Präoperative Identifikation von Patienten mit (primären) Hämostasestörungen

Wir präsentieren eine große prospektive Untersuchung, in der vor großen elektiven operativen Eingriffen nach Hämostasestörungen ein Screening erfolgte. 5649 erwachsene, nicht selektierte Patienten (2631 Frauen, 3018 Männer) wurden über ein Jahr im Universitätsklinikum Charité untersucht. Ein standardisierter Fragebogen mit 12 Fragen wurde benutzt. Des Weiteren wurden die plasmatischen Routinegerinnungstests (aPTT, PT) mit der Thrombozytenzählung und die In-vitro-Verschlusszeiten (PFA 100: Kollagen- Epinephrin, Kollagen-ADP) gemessen. Wenn die Blutungsanamnese positiv (eine Frage positiv beantwortet) war, wurden folgende Screening-Tests zusätzlich durchgeführt: In-vivo-Blutungszeit (Surgicutt), von-Willebrand- Faktor (VWF : Ag, VWF : Rcof) und weiterführende hämostaseologische Differenzialdiagnostik. Ergebnisse: Die Blutungsanamnese war negativ bei 5021 Patienten (88,8%) und positiv bzw. enthielt einen Hinweis auf Medikamente, die eine Hämostasestörung induzieren können, bei 628 Patienten (11,2%). Hämostasestörungen wurden bei 256 (40,8%) in dieser letzten Patientengruppe gefunden. Die meisten der Patienten mit Hämostasestörungen wurden mit dem PFA-100: C/E (n=250; 97,7%) identifiziert. Die Sensitivität des PFA-100: Kollagen-Epinephrin war am höchsten (90,8%) im Vergleich zu anderen Screeningtests (BT, aPTT, PT, VWF : Ag). Der positive Vorhersagewert (zu Erkennung von Hämostasestörungen) des PFA-100: Kollagen- Epinephrin mit der standardisierten Blutungsanamnese war hoch (82%), aber der negative war mit 93% höher. Schlussfolgerungen: Primäre Hämostasestörungen treten häufiger als plasmatische Hämostasestörungen auf. Ein standardisierter Fragebogen zur Blutungsanamnese und, sofern indiziert, der PFA-100: Kollagen-Epinephrin und/ oder weitere spezifische Tests können zu einer signifikanten Reduktion der Kosten bei einer hohen Identifikationssrate von vorwiegend primären Hämostasestörungen führen. Nationale Empfehlungen sind bereits formuliert.

Risikoschwangerschaften und deren Therapie

Recurrent abortions are a common problem. A therapy with low-molecular-weight heparin is usual in deep vein thrombosis with thrombophilia, in woman with recurrent abortions or other risks, like EPH-gestosis or HELLP-Syndrom. Patients, method: The efficacy of a mono-therapy with LMWH (3000–16 000 daily) in women with risk pregnancies has been examined prospectively. The dates of 676 pregnant women have been analysed and compared to the current literature about live birth rates without therapy and tot he results of other, similar studies. The live birth rate has been the target variable. Results: We obtained main a live birth rate of 98.6%.There has been no record of serious adverse effects. We obtained a live birth rate of 95.8% if NMH therapy starts early, and a live birth rate of 100% if NMH therapy starts between week 20 and 25. For the live birth rate the existence of thrombophilic gene polymorphisms is irrelevant. Conclusion: The high live birth weight is depended on early starting the therapy with NMH. For the late risk it is favourable to start the therapy with heparin between week 20 and 25 week of pregnancy.

Therapeutischer Nutzen von niedermolekularem Heparin bei Frauen mit rezidivierenden Aborten

Rezidivierende Aborte sind leider häufig. Möglicherweise hilft eine Therapie mit niedermolekularem Heparin (NMH), eine weitere Schwangerschaft erfolgreich auszutragen. Bei Frauen mit rezidivierenden Aborten werden eine systemische, inflammatorische Immunantwort und vermehrt vaskuläre Thrombosen in der Plazenta nachgewiesen. Weil Heparine sowohl eine antikoagulatorische als auch eine antiinflammatorische Komponente besitzen, untersuchten wir die Wirksamkeit einer Thera-pie mit NMH.

