Coronary intravascular lithotripsy and rotational atherectomy for severely calcified stenosis: Results from the ROTA.shock trial

BACKGROUND

Severely calcified coronary lesions present a particular challenge for percutaneous coronary intervention.

AIMS

The aim of this randomized study was to determine whether coronary intravascular lithotripsy (IVL) is non-inferior to rotational atherectomy (RA) regarding minimal stent area (MSA).

METHODS

The randomized, prospective non-inferiority ROTA.shock trial enrolled 70 patients between July 2019 and November 2021. Patients were randomly (1:1) assigned to undergo either IVL or RA before percutaneous coronary intervention of severely calcified coronary lesions. Optical coherence tomography was performed at the end of the procedure for primary endpoint analysis.

RESULTS

The primary endpoint MSA was lower but non-inferior after IVL (mean: 6.10 mm2 , 95% confidence interval [95% CI]: 5.32-6.87 mm2 ) versus RA (6.60 mm2 , 95% CI: 5.66-7.54 mm2 ; difference in MSA: -0.50 mm2 , 95% CI: -1.52-0.52 mm2 ; non-inferiority margin: -1.60 mm2 ). Stent expansion was similar (RA: 0.83 ± 0.10 vs. IVL: 0.82 ± 0.11; p = 0.79). There were no significant differences regarding contrast media consumption (RA: 183.1 ± 68.8 vs. IVL: 163.3 ± 55.0 mL; p = 0.47), radiation dose (RA: 7269 ± 11288 vs. IVL: 5010 ± 4140 cGy cm2 ; p = 0.68), and procedure time (RA: 79.5 ± 34.5 vs. IVL: 66.0 ± 19.4 min; p = 0.18).

CONCLUSION

IVL is non-inferior regarding MSA and results in a similar stent expansion in a random comparison with RA. Procedure time, contrast volume, and dose-area product do not differ significantly.

[Influence of adjuvant pain medication on quality of life in the treatment of postmenopausal osteoporosis]

AIM OF THE STUDY

Chronic pain is the main symptom of postmenopausal osteoporosis. This can decrease mobility and quality of life of the patients. The hypothesis of this study was that administration of an adjuvant pain medication is essential additionally to the basic therapy. The second question was if a recommendation can be formulated whether a peripheral or a central acting pain medication is more effective to prevent osteoporosis induced chronic pain.

METHODS

Three pseudorandomised patient groups were prospectively compared. Group 1 was treated with alendronate, vitamin D, and calcium. Group 2 also received ibuprofen, and group 3 also received tramadol. In 117 women suffering from postmenopausal osteoporosis, quality of life was measured before and 26 weeks after therapy using the International Osteoporosis Foundation Qualeffo-41 score, and pain intensity was measured using a visual analogue scale.

RESULTS

No therapy-associated complications were observed during the study. After 26 weeks, quality of life significantly increased in groups 2 and 3 compared with group 1 (p<0.001). Pain intensity decreased in group 1 by only 6 points, whereas it decreased in group 2 by 31 points and in group 3 by 24 points. Pain relief was significantly different between the treatment groups and the control group and between the treatment groups themselves (p<0.001 and p<0.01).

CONCLUSION

We conclude that pain therapy with an almost peripherally acting drug such as ibuprofen can reduce osteoporosis-associated chronic pain better than a centrally acting pain medication such as tramadol. It therefore can be recommended to prescribe ibuprofen rather than tramadol for treating osteoporosis-associated chronic pain in postmenopausal women if the specific risk for gastrointestinal side effects is considered.

[Episodes of depression with attempted suicide after taking valsartan with hydrochlorothiazide]

HISTORY AND CLINICAL FINDINGS

A 43-year-old woman was admitted after a suicide attempt with 1.5 g atenolol. Physical and neurological examination showed no abnormality, but psychiatric examination revealed symptoms of a major depression. Four weeks prior to admission a valsartan-hydrochlorothiazide combination had been added to the antihypertensive medication.

