in death in 59%. Despite the lack of randomized trials, LIF is an established form of therapy in the vertebrobasilar territory. In the carotid territory randomized clinical studies could demonstrate the efficacy of intravenous fibrinolytic therapy in some stroke patients. It can be presumed from pilot studies that LIF is superior to the intravenous version in the carotid territory.     

Fibrinolytic therapy with low-dose recombinant tissue plasminogen activator in retinal vein occlusion

In a retrospective study the outcome of patients treated by the Kapandji-Sauvé procedure was evaluated. In the period from 1989 to 1993, 18 patients were operated. The arthrodesis of the distal radioulnar joint was performed by a dorsoulnar incision using one screw. A 2 cm long segment of the ulna was resected. Indications for Kapandji-Sauvé procedures were in 12 cases deformities subsequent to wrist fractures, in three cases osteoarthrosis of the distal radioulnar joint, in two cases Madelung's deformity and in one case Kienb?ck's disease. The mean follow-up time was 5.1 years (range 3 to 7 years). There was one case of reossification, which required reoperation. No other complications were seen. An excellent result was obtained in seven patients, a good result in nine patients, one patient showed satisfactory and one poor results. Grip strength was normal in six cases, reduced up to 20% in seven cases and reduced up to 50% in five cases. 13 patients returned to their previous occupation. 12 patients showed a range of pronation-supination of more than 150 degrees. There was no correlation between X-ray findings and clinical outcome in patients.     

Acute treatment-related diarrhea during postoperative adjuvant therapy for high-risk rectal carcinoma

STUDY OBJECTIVES: To examine the main therapeutic response patterns to high doses of salbutamol and to determine the factors that contribute to outcome in acute severe asthma. SETTING: The emergency department (ED) of a large, urban hospital with primary and referral care responsibilities. PATIENTS AND DESIGN: One hundred sixteen consecutive patients with acute exacerbations of asthma were enrolled in the trial, using a prospective sequential design. INTERVENTIONS: All patients were treated with salbutamol delivered with a metered-dose inhaler into a spacer device in four puffs (400 microg) at 10-min intervals. The protocol involved 3 h of this treatment (1,200 microg each 30 min). MEASURES AND RESULTS: A dose-response increase in pulmonary function was found, but only 70% improved sufficiently to be discharged. Of these, almost 70% required < or =2.4 mg of the drug within 1 h to reach the discharge threshold, whereas the remainder 30% need > or =3.6 mg. In 30% of subjects, salbutamol was ineffective. These patients were characterized by a more severe disease as judged by previous beta2-agonist use, larger duration of attack before ED visit, and a more severe obstruction at presentation. However, the most important predictors of outcome were peak expiratory flow rate (PEFR) as percent of predicted, PEFR as liters per minute, and PEFR variation over baseline value, all at 30 min. CONCLUSIONS: This study described two different therapeutic response patterns to salbutamol. Almost 70% of patients were sensitive to salbutamol (good response pattern), and in this group, 2.4 to 3.6 mg represents optimal treatment. In the remainder 30% of patients (poor response pattern), salbutamol in high doses had little effect. However, the outcome was not determined by the intensity of the initial symptoms or by the value of the presenting PEFR, but rather by the early (30 min) short-term response to treatment.     

Management and therapy of postoperative complications after "gastric banding" for morbid obesity

Laparoscopic gastric banding has become a common procedure in bariatric surgery. Early as well as late complications are, in comparison to conventional techniques, rare. Complications arising from the operative technique are: perforation, early pouch dilatation, gastric slippage, infections of the port and the band, erosion and defects of the band tube. Insufficient weight loss and late pouch dilatation arise from unsatisfactory compliance on the part of the patient. In 7.5% of 146 cases, reoperations were necessary. Obstruction of the pouch stoma and a slippage resulted in total food intolerance. After radiologic diagnosis the band system should be deflated first and a naso-gastric tube applied. If this does not result in the pouch collapsing, a revision operation is needed.     