Patienten und Methode: Die Wirksamkeit einer Monotherapie mit NMH (5 000 I.E. täglich) bei Frauen mit mindestens zwei Frühaborten oder einem Spätabort in der Anamnese wurde retrospektiv untersucht. Dazu wur-den die Daten von 147 Schwangerschaften ausgewertet. Zielvariable war die Lebendgeburtenrate. Zudem wurde untersucht, ob bestimmte Faktoren die Wahrscheinlichkeit eines Abortes erhöhen.

Ergebnisse: Es wurde eine Lebendgeburtenrate von 86,4 % erreicht. Es sind keine schwer- wiegenden Nebenwirkungen des Heparins aufgetreten. Als Risikofaktoren, trotz Therapie einen Abort zu erleiden, fanden wir eine im ers-ten Trimenon erhöhte Protein S-Aktivität und eine erniedrigte Faktor VIII-Aktivität sowie einen aktiven Nikotinabusus.

Schlussfolgerung: Es wurde eine Lebendgeburtenrate erreicht (86,4 %), die der von gesunden Frauen (87,2 %) entspricht. Dabei ist es unwesentlich, ob die Frauen Träger thrombophiler Genpolymorphismen sind oder nicht. Trotz einer Therapie mit NMH stellen aktiver Nikotinabusus und fehlende schwangerschaftstypische Veränderungen der Gerinnung, Risikofaktoren für einen Abort dar. Wir empfehlen diese Werte in Risikoschwangerschaften zu kontrollieren.

[Protein Z deficiency in unexplained affinity to thromboses, bleedings or abortions]

A protein Z deficiency is presumably related with a threefold risk of venous and arterial thrombosis. Mucosal bleedings and post-operative haematomas can occur more frequently. This is seen in an increased in vivo bleeding time without other plasmatic coagulation disorders or thrombopathies. Pregnancy complications, especially abortions before the 15th week of gestation, are described as well.

PATIENTS, METHODS

Since May 2011 the plasmatic concentration of protein Z has been tested in 684 patients of the Hämostaseologicum.

RESULTS

In 74 patients a protein Z deficiency has been found. In other 45 patients protein Z was reduced because of the intake of phenprocoumon or coumadin. Of the 74 patients with diminished protein Z concentration 39 were marginally decreased (protein Z 1000-1500 µg/l). Of the 35 patients with a protein Z concentration <1000 µg/l 12 had had a thrombosis before (6 strokes, 3 DVT or PE, 1 arterial thrombosis, 1 retinal branch vein occlusion, 1 acute hearing loss). 7 had arterial hypertension, 2 suffered from diabetes mellitus. Of the patients who had a thrombosis 6 had a heterozygous factor V Leiden mutation. 10 had a microcirculation disorder (Raynaud's phenomenon), 4 had had bleeding complications before, 3 had a von Willebrand disease type I, 6 patients had had abortions and 4 were healthy. Of the 39 patients with protein Z concentrations between 1000 and 1500 µg/l 18 had experienced a thrombosis before (9 DVT or PE, 3 myocardial infarctions, 1 CHD, 3 strokes, 1 retinal branch vein occlusion, 1 PAOD I, 1 tinnitus). 5 additionally had arterial hypertension. 13 suffered from Raynaud's phenomenon, of which 7 had a hypotension. Of the patients with thromboses 3 had a heterozygous factor V Leiden mutation and one a protein C deficiency. 7 patients had had an abortion before. Bleeding complications were seen in 4 patients, of which 3 suffered from von Willebrand disease type 1.