INVESTIGATIONS

Laboratory tests, electrocardiography, chest-x-ray, electroencephalography and cranial computerised tomography showed no abnormality.

DIAGNOSIS AND COURSE

The depressive disorder resolved within ten days after discontinuation of valsartan and hydrochlorothiazide without specific treatment. Blood pressure was normal under treatment with metoprolol.

CONCLUSION

Depressive drug reactions can produce a substantial morbidity. This case of a drug induced affective disorder should heighten the awareness of unusual reactions to valsartan-hydrochlorothiazide therapy.

Tolerance of granulocyte donors towards granulocyte colony-stimulating factor stimulation and of patients towards granulocyte transfusions: results of a multicentre study

Data of 507 granulocyte donations from 183 donors were evaluated. No severe granulocyte colony-stimulating factor (G-CSF)-related side-effects were observed. Three donors complained of severe itching following infusion of hydroxyethyl starch (HES). A high proportion (85%) of the donors stated that they would donate granulocytes again. The mean granulocyte yield was 4.3 x 10(10). High-molecular-weight HES resulted in a significantly higher yield compared with low-molecular-weight HES. Mild, but no severe, adverse transfusion reactions were observed in 16% of the recipients. A leucocyte alloimmunization rate of 24% was found. G-CSF stimulation and transfusion of G-CSF-mobilized granulocytes were well tolerated by donors and recipients, respectively.

Superior safety of reboxetine over amitryptiline in the elderly

Under antidepressive treatment with amitryptiline (100 mg/d) a 71-year old woman developed delirious symptoms, hyponatremia and a grand mal seizure followed by cardiovascular arrest. A few month later she ingested 48 mg reboxetine with suicidal intent. Overdosing of reboxetine, a selective noradrenaline re-uptake inhibitor, proceeded without complications.

A new endotoxin adsorber: first clinical application

In an open, uncontrolled pilot study, 5 men and 1 woman with suspected gram-negative sepsis were treated with a new whole-blood endotoxin adsorption system. Lipopolysaccharide (LPS) adsorption was carried out by hemoperfusion over high-affinity polymethacrylate-bound albumin (Fresenius Endotoxin Adsorber EN 500). All patients suffered from endotoxemia (>20 pg/ml LAL) and met at least two systemic inflammatory response syndrome (SIRS) criteria. Four patients suffered from pneumonia due to mechanical ventilation, one from peritonitis, and one from pneumonia and peritonitis. Endotoxin adsorption was very well tolerated, and efficient LPS removal was shown in all patients. Apache II score immediately before immunoadsorption was 23.5 and was 22.3 after the last treatment. All 6 critically ill patients improved substantially and were discharged from the intensive care unit. LPS whole blood immunoadsorption is a promising new method. No side effects have been observed thus far. A large controlled study to prove clinical efficacy in patients with severe sepsis is under way.

The Role of Ethylene Production in Virulence of Pseudomonas syringae pvs. glycinea and phaseolicola

ABSTRACT The importance of ethylene production for virulence of Pseudomonas syringae pvs. glycinea and phaseolicola was assayed by comparing bacterial multiplication and symptom development in bean and soybean plants inoculated with ethylene-negative (efe) mutants and wild-type strains. The efe mutants of Pseudomonas syringae pv. glycinea were significantly reduced in their ability to grow in planta. However, the degree of reduction was strain-dependent. Population sizes of efe mutant 16/83-E1 that did not produce the phototoxin coronatine were 10- and 15-fold lower than those of the wild-type strain on soybean and on bean, and 16/83-E1 produced very weak symptoms compared with the wild-type strain. The coronatine-producing efe mutant 7a/90-E1 reached fourfold and twofold lower population sizes compared with the wild-type strain on soybean and bean, respectively, and caused disease symptoms typical of the wild-type strain. Experiments with ethylene-insensitive soybeans confirmed these results. The virulence of the wild-type strains was reduced to the same extent in ethylene-insensitive soybean plants as the virulence of the efe mutants in ethylene-susceptible soybeans. In contrast, the virulence of Pseudomonas syringae pv. phaseolicola was not affected by disruption of the efe gene.