Percutaneous ethanol injection therapy for the treatment of postoperative recurrent primary liver cancer

This article reported 109 cases of postoperative recurrent primary liver cancer, treated with percutaneous ethanol injection therapy (PEIT) under the guidance of conventional ultrasonic transducer, the total number of injection being 637 times. No metastasis through the needle track or other serious complications were encountered. The 1.3 and 5 year survival rates were 92.6%, 47.8%, and 19%, respectively. We noted that the key factor affecting the efficacy of treatment was the accurate localization of puncture, rather than the times of injection or the quantity of ethanol injected. Criteria for the judgement of treatment and precautions to be noted concerning the procedure were suggested. It is concluded that PEIT is the treatment of choice in the management of non-operable, single, and comparativly smalle focus of postoperative recurrent primary liver cancer.     

Interscalene brachial plexus catheter for anesthesia and postoperative pain therapy. Experience with a modified technique

OBJECTIVES: This study was conducted to evaluate a modified technique of interskalene brachial plexus anaesthesia (ISB) and postoperative catheter analgesia for shoulder surgery. The original method described by Winnie bears some rare but life-threatening complications (inadvertent subarachnoid or intra-arterial injection, pneumothorax). MATERIALS AND METHODS: Ninety-one patients with chronic rheumatoid arthritis who were scheduled for open or closed shoulder surgery received a modified ISB with catheter insertion. The injection site was more cephalad than that described by Winnie and the cannula was directed towards the junction between the medial and lateral third of the clavicle. Intra- and postoperative management, complications, and patients' satisfaction were recorded and evaluated. RESULTS: Implementation of ISB was possible in all cases, however, 3% of these presented technical problems. Anaesthesia with 300 mg mepivacaine 1% was successful in 94% of patients without and in 96% with augmentation after an average of 32 min; 10% of the patients suffered a drop in blood pressure after being placed in the beach-chair position for surgery. Postoperatively, all patients received 20 ml bupivacaine 0.25% for pain management via the catheter; 11% needed an additional analgesic drug. The catheter was removed after an average of 5 days. Signs of superficial local infection were noticed in 8 cases. Side effects occurred in 13% as Horner's syndrome, in 6.5% as recurrent laryngeal nerve block, and in 3.3% as phrenic nerve block. The acceptance of this anaesthetic technique among the patients was very high (96.7%). CONCLUSION: We consider the modified ISB with catheter a safe and effective procedure for anaesthesia and postoperative pain management of open and closed shoulder surgery.     

Fibrinolytic components in nasal mucosa and nasal secretion

Effects of a newly synthesized antiulcer agent, YJA20379-4, on gastric proton pump (H+/K+-ATPase) activity, Helicobacter pylori (H. pylori) growth, gastric acid secretion, and gastro-duodenal lesions, were examined in comparison with those of omeprazole. YJA20379-4 markedly inhibited the H+/K+-ATPase activity in a concentration-dependent manner and the inhibitory effect was increased under a weak acidic condition; the IC50 values were 32 and 81 microM at pH 6.4 and 7.4, respectively. The inhibition was completely antagonized by 0.5 mM dithiothreitol (DTT). In addition, YJA20379-4 showed a significant anti-H. pylori activity determined by the agar dilution method. The value of minimum inhibitory concentration (MIC, 3.9-11.7 microg/ml) was at least 3 times more potent than that of omeprazole. In pylorus ligated rats, YJA20379-4 inhibited basal gastric acid secretion when administered by the intraduodenal route (ED50: 23.6 mg/kg). In experimental ulcer models, YJA20379-4 administered by the oral route dose-dependently prevented the development of gastro-duodenal lesions in rats. Moreover, repeated administration of YJA20379-4 promoted the healing of gastric ulcers induced by acetic acid. On the basis of the data obtained, it is suggested that YJA20379-4 has a wide spectrum of antiulcer activities, and its mode of antiulcer actions is dependent on the inhibition of H+/K+-ATPase activity and H. pylori growth and the enhancement of a mucosal defense. Thus, YJA20379-4 might prove to be a beneficial therapy for gastritis and peptic ulcer diseases.     