Protein-Z-Mangel bei ungeklärter Neigung zu Thrombosen, Blutungen oder Aborten

A protein Z deficiency is presumably related with a threefold risk of venous and arterial thrombosis. Mucosal bleedings and post-operative haematomas can occur more frequently. This is seen in an increased in vivo bleeding time without other plasmatic coagulation disorders or thrombopathies. Pregnancy complications, especially abortions before the 15th week of gestation, are described as well. Patients, methods: Since May 2011 the plasmatic concentration of protein Z has been tested in 684 patients of the Hämostaseologicum. Results: In 74 patients a protein Z deficiency has been found. In other 45 patients protein Z was reduced because of the intake of phenprocoumon or coumadin. Of the 74 patients with diminished protein Z concentration 39 were marginally decreased (protein Z 1000–1500 μg/l). Of the 35 patients with a protein Z concentration <1000 μg/l 12 had had a thrombosis before (6 strokes, 3 DVT or PE, 1 arterial thrombosis, 1 retinal branch vein occlusion, 1 acute hearing loss). 7 had arterial hypertension, 2 suffered from diabetes mellitus. Of the patients who had a thrombosis 6 had a heterozygous factor V Leiden mutation. 10 had a microcirculation disorder (Raynaud’s phenomenon), 4 had had bleeding complications before, 3 had a von Willebrand disease type I, 6 patients had had abortions and 4 were healthy. Of the 39 patients with protein Z concentrations between 1000 and 1500 μg/l 18 had experienced a thrombosis before (9 DVT or PE, 3 myocardial infarctions, 1 CHD, 3 strokes, 1 retinal branch vein occlusion, 1 PAOD I, 1 tinnitus). 5 additionally had arterial hypertension. 13 suffered from Raynaud’s phenomenon, of which 7 had a hypotension. Of the patients with thromboses 3 had a heterozygous factor V Leiden mutation and one a protein C deficiency. 7 patients had had an abortion before. Bleeding complications were seen in 4 patients, of which 3 suffered from von Willebrand disease type 1.

[Risk pregnancies and how to treat them]

Recurrent abortions are a common problem. A therapy with low-molecular- weight heparin is usual in deep vein thrombosis with thrombophilia, in woman with recurrent abortions or other risks, like EPH-gestosis or HELLP-Syndrom.

PATIENTS, METHOD

The efficacy of a mono-therapy with LMWH (3000-16000 daily) in women with risk pregnancies has been examined prospectively. The dates of 676 pregnant women have been analysed and compared to the current literature about live birth rates without therapy and tot he results of other, similar studies. The live birth rate has been the target variable.

RESULTS

We obtained main a live birth rate of 98.6%. There has been no record of serious adverse effects. We obtained a live birth rate of 95.8% if NMH therapy starts early, and a live birth rate of 100% if NMH therapy starts between week 20 and 25. For the live birth rate the existence of thrombophilic gene polymorphisms is irrelevant.

CONCLUSION

The high live birth weight is depended on early starting the therapy with NMH. For the late risk it is favourable to start the therapy with heparin between week 20 and 25 week of pregnancy.

Influence of blood donation on levels of water-soluble vitamins

Iron depletion is a well-known side effect of blood donation. Research evidence also suggests an increasing prevalence of vitamin deficiency in apparently healthy subjects, but there is little information regarding the relationship between blood donation and vitamin status. A total of 217 volunteers (80 first-time and 137 repeat blood donors) were consecutively enrolled in the study. All subjects completed self-administered medical history and food intake forms, which included questions regarding alcohol consumption and smoking as well as on vitamin supplement, iron and contraceptive use (females). Vitamin B6, folic acid, vitamin B12 and biotin levels were measured using standard techniques. The mean vitamin levels of first-time and repeat blood donors did not significantly differ. Vitamin deficiencies occurred in both first-time and repeat blood donors but not on vitamin supplements. Vitamin status was affected by alcohol, nicotine and contraceptives. Blood donation does not decrease the level of water-soluble vitamins. Vitamin deficiencies occur in apparently healthy first-time as well as in repeat blood donors and can be prevented by vitamin supplementation.

[Preoperative identification of patients with impaired (primary) haemostasis. A practical concept]

The findings of a large prospective study designed to identify primary and/or secondary haemostatic disorders before surgical interventions are presented. A total of 5649 unselected adult patients were enrolled to identify impaired haemostasis before surgical interventions. Each patient was asked to answer a standardized questionnaire concerning bleeding history. Activated partial thromboplastin time (aPTT), prothrombin time (PT), and platelet counts (PC) including PFA-100 (platelet function analyzer): collagen-epinephrine (C/E), and collagen-ADP (C/ADP) were routinely done in all patients. Additional tests, bleeding time (BT), von Willebrand factor (VWF:Ag, VWF:Rcof) and a further haemostaseological diagnostic was performed only in patients with a positive bleeding history and/or evidence of impaired haemostasis; e.g., drug ingestion. The bleeding history was negative in 5021 patients (88.8%) but positive in the remaining 628 (11.2%). Impaired haemostasis could be verified only in 256 (40.8%) of these patients. The vast majority was identified with PFA-100: C/E (n = 250; 97.7%). The sensitivity of the PFA-100: collagen-epinephrine was the highest (90.8%) in comparison to the other screening tests (BT, aPTT, PT, VWF : Ag). The positive predictive value (to detection of impaired haemostasis) of the PFA-100: collagen-epinephrine with the standardized questionnaire was high (82%), but the negative predictive value was higher (93%). The use of a standardized questionnaire and, if indicated, the PFA-100: C/E and/or other specific tests not only ensure the detection of impaired haemostasis in almost every case but also a significant reduction of the costs. Based on these data, national regards are formulated or under construction.