Lipoprotein (a) up-regulates the expression of the plasminogen activator inhibitor 2 in human blood monocytes

Elevated plasma lipoprotein (a) (Lp[a]) and cardiac events show a modest but significant association in various clinical studies. However, the influence of high Lp(a) on the gene expression in blood monocytes as a major cell involved in atherogenesis is poorly described. To identify genes influenced by elevated serum Lp(a), the gene expression was analyzed on a complementary DNA microarray comparing monocytes from a patient with isolated Lp(a) hyperlipidemia and coronary heart disease with monocytes from a healthy blood donor with low Lp(a). By using this approach, numerous genes were found differentially expressed in patient-versus-control monocytes. Verification of these candidates by Northern blot analysis or semiquantitative polymerase chain reaction in monocytes from additional patients with Lp(a) hyperlipidemia and healthy blood donors with elevated Lp(a) confirmed a significant induction of plasminogen activator inhibitor type 2 (PAI-2) messenger RNA (mRNA) in monocytes from male, but not from female, individuals with high Lp(a), indicating that this observation is gender specific. This led also to increased intracellular and secreted PAI-2 protein in monocytes from male probands with Lp(a) hyperlipidemia. Plasminogen activator inhibitor type 1 (PAI-1) mRNA was found suppressed only in the patients' monocytes and not in healthy probands with high Lp(a) levels. Purified Lp(a) induced PAI-2 mRNA and protein and reduced PAI-1 expression in monocytes isolated from various controls. The finding that PAI-2 is elevated in monocytes from male patients with isolated Lp(a) hyperlipidemia and male healthy probands with high Lp(a) and that purified Lp(a) up-regulates PAI-2 in control monocytes in vitro indicate a direct, but gender-specific, effect of Lp(a) for the induction of PAI-2 expression.

Effects of newer atypical antipsychotics on autonomic neurocardiac function: a comparison between amisulpride, olanzapine, sertindole, and clozapine

As part of a prospective clinical study investigating the effects of atypical neuroleptics on autonomic neurocardiac function (ANF), serial standardized recordings of conventional electrocardiograms and computer-calculated measurements of 5-minute resting heart rate variability (HRV) were obtained from 51 medication-free inpatients with schizophrenia (DSM-III-R-diagnosed) before and after an average of 14.1 days of treatment with amisulpride 400 mg/day (N = 12), olanzapine 20 mg/day (N = 13), sertindole 12 mg/day (N = 13), or clozapine 100 mg/day (N = 13). Reference values for the HRV data were obtained from a large group of well-matched healthy controls (N = 70). The most important findings were the following: (1) clozapine, olanzapine, and sertindole all prolonged mean frequency-corrected QTc times, which, in the case of sertindole, proved to be significant (Wilcoxon test p <0.05); (2) sertindole and clozapine significantly increased the mean resting heart rate; and (3) only clozapine significantly reduced the parasympathetic resting tone. The results of the HRV studies are discussed considering the in vitro receptor profiles of the atypical neuroleptics under study. Potential implications for the cardiac safety and tolerance of these drugs are also discussed.