Fibrinolytic components in fetal membranes and amniotic fluid

OBJECTIVE: We evaluated fibrinolytic components in plasma and amniotic fluid of pregnant women and in postpartum fetal membranes. STUDY DESIGN: Fibrinolytic parameters in amniotic fluid and plasma were measured by means of enzyme-linked immunosorbent assays. Fetal membranes collected after spontaneous labor at term were analyzed by immunohistochemical methods with immunospecific antibodies against fibrinolytic components. RESULTS: Amniotic fluid contained high plasminogen activator inhibitor-1 concentrations but had low activity. Strong staining for plasminogen activator inhibitor-1 and vitronectin was observed in chorionic trophoblasts and moderate staining in decidual connective tissue. Strong staining for plasminogen activator inhibitor-2 was seen in decidual cells. Although prominent staining of plasminogen activators and plasminogen were observed in the amniotic epithelium, virtually no plasminogen activator inhibitor-1, plasminogen activator inhibitor-2, or alpha 2-plasmin inhibitor staining was detected. CONCLUSION: The delicate balance of fibrinolytic activators and inhibitors in fetal membranes and amniotic fluid may contribute to the triggering of membrane rupture at term.     

Ozone therapy of diffuse peritonitis in the early postoperative period

The functional status of the oxidative-antioxidative system was studied in 72 patients after vast cancer operations. Traditional surgical treatment and its combination with intraoperative irradiation were shown to lead to tense antioxidative defense and to suppressed T-cell immunity and to call for antioxidative and immunomodulating therapy. High intraoperative blood loss complicated by hemorrhagic shock injured the oxidative-antioxidative system greatly. The magnitude of this damage correlated with the rate of prehypoxia. Addition of the potent antioxidant Ceruloplasmin to the drug regimen normalized a recovery period, helped to correct posthypoxic multiorgan insufficiency, to recover oxidative-antioxidative balance, and to decrease the incidence of pyoinflammatory complications. Patients with endogenous intoxication showed activated lipid peroxidation, decreased functional activity of antioxidative defense components and of T-cell immunity in homeostasis. The use of Ceruloplasmin and Laprot had pronounced antiinflammatory and detoxifying effects on the patient's body and activated its antioxidative defense.     

The mediastinum and hemothorax, pyothorax, and pneumothorax in the dog

Contrary to the reported clinical, anatomic, and histologic evidence of communication between the 2 pleural cavities through the mediastinum in the dog, it was found that acute or chronic pathologic processes in one pleural cavity remained confined to that cavity unless the mediastinum was mechanically injured. These results were obtained in a series of experiments involving 39 dogs in which hemothorax or pyothorax or pneumothorax was unintentionally induced.     

Phase III randomized trial of surgery with or without intraoperative photodynamic therapy and postoperative immunochemotherapy for malignant pleural mesothelioma

BACKGROUND: Patients with malignant pleural mesothelioma (MPM) usually die of progressive local disease. This report describes the results of a Phase III trial comparing maximum debulking surgery and postoperative cisplatin, interferon alpha-2b, and tamoxifen (CIT) immunochemotherapy with and without intraoperative photodynamic therapy (PDT) to determine (1) whether such a multimodal approach can be performed with minimum morbidity and mortality in malignant pleural mesothelioma (MPM), and (2) whether first-generation (i.e., 630-nm laser light, Photofrin II) intrapleural PDT impacts on local recurrence of survival. METHODS: From July 1993 to June 1996, 63 patients with localized MPM were randomized to either PDT or no PDT. The tumors of 15 patients could not be debulked to 5 mm. Patients assigned to PDT (n = 25) and no PDT (n = 23) were similar with respect to age, sex, tumor volume, and histology. RESULTS: The type of resection (11 pleurectomies and 14 pneumonectomies vs. 12 pleurectomies and 11 pneumonectomies), length postoperative stay, and ICU time were comparable (PDT vs. no PDT). There was one operative death (hemorrhage), and each group had two bronchopleural fistulas. Postoperative staging divided patients into the following categories: stage I: PDT, 2, no PDT, 2; stage II: PDT, 2, no PDT, 2; stage III, PDT, 21; no PDT, 17; stage IV, PDT, 0; no PDT, 2. Comparable numbers of CIT cycles were delivered. Median survival for the 15 non-debulked patients was 7.2 months, compared to 14 months for the 48 patients on protocol. There were no differences in median survival (14.4 vs. 14.1 months) or median progression-free time (8.5 vs. 7.7 months), and sites of first recurrence were similar. CONCLUSIONS: Aggressive multimodal therapy can be delivered for patients with higher stage MPM. First-generation PDT does not prolong survival or increase local control for MPM.     