Therapie der tiefen Beinvenenthrombose mit Dalteparin

Ziel: Untersuchung des Laborwertverlaufes und des individuellen Wirksamkeitsnachweises bei ambulanter Therapie tiefer Beinvenenthrombosen mit Dalteparin. Patienten, Material, Methoden: Wir behandelten ambulant 10 Patienten mit einer frischen TVT täglich mit 2 × 100 IE Dalteparin (Fragmin®)/kg Körpergewicht abweichend von den Leitlinien für die Dauer von 14 Tagen durch subkutane Selbstinjektion. Ergebnisse: Die HepZeit (Anti-FXa-Aktivität) lag bei 9/10 Patienten innerhalb und bei einem Patienten unterhalb des therapeutischen Bereichs. Die D-Dimere bildeten sich unter der Antikoagulationsbehandlung vollständig zurück. Die Thrombusgröße änderte sich im Beobachtungszeitraum nicht. Schlussfolgerung: Die ambulante Therapie ist eine sichere, wirksame und ökonomisch überlegene Alternative zur stationären Therapie. Die D-Dimere erwiesen sich als aussagefähiger Verlaufsparameter.

Validation of the sterilization procedure of allogeneic avital bone transplants using peracetic acid-ethanol

Different procedures are available to inactivate bacteria and fungi, including their spores, as well as viruses in human bone transplants. The most efficient methods are considered to be gamma irradiation and thermal inactivation as well as chemical sterilization methods like the peracetic acid-ethanol treatment (PES). Following national and international standards or draft standards, the antimicrobial effectiveness of this procedure was evaluated. Due to the standardizable size as well as the clinical relevance, defatted human spongiosa cuboids (15x15x15 mm) served as model system. After treatment with PES for 2 and 4 hours, respectively, the titre of living micro-organisms was determined in the supernatant and the cuboid. A reduction in the titre of viable micro-organisms below the detection level (reduction factor >5 log10) was already achieved after an incubation time of 2 hours (Staphylococcus aureus, Enterococcus faecium, Pseudomonas aeruginosa, Bacillus subtilis, Clostridium sporogenes, Mycobacterium terrae, Candida albicans as well as spores of Bacillus subtilis). No viable micro-organisms could be detected in any of the PES-treated test cuboids. Spores of Aspergillus niger were also completely inactivated. The PES procedure proved to be a reliable method for the sterilization of human bone transplants derived from spongiosa.

Cardiac death after autologous stem cell transplantation (ASCT) for treatment of systemic sclerosis (SSc): no evidence for cyclophosphamide-induced cardiomyopathy

In patients with systemic sclerosis (SSc) treatment-related mortality after autologous stem cell transplantation (ASCT) appears to be increased as compared to patients with hematological malignancies. In our phase I/II study on ASCT in autoimmune diseases a patient with SSc died on day 2 after ASCT. Here we report the results of the autopsy which revealed advanced pulmonary and cardiac fibrosis as the most probable cause of death. In spite of detailed technical examination before enrollment, the cardiopulmonary function tests did not reflect the advanced stage of the disease. We conclude that in selected patients with SSc, biopsies should be performed to reduce mortality after ASCT.