Transplant characteristics: minimal residual disease and impaired megakaryocytic colony growth as sensitive parameters for predicting relapse in acute myeloid leukemia

Dose escalation during consolidation therapy of de novo AML, including myeloablative chemotherapy supported with autologous peripheral blood stem cell transplantation (aPBSCT), continuously improved outcome. Therefore, quality control of transplants is getting increasing interest. We studied leukapheresis products (LPs), consecutively collected during postremission treatment of 20 patients with de novo AML for minimal residual disease (MRD) by 5-parametric flow cytometry and for myelodysplasia (MDS)-associated alterations by paired lineage-selected colony assays for colony-forming units-megakaryocytes (CFU-mega) and burst-granulocytes-monocytes colony-forming units (CFU) to evaluate the predictive value of these transplant-associated parameters on outcome. We defined the leukemia-associated immunophenotype at diagnosis and studied the impact of MRD detection in LPs collected after double induction with TAD (thioguanine, daunorubicin, cytarabine) and HAM (mitoxantrone, high-dose cytarabine, n=18 patients) and TAD consolidation treatment (n=20 patients) on outcome after aPBSCT. The level of MRD in the transplants correlated with the relapse-free survival (RFS) using a cut-off level of 1 x 10(-3) residual leukemic cells. The median RFS was 6 months for the group with > or = 1 x 10(-3) residual leukemic cells and has not been reached in the group with low MRD levels (< 1 x 10(-3)). By using the same cut-off level a weak correlation could also be demonstrated between MRD in the pregraft bone marrow and RFS (P = 0.04). Quantitatively abnormal megakaryocytic colony growth in the back-up LPs collected after double induction and in the transplant LPs was characterized by the ratio CFU-mega/CFU. In the group of relapsing patients the ratio CFU-mega/CFU was significantly lower than in the group of patients with CCR (P = 0.004), both in the back-ups and in the transplants. All patients with CFU-mega/CFU ratios < 0.12 relapsed, five of seven patients developed MDS before progressing to full leukemic relapse. Using the optimized cut-off level for the ratio CFU-mega/CFU (< vs > or = 0.12), seven of 10 relapsing patients (70%) could be identified to be at risk of relapse, whereas MRD in the transplants identified only 50% of the relapses and MRD in the pregraft bone marrow 25%. In conclusion, the study could identify two pretransplant risk factors predicting relapse in patients with AML receiving aPBSCT in first CR: MRD in transplants as well as MDS-like alterations within the transplants. These results may have multifold implications on the design of risk-adapted chemotherapy as well as on purging techniques and may contribute to a better understanding of leukemogenesis.

Protein tyrosine kinases in bacterial pathogens are associated with virulence and production of exopolysaccharide

In eukaryotes, tyrosine protein phosphorylation has been studied extensively, while in bacteria, it is considered rare and is poorly defined. We demonstrate that Escherichia coli possesses a gene, etk, encoding an inner membrane protein that catalyses tyrosine autophosphorylation and phosphorylation of a synthetic co-polymer poly(Glu:Tyr). This protein tyrosine kinase (PTK) was termed Ep85 or Etk. All the E.coli strains examined possessed etk; however, only a subset of pathogenic strains expressed it. Etk is homologous to several bacterial proteins including the Ptk protein of Acinetobacter johnsonii, which is the only other known prokaryotic PTK. Other Etk homologues are AmsA of the plant pathogen Erwinia amylovora and Orf6 of the human pathogen Klebsiella pneumoniae. These proteins are involved in the production of exopolysaccharide (EPS) required for virulence. We demonstrated that like Etk, AmsA and probably also Orf6 are PTKs. Taken together, these findings suggest that tyrosine protein phosphorylation in prokaryotes is more common than was appreciated previously, and that Etk and its homologues define a distinct protein family of prokaryotic membrane-associated PTKs involved in EPS production and virulence. These prokaryotic PTKs may serve as a new target for the development of new antibiotics.