Fibrinolytic response in subjects with hypertriglyceridemia and low HDL cholesterol

The combination of hypertriglyceridemia and low high-density lipoprotein cholesterol (HDL-C) appears to be an excessively high risk factor for coronary artery disease (CAD). In the Helsinki study, both coronary events and mortality were decreased by gemfibrozil, especially in subjects with low HDL-C and high triglycerides (TG). On the other hand, it is known that high levels of TG can be associated with high levels of circulating plasminogen activator inhibitor (PAI), which is also a possible risk factor for CAD. The aim of the present study was to see: 1) whether the combination of low HDL-C and high TG is associated with a more impaired fibrinolytic response than in either isolated condition, and 2) whether gemfibrozil administration can improve fibrinolysis in patients with both high TG and low HDL-C. Twelve non-obese, non-diabetic subjects (eight men, four women; mean age 55 +/- 13 yrs) with low HDL-C (< 35 mg/dL men; < 45 mg/dL women) and high TG (mean 253.6 +/- 42.6 mg/dL) entered the study (Group A). Additionally fourteen comparable subjects with normal HDL-C were also investigated (Group B), plus 12 comparable subjects with isolated low HDL-C (Group C). Ten healthy people served as the control group. The following plasma fibrinolytic parameters were measured: tissue plasminogen activator antigen, PAI antigen and activity, euglobulin fibrinolytic activity (EFA) on fibrin plates, plasminogen and alpha-2-antiplasmin activities. All except the latter two values were also measured after venous occlusion (vo). In baseline conditions, patients in Groups A and B had higher EFA values before vo and higher PAI-1 antigen and alpha-2-antiplasmin levels after vo than those of controls or the subjects in Group C. The relationship between PAI antigen and PAI activity and TG was not confirmed in our population (n = 48). We also saw no interference due to HDL-C, while there was a significant relationship between EFA before vo and both TG and cholesterol. After gemfibrozil treatment (600 mg bid for 12 weeks), the lipid profiles of subjects with high TG and low HDL-C were significantly improved. There was also a slight reduction of PAI activity after vo, while the PAI-1 antigen had decreased significantly from baseline after vo (56.3 +/- 13 ng/mL before vo; 48.4 +/- 21 ng/mL after vo; P = 0.04). The higher risk of CAD in patients with low HDL-C and high TG might be in part related to impairment of fibrinolysis, which occurs in patients with isolated high TG. The close relationship existing between both TG and cholesterol levels and fibrinolytic activity confirm the key role of this latter process in the development of CAD.     

Improved outcome in patients treated with postoperative radiation therapy for pathologic stage I/II endometrial cancer

OEE33, a component of the oxygen-evolving enzyme in chloroplasts, normally resides in the thylakoid lumen. In an attempt to study the fate of mistargeted proteins in chloroplasts, we substituted the bipartite transit peptide of OEE33 with that of CAB7, an integral thylakoid-membrane protein. As a result, when imported into isolated chloroplasts, the chimeric protein protein was targeted to the stroma instead of the thylakoid lumen. Whereas the wild-type OEE33 was totally stable for at least 2 h, the chimeric protein was rapidly degraded, with a half-life of 60 min. Degradation of the chimeric protein was stimulated by ATP supplementation. Degradation could also be observed in lysed chloroplasts, in an ATP-stimulated manner. When lysates were fractionated, the proteolytic activity was found to be associated mainly with the stromal fraction. This activity was very effectively inhibited by all tested inhibitors of serine proteases. Western blot analysis demonstrated that the stromal fraction active in degrading the chimeric OEE33 contains ClpC and ClpP, homologues of the regulatory and proteolytic subunits, respectively, of the bacterial, ATP-dependent, serine-type Clp protease.     

Preoperative and postoperative colonoscopy for colorectal carcinoma

A patient with documented ZE syndrome responded to intravenous magnesium infusion by increased gastric acid output and increased serum gastrin concentration. A patient with acid hypersecretion but no gastrinoma had no substantial alteration in acid output or serum gastrin concentration following magnesium administration. This suggests that magnesium caused gastrin to be released from a gastrinoma.     

Interaction between Tb 3 and Fibrinolytic Principle from Agkistrodon Acutus Venom

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Are they getting enough? Meeting the oxygen therapy needs of postoperative patients

Many patients require oxygen therapy as part of their postoperative care. A study to assess whether patients were actually given the supplementary oxygen prescribed showed many received only intermittent therapy. Placing more emphasis on oxygen therapy in nurse education would do much to improve its use in practice.