Effects of an onion-olive oil maceration product containing essential ingredients of the Mediterranean diet on blood pressure and blood fluidity

Twenty-four patients with arterial hypertension (WHO class I) received either 4 capsules of an onion-olive oil maceration product, containing essential ingredients of the Mediterranean diet, or placebo daily over a period of one week. In order to investigate the acute effect on arterial blood pressure, measurements were performed before and 5 h after the administration of the first dose of 4 capsules verum or placebo, respectively. For the evaluation of the long term effect further blood pressure measurements were performed after one week's treatment with a daily dose of 4 capsules. After a wash-out phase of 2 weeks followed by a crossover, the second study phase, which was identical in design, was carried out. In addition patients were instructed to measure their blood pressure 4 times daily at home for the whole study period. Haemorheological parameters (platelet aggregation, erythrocyte aggregation, plasma viscosity and haematocrit) were also determined at the measuring points mentioned above. The onion-olive oil maceration product led to a significant decrease in systolic blood pressure. There was also a trend towards a decrease in diastolic blood pressure. The improved blood fluidity observed resulted from a decrease in haematocrit. All effects could be shown immediately and after one week's administration.

Release of WBC-derived IL-1 receptor antagonist into supernatants of RBCs: influence of storage time and filtration

BACKGROUND

Transfusion-associated immunodepression may be related to the transfer of immunoinhibitory cytokines with blood components.

STUDY DESIGN AND METHODS

After evidence of increasing concentrations of IL-1 receptor antagonist (IL-1RA) but not of IL-10 was obtained in supernatants of stored RBC units that were WBC-reduced by centrifugation (C-RBCs) in a pilot study, IL-1RA concentrations were determined weekly in supernatants of C-RBCs and in units that underwent prestorage WBC reduction by in-line filtration (F-RBCs) over a 49-day storage. For assessing total IL-1RA content, complete cell lysis by repeated freezing and thawing was done. The results were related to the changes in WBC count during storage. The dependency of IL-1RA content on preparation procedures was assessed.

RESULTS

The prestorage IL-1RA concentration in C-RBCs (859 +/- 218 pg/mL) was significantly higher than in F-RBC (75 +/- 13 pg/mL). Whereas no changes were seen in F-RBCs during storage, IL-1RA levels in C-RBC supernatants drastically increased to levels about 50 times those in normal plasma (16,327 +/- 2,686 pg/mL on Day 49). Follow-up analysis revealed stringent correlation between IL-1RA release into supernatants and the current loss of WBCs (r = 0.79, n = 42; p<0.001). The total IL-1RA content did not change during storage and was directly dependent on prestorage WBC count. Preparation procedures altered the IL-1RA content only by WBC reduction.

CONCLUSION

The immunosuppressive cytokine IL-1RA is transmitted by RBCs in relation to WBC content and storage time.

Influence of the onion as an essential ingredient of the Mediterranean diet on arterial blood pressure and blood fluidity

Mediterranean diet has got a favourable effect on life expectancy. One of the crucial components of the diet are onions. In an open and a randomized, placebo-controlled, double-blind, cross-over phase-I study a spontaneous pharmacological effect 5 h after administration of an onion-olive-oil maceration capsule formulation on arterial blood pressure could be demonstrated in apparently healthy subjects. In addition to a decrease in arterial blood pressure, a significant reduction in plasma viscosity and haematocrit were observed. These results are indicating a vasodilative effect of the onion-olive-oil-maceration product. The stickiness of the platelets was reduced. The effects were stronger in subjects with reduced blood fluidity compared to those subjects with normal rheological parameters.

Autologous stem-cell transplantation in refractory autoimmune diseases after in vivo immunoablation and ex vivo depletion of mononuclear cells

Autoimmune diseases that are resistant to conventional treatment cause severe morbidity and even mortality. In the present study we demonstrate that complete remissions can be achieved in refractory polychondritis and systemic lupus erythematosus (SLE), even at advanced stage, with the use of autologous stem-cell transplantation (SCT). Remissions persisted after reconstitution of the immune system. In the treatment of advanced systemic sclerosis (SSc), stable disease may be achieved with autologous SCT.

The antiatherosclerotic effect of Allium sativum

In a randomized, double-blind, placebo-controlled clinical trial, the plaque volumes in both carotid and femoral arteries of 152 probationers were determined by B-mode ultrasound. Continuous intake of high-dose garlic powder dragees reduced significantly the increase in arteriosclerotic plaque volume by 5-18% or even effected a slight regression within the observational period of 48 months. Also the age-dependent representation of the plaque volume shows an increase between 50 and 80 years that is diminished under garlic treatment by 6-13% related to 4 years. It seems even more important that with garlic application the plaque volume in the whole collective remained practically constant within the age-span of 50-80 years. These results substantiated that not only a preventive but possibly also a curative role in arteriosclerosis therapy (plaque regression) may be ascribed to garlic remedies.