Screening for concomitant alcohol abuse in schizophrenia: clinical significance of the Munich Alcoholism Test and laboratory tests

For the early and correct diagnosis of the comorbidity of schizophrenia and alcoholism, a valid laboratory marker would be most helpful in clinical practice. Seventy schizophrenics admitted to a general psychiatric unit of an urban hospital located in a large industrial area in Germany prospectively underwent a detailed addiction history, the Munich Alcoholism Test (MALT) and determinations of serum gamma-glutamyltransferase (gammaGT) and carbohydrate-deficient transferrin (CDT). Cutoff levels for laboratory tests represented the 95th percentile of data obtained from 100 matched healthy controls. Using the MALT, we found evidence of concomitant alcohol consumption in 42.8% of the study patients. The sensitivities of gammaGT and CDT for detecting alcohol abuse (confirmed using DSM III-R criteria) were 70.6 and 58.8%, respectively. Our data suggest that the MALT can be used as a reliable screening test for alcohol use in schizophrenia. In neuroleptic-treated schizophrenics with pathological gammaGT, but low MALT scores, the corresponding CDT may serve as a highly specific marker to verify a concomitant alcohol abuse.

Chronic inflammatory demyelinating polyradiculoneuropathy: superiority of protein A immunoadsorption over plasma exchange treatment

We present a patient with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) who was treated regularly with plasma exchanges (PE) because response to other therapies including i.v. immunoglobulins was not adequate. To reduce nonspecific protein losses due to repeated PE and increase IgG-removal, immunoadsorption (i.a.)-therapy using sepharose-bound protein A was initiated. Retrospective analysis of clinical data including muscle strength and walking distance shows that IA led to more rapid and greater functional improvement than PE in this patient with no relevant side effects. After 3 years of therapy lymphoma was diagnosed and treated. The patient had no relapses of CIDP for 17 months, when his functional status deteriorated again necessitating further IA-therapy. It is concluded that IgG removal by IA in CIDP is more effective and has fewer complications than PE. Due to the chronic course of CIDP requiring repeated interventions IA is also not more expensive than PE.

Lipoprotein(a) apheresis in severe coronary heart disease: an immunoadsorption method

Lipoprotein(a) (Lp[a]) is associated with an increased cardiovascular risk. It is similar to low-density lipoprotein with an additional molecule of apo A covalently linked to apo B-100 by one disulfide bridge. Apo A is highly homologous to plasminogen. The kringle 4 motive of plasminogen is repeated between 10 and 40 times in apo (a). Currently, there is no drug therapy available to lower Lp(a). Since October 1993, we have carried out over 160 immunoadsorption treatments on 3 patients with elevated Lp(a) as their only risk factor and a history of myocardial infarction. Lp(a) was removed from plasma by sepharose coupled anti-Lp(a) columns. Lp(a) levels were lowered from above 170 mg/dl to below 30 mg/dl immediately after Lp(a) apheresis. To achieve this, the patient's plasma volume had to be treated 2 to 3 times. Nonspecific protein loss during column changes remained negligible. There were no serious unwanted effects during or after treatment. Minor circulatory problems (tachycardia, flush) occurred in 11% of the treatments but only with plasma flow rates above 55 ml/min. In 1 patient, coronary angiography after 2 years and in another patient after 1 year showed no progression. The third patient has not yet had repeat coronary angiography. Like the others, he reported subjective improvement after 1 year of apheresis. It is concluded that Lp(a) apheresis may retard progression of atherosclerosis in patients with selective Lp(a) elevation. Further studies to support this hypothesis are needed.

[Effect of processed blood volume, leukocyte count and concentration of CD34-positive cells in peripheral blood on efficiency of stem cell apheresis]