Rapid reversal of nephrotic syndrome due to primary systemic AL amyloidosis after VAD and subsequent high-dose chemotherapy with autologous stem cell support

In a patient with nephrotic syndrome, renal biopsy revealed AL amyloid deposits. Monoclonal lambda light chains were identified in serum and urine. A low percentage of monoclonal plasma cells was detected in the bone marrow. The patient received four cycles of VAD and subsequent high-dose chemotherapy (HDCT) with melphalan (200 mg/m2) followed by autologous peripheral blood stem cell transplantation. Proteinuria rapidly diminished during chemotherapy. Three months after HDCT, the patient has no edema, and no signs of plasma cell dyscrasia are currently detectable. Using VAD before starting HDCT may improve the condition of patients with amyloidosis and reduce transplantation-related morbidity and mortality.

Plateletpheresis-induced increase in platelet reactivity using different cell separators

OBJECTIVE

Since plateletpheresis is being used increasingly, it is important to regard quality control to check health risks for donors and to exclude these.

DESIGN

Controlled randomised prospective open comparative study.

SETTING

Department of Transfusion Medicine of a University Clinic.

PARTICIPANTS

112 platelet donors were examined.

INTERVENTIONS

Prior to and after plateletpheresis platelet reactivity was determined. The platelet concentrates in the two groups of 56 donors each were produced using either the cell separator 'CS-3000' and the collecting chamber PLT 30TM with the Omnix system (group I) or the cell separator 'AS-104' (group II).

RESULTS

In group I five donors showed a pathologically increased platelet reactivity (p = 0.1297) after plateletpheresis. In group II there were 10 donors with a pathologically increased platelet reactivity (p = 0.0046) after plateletpheresis. The mean concentration of platelets was reduced by separation using the CS-3000 Omnix from 238 +/- 49 x 10(3)/microliters to 172 +/- 32 x 10(3)/microliters (68 +/- 27 x 10(3)/microliters) and from 243 +/- 53 x 10(3)/microliters to 180 +/- 31 x 10(3)/microliters (63 +/- 33 x 10(3)/microliters) using the AS-104. In the first case the platelet yield was 3.9 x 10(11) platelets/concentrate, in the latter case it was 2.9 x 10(11) platelets/concentrate. The 'CS-3000 Omnix' is significantly more effective in separating (58.4 +/- 15.5%) than the 'AS-104' with 44.2 +/- 7.2% (p < 0.0001).

CONCLUSIONS

Since both donor groups were comparable regarding all factors recorded--especially the cardiovascular risk factors--the separation process could be responsible for the different traumatisation of platelets.

[The legally required guidelines for reporting risks or side-effects caused by blood components]

OBJECTIVE

To prevent dangers to health resulting from the application of drugs, the legislator requires the central registration and evaluation of all drug risks, especially of side effects and reciprocal effects. Since 1988 pharmaceutical enterprises have had to denominate a qualified person ('Stufenplanbeauftragter') who is responsible for the fulfilment of obligatory reporting. In case of complaints or side effects he has to take suitable measures according to a special plan ('Stufenplan').

DATA SOURCES

The basis of this survey are the legal requirements for drugs ('Arzneimittelgesetz') and supplementary regulations which define the duties of the 'Stufenplanbeauftragter'.

RESULTS

Blood components are subject to the legal requirements ('Arzneimittelgesetz') without reservations. Therefore the corresponding regulations have to be applied without modification in institutes for transfusion medicine. In this article the tasks of the 'Stufenplanbeauftragter' are summarized and practical experience of a university institute for transfusion medicine is presented.

CONCLUSIONS

In connection with the transmission of viral infectious diseases it became evident that the 'Stufenplanbeauftragter' is very important for the initiation of effective measures in case of serious side effects. The security of blood components could be improved by the realization of the corresponding legal requirements in the institutes for transfusion medicine.

Der gesetzlich vorgeschriebene Stufenplan bei Beanstandungen oder Nebenwirkungen von Blutkomponenten

<i>Ziel: </i>Zur Verhütung einer Gefährdung der Gesundheit von Mensch und Tier bei Anwendung von Arzneimitteln fordert der Gesetzgeber im Arzneimittelgesetz die zentrale Erfassung und Auswertung von Arzneimittelrisiken, insbesondere von Nebenwirkungen und Wechselwirkungen mit anderen Mitteln. Bereits seit 1988 müssen die pharmazeutischen Unternehmen einen qualifizierten Stufenplanbeauftragten benennen, der für die Erfüllung der Anzeigepflichten von Arzneimittelrisiken verantwort-lich ist und gemäβ einem internen Maβnahmenplan («Stufenplan») geeignete Maβ-nahmen bei Auftreten von Beanstandungen ergreifen muβ. <i>Quellen und Auswahlkriterien: </i>Grundlagen dieser Übersicht sind die gesetzlichen Bestimmungen, insbesondere das Arzneimittelgesetz und ergänzende Vorschriften, die die Pflichten des Stufenplanbeauftragten präzisieren. <i>Ergebnisse: </i>Blutkomponenten unterliegen ohne Einschränkung den Vorschriften für Arzneimittel, so daβ die entsprechenden Richtlinien für transfusionsmedizinische Einrichtungen unverändert zur Anwendung kommen. In diesem Artikel werden die geltenden Vorschriften zusammengefaβt. Am Beispiel einer transfusionsmedizinischen Abteilung an einer Universitätsklinik wird die praktische Umsetzung dar-gestellt. <i>Schluβfolgerungen: </i>Im Zusammenhang mit der Übertragung viraler Infektions-krankheiten hat sich in den letzten Jahren mehrfach gezeigt, wie wichtig die Funk-tion des Stufenplanbeauftragten für die Ergreifung effektiver Maβnahmen beim Auftreten von schwerwiegenden Nebenwirkungen ist. Durch die in den transfusions-medizinischen Einrichtungen erfolgte Umsetzung der entsprechenden gesetzlichen Bestimmungen konnte die Arzneimittelsicherheit von Blutkomponenten entschei-dend verbessert werden.

The BFM-protocol for HIV-negative Burkitt's lymphomas and L3 ALL in adult patients: a high chance for cure

During a period of 9 years we used the pediatric BFM-NHL protocol for treatment of 14 adult patients with Burkitt's lymphoma or L3 acute lymphoblastic leukemia. Ten of 14 patients obtained a complete remission including 5/8 with stage-IV disease or B-ALL. After a median follow-up of 55 months none of these ten patients relapsed. The projected survival after 8 years is 71%. Toxicity was moderate, with one early death; a tumor lysis syndrome occurred in four patients. From our experience we conclude that the BFM-NHL protocol is very effective in adult patients, with a high cure rate and acceptable toxicity, even in advanced stages of disease.

Overview of clinical trials with urapidil

Urapidil has been approved as sustained-release capsules containing 30, 60 and 90 mg, respectively, and as ampules containing 25 and 50 mg for treatment of all grades of hypertension, in several countries in Europe, South America, as well as in Japan and other Asian regions. In general, the treatment should start with 60 mg twice daily, 1 capsule in the morning and 1 in the evening. This schedule may be adapted according to the therapeutic needs. During the last few years, urapidil has been investigated extensively in comparison with several types of established antihypertensive drugs. Urapidil given orally has been tested in comparative trials against placebo, acebutolol, metoprolol, captopril, nifedipine and nitrendipine with responder rates of 40 to 70%. These responder rates are to be expected for a variety of antihypertensive drugs in monotherapy. Further studies with clonidine, prazosin and alpha-methyldopa showed similar responder rates as established for the other antihypertensive drugs studied. Adverse reactions include dizziness, headache and nausea and occasionally tiredness, orthostatic dysregulation and gastric disorders. These symptoms were transient, mostly occurring during the early phases of therapy and disappearing as treatment continued. Adverse effects are considered to be mainly due to blood pressure reduction. Intravenous comparative trials have been performed with urapidil against placebo, diazoxide and sodium nitroprusside. Adverse effects of parenterally applied urapidil are similar to those observed during oral treatment. Specific contraindications for urapidil are unknown. However, as for other vasodilating drugs, intravenous urapidil should not be administered to patients with stenosis of the aortic isthmus or with aortic valve insufficiency.