Despite many published studies no parameter could be identified yet to acceptably and individually predict collection results in stem cell apheresis. We analyzed leukocyte counts and processed blood volume, absolute and relative CD34+ cell counts, and overall collection efficiency in 120 patients with hematological and solid malignancies (354 leukaphereses using the Cobe Spectra cell separator, a median of 3 per patient, span 1-9). Stem cells were mobilized into peripheral blood by conventional chemotherapy followed by daily doses of G-CSF. CD34+ progenitor cell counts were monitored through multiparametric flow cytometry. Blood and collection flows varied in the range of 45-90 ml/min and 0.7-1.5 ml/min, respectively. CD34+ progenitor cells were enriched 38-fold in the apheresis product as compared to peripheral blood at a processed blood volume lower than one total blood volume. Efficiency continuously declined, on to a 25-fold concentration at a processed blood volume above the 3-fold total blood volume. Total collection efficiency, calculated from the absolute content of CD34+ progenitor cells in peripheral blood and apheresis concentrate (a parameter for progenitor cell mobilization during the apheresis), reached a plateau at a processed blood volume above the 3-fold total blood volume. However, variation among individual patients was high. The concentration rate of CD34+ cells at a leukocyte count below 5,000/microliter averaged 50 and declined continuously to 8 at leukocyte counts between 45,000 and 50,000/microliter. To summarize, in 70% of patients with leukocyte counts below 5,000/microliter and CD34+ progenitor cell counts above 10,000/ml, more than 1.5 x 10(6) progenitors per kg body weight could be collected in a single leukapheresis. According to the presented data, the variation in overall collection efficiency is mainly due to: 1) varying mobilization of progenitors during the apheresis procedures itself and 2) dependence on peripheral leukocyte counts.

[Clinical and flow cytometry outcome of improved photopheresis methods in dermatologic patients]

In photopheresis, 8-methoxypsoralen (8-MOP) is added to a mononuclear cell concentrate and then activated by UVA light, thus forming covalent bonds between DNA strands. Infusion of these modified cells that are not able to replicate any more seems to lead to the elimination of pathogenic T-cell clones and clinical improvement in patients suffering from cutaneous T-cell lymphoma, graft versus host reactions, and various autoimmune diseases. The original method described by Edelson et al. (1987) was improved by the following modifications proposed by Andreu et al. (1994): i) by using a cell separator (COBE Spectra) that produced purer concentrate with less red blood cells absorbing UVA light. ii) By applying 8-MOP directly into the collection bag, the drug side effects due to the oral application of the thousandfold dose and varying serum levels were avoided. iii) By irradiating the concentrate after collection, all cells received the same irradiation dosage. We treated 2 men with cutaneous T-cell lymphoma, 2 women with atopic eczema and 1 man with severe pustular psoriasis with overall 123 extracorporeal photochemotherapy (ECPC) sessions. In addition to routine laboratory analysis, detailed characterization of lymphocyte subpopulations was carried out by flow cytometry to differentiate T-helper and T-suppressor cells and their activation (HLA-DR, CD 25), B, NK cells, and monocyte subpopulations. The following mediators soluble were analyzed as well: Il-2-receptor and as indicators of acute phase reaction Il-8, neopterin and Il-1 beta. We observed a good clinical improvement independent of no significant trend in the immunological phenotype of circulating blood leukocytes. Our results suggest that ECPC effects are not mediated by a systemic immune response or alternatively are not measured in the blood compartment.

[Benefits and risks of electroconvulsive therapy (ECG) in elderly patients with cardiovascular risk factors]

Between January 1995 and June 1996, 24 inpatients at our hospital (mean age 55.6 years) were treated with electroconvulsive therapy (ECT). Clinical improvement was observed in 80% of the patients, including those without risk factors (NRG, n = 16), as well as those with concomitant cardiovascular diseases (RG, n = 8). During a mean period of observation of 224 days after the end of ECT 7 patients (35%) relapsed. The rate of relapse was higher in RG than in NRG patients (57.1 vs 23.1%). In all cases ECT was well tolerated; 285 applications of ECT did not result in mortality or persistent morbidity. However, RG patients may be at increased risk for the development of minor cardiovascular complications, which were noted in three RG patients (37.5%), but only in one patient (6.2%) in the NRG (Fisher's test, P = 0.09). Taken together, our results demonstrate that ECT is a safe treatment regimen for depression even in medically ill patients of old age.