Immunoglobulin and T cell receptor gene rearrangements in lymphoproliferative disorders

Thirty-one samples representing Hodgkin's and non-Hodgkin's lymphomas, angioimmunoblastic lymphadenopathy (AILD), and benign follicular hyperplasia in HIV infections were examined for rearrangements of the immunoglobulin (Ig) and T cell receptor (TcR) beta-chain gene loci. In 11 of 12 non-Hodgkin's lymphomas (classified as Burkitt lymphoma (2), centrocytic lymphoma (1), centrocytic-centroblastic lymphoma (5), centroblastic lymphoma (3], only rearranged Ig genes could be detected. The exceptional case was an unclassified high-grade lymphoma, which represented a rearrangement of the TcR beta-chain. We also examined DNA from lymphoid neoplasms in which the lineage of the malignant cell was still controversial. Rearrangement of the TcR could exclusively be demonstrated in all 3 cases of AILD. One Ig gene rearrangement and 4 TcR beta-chain rearrangements were found in 13 samples of Hodgkin's lymphomas (11 lymph nodes, 1 pleura effusion and 1 bone biopsy with proven infiltration). Examination of 3 cases of benign follicular hyperplasia in HIV infection represented one Ig rearrangement.

[Sequential high-dose cytarabine therapy in combination with asparaginase in acute myeloid leukemia]

Between 1984 and 1987 14 patients with acute non-lymphocytic leukemia were treated with sequential high-dose cytosine arabinoside in combination with asparaginase. Twelve patients were suffering from refractory leukemia; in these patients complete remissions were achieved in 58%. The efficacy of this schedule was much better in patients with substantial leukemia cell reduction due to antecedent conventional therapy and no more than 25% blast cells in the bone marrow. In this subgroup complete remissions were achieved in 75% and 86% respectively, taking into account only the completed treatment courses. Beside the well-known side-effects such as alopecia, nausea, vomiting and hepatotoxicity, we observed an increase in severe infections. Three patients died of pulmonary mycosis.

Inhibition of human neutrophil migration by supernatants from Hodgkin's disease-derived cell lines

The contribution of defective neutrophil function to the increased susceptibility to infection observed in patients with Hodgkin's disease is unclear. We describe cell-directed inhibition of normal human neutrophil migration by serum-free culture supernatants of the Hodgkin-derived cell line L428 KSA, tentatively termed Hodgkin-derived leucocyte factor (HDLF). This factor inhibits both random migration and migration toward different chemoattractants, appears to bind to the cell surface and is stable at 56 degrees C but destroyed at 100 degrees C. Hodgkin-derived leucocyte factor also stimulates basal neutrophil superoxide production but the cells remain fully responsive to n-formyl-methionylleucylphenylalanine. Gel filtration chromatography shows a single peak of migration-inhibitory and superoxide-stimulatory activity at approximately 70,000 g mol-1. Hodgkin-derived leucocyte factor migration inhibition persists in neutrophils from a patient with chronic granulomatous disease. Activity of HDLF is completely destroyed by trypsin but unaffected by the protease inhibitor phenyl-methylsulphonylfluoride. Hodgkin's factor appears to be different from previously described neutrophil migration inhibitory factors.

[High-dose cytarabine treatment with asparaginase (Capizzi schedule) in recurrent or refractory AML in the adult]

4 patients with refractory AML or AML in relapse were treated with high dose Ara-C and L-asparaginase. Although only one patient was resistant against this type of treatment, a durable complete remission could be achieved in only one case. Severe myelosuppression was observed in all 4 cases; non-hematologic toxicity, however, was minimal.

The erythrocyte-stasis-meter (ESM): a device to determine a universal parameter for the flow characteristics of blood

A new experimental method is described which permits estimation of flow ability of blood: measuring the yield shear stress with the erythrocyte-stasis-meter (ESM). This method is based on the phenomenon that pathological blood under low pressure behaves like a solid body. Knowing the pressure difference at the transition point from solid to fluid behavior and the geometry of the channel, the yield shear stress can be calculated.