Structural organization and characterization of the promoter region of a human carboxylesterase gene

A gene encoding a human liver carboxylesterase has been isolated and characterized. Analysis of three overlapping genomic lambda clones revealed that the gene spans about 30 kb and is made of 14 exons being 39 to 379 bp in length. The encoded protein is 550 amino acids long and is highly homologous to carboxylesterases of various mammalian species. The transcription start site was determined by 5'-RACE PCR. An additional 900 bp of DNA from the 5' flanking region of the gene was cloned and sequenced in order to elucidate the structure of the promoter. In this sequence several possible binding sites for transcription factors have been identified, but no TATA-box was present. When different parts of the putative promoter region were ligated in front of the luciferase gene and the constructs were transfected into CHO cells, the reporter gene was effectively transcribed, as demonstrated by the expression of enzyme activity.

[Specific Lp(a) apheresis for secondary prevention of arteriosclerosis]

Lipoprotein(a) (Lp(a)) is an independent risk factor for arteriosclerosis. It consists of the Lp(a)-specific apo(a) which is bound to the apo-B of an LDL particle by a disulfide bridge. Apo(a) is homologous to parts of the plasminogen molecule: It consists of one kringle 5 and 10-40 kringles 4 of the plasminogen molecule. Due to the lack of alternative drug treatment, 3 patients with early onset of arteriosclerosis, rapid progression, and elevated Lp(a) as their dominating risk factor were treated weekly with specific Lp(a)-aphereses. Since October 1992, we carried out 229 immunoadsorptions (IA) with specific columns containing anti-Lp(a) antibodies covalently bound to sepharose. To reduce Lp(a) from preapheresis values of 142 +/- 53 mg/dl to 25 +/- 11 mg/dl immediately after apheresis, we had to adsorb 1.4-3 patient's plasma volumes. Lp(a) rise to preapheresis values took 3-4 days. Protein reduction caused by loss of plasma during column changes remained tolerable (total protein before IA: 71 +/- 4 g/l, after IA: 56 +/- 4 g/l. Immediately after IA, these values were measured after the application of 991 +/- 207 ml of ACDB with 5,000 IU of heparin as anticoagulant. Hemoglobin remained unchanged (before IA: 13.4 +/- 1.4 g/dl, after IA: 13.6 +/- 1.5 g/dl). Side effects were mainly flush and tachycardia. They were seen especially when using new columns and plasma flow rates above 55 ml/min and were immediately reverted by interrupting the IA. Control angiography performed after 2 years in 2 patients showed no progression of disease, in the 3rd patient, the stress test showed a significant improvement as did clinical parameters. In our hands, IAs are a safe and efficient method for Lp(a) reduction and secondary prevention of myocardial infarction. Therapeutic efficiency should further be proven by a controlled trial.

Mitochondrial DNA variations and nuclear RFLPs reflect different genetic similarities among 23 Arabidopsis thaliana ecotypes

The mitochondrial genome of 23 Arabidopsis thaliana ecotypes was analysed by Southern hybridization in total cellular DNA. Firstly, the extent of divergence between the mitochondrial genomes in closely related lines of one plant species and secondly, the use of mitochondrial versus nuclear RFLPs to determine evolutionary relationships between Arabidopsis ecotype isolates was investigated. Highly divergent stoichiometries of alternative mitochondrial genome arrangements characterize individual ecotypes including the complete loss of a 5 kb region from ecotype Landsberg without apparent effect on plant viability. The genetic similarities between ecotypes suggested by mitochondrial genome arrangements differ from those deduced from 18 nuclear RFLP loci (CAPS markers). Similarity of nuclear RFLP patterns among the 23 Arabidopsis ecotypes neither correlates with their geographic origin nor with the observed mitochondrial genome arrangements. A promiscuous mitochondrial sequence insertion previously identified in ecotype Columbia is also found in the nuclear genomes of ecotypes Eifel, Enkheim and Hilversum. Two ecotypes (Eifel and Tabor) displaying identical RFLP patterns at all 18 nuclear loci show differences in both this sequence transfer and a mitochondrial DNA recombination event.

Lipoprotein(a)-apheresis in the secondary prevention of coronary heart disease

Lipoprotein(a) [Lp(a)] is one important cause of atherosclerosis. It consists of one molecule of low density lipoprotein and an additional molecule of apo(a) linked to apoB-100 by a disulfide bridge. Apo(a)s are partially homologous to plasminogen, with one kringle 5 and 10-40 repeats of kringle 4. As there is no drug therapy available, we treated three patients who had suffered from at least one myocardial infarction and had Lp(a) as the only risk factor for atherosclerosis. Since October 1992, 186 immunoadsorption treatments have been carried out weekly with Sepharose-coupled anti-Lp(a)-columns. To achieve a reduction in Lp(a) from 78-250 mg/dL before apheresis to below 25 mg/dL immediately after apheresis, patient plasma volume had to be treated two to three times. Treatments lasted 3-5 h. Immediately reversible side-effects such as flushing and tachycardia during the first treatment were seen in 9% of immunoadsorptions. Non-specific protein loss remained tolerable, if one takes into account that the patients received approximately 1 L of ACDB with heparin as anticoagulant and some of the column-rinsing buffer. One patient's clinical condition and exercise test improved dramatically as did coronary angiography after 2 years. Another patient had no change after 1 year, the third patient showed subjective improvement and has not yet had repeat angiography after 1 year of treatment. We conclude that Lp(a)-apheresis may retard progression of atherosclerosis in patients with selective Lp(a) elevation. Further studies to support this hypothesis are needed.

copia-, gypsy- and LINE-like retrotransposon fragments in the mitochondrial genome of Arabidopsis thaliana

Several retrotransposon fragments are integrated in the mitochondrial genome of Arabidopsis thaliana. These insertions are derived from all three classes of nuclear retrotransposons, the Ty1/copia-, Ty3/gypsy- and non-LTR/LINE-families. Members of the Ty3/gypsy group of elements have not yet been identified in the nuclear genome of Arabidopsis. The varying degrees of similarity with nuclear elements and the dispersed locations of the sequences in the mitochondrial genome suggest numerous independent transfer-insertion events in the evolutionary history of this plant mitochondrial genome. Overall, we estimate remnants of retrotransposons to cover > or = 5% of the mitochondrial genome in Arabidopsis.

Treatment of severe localized scleroderma by plasmapheresis--report of three cases

We report three patients with severe, localized scleroderma, and with elevated titres of antinuclear antibodies, who were treated by plasmapheresis in combination with systemic steroid therapy. The therapeutic effectiveness of plasmapheresis was assessed on the basis of improvement in cutaneous and joint lesions. In all cases, significant improvement occurred after 2 months of therapy. Thus, in addition to treating systemic sclerosis, plasmapheresis can also be recommended for treatment of severe cases of localized scleroderma with elevated titres of antinuclear antibodies and antibodies to ss-DNA.

Defective nitrovasodilator-stimulated protein phosphorylation and calcium regulation in cGMP-dependent protein kinase-deficient human platelets of chronic myelocytic leukemia

The presence and functional role of the cyclic nucleotide signal transduction system was investigated in platelets from patients with myeloproliferative disorders. Platelets from certain patients with chronic myelocytic leukemia showed decreased expression of cGMP-dependent protein kinase, and platelets from two such patients were studied in some detail. These platelets had very little if any cGMP-dependent protein kinase but a normal level of cAMP-dependent protein kinase. They also contained a normal level of VASP (vasodilator-stimulated phosphoprotein, a specific substrate of both cAMP- and cGMP-dependent protein kinase), as well as a functionally intact prostaglandin E1-stimulated cAMP-mediated VASP phosphorylation. In contrast, sodium nitroprusside-stimulated VASP phosphorylation was severely impaired in these cGMP-dependent protein kinase-deficient platelets, despite an exaggerated cGMP response to sodium nitroprusside. Furthermore, whereas selective activation of the cGMP-dependent protein kinase by 8-(4-chlorophenylthio)-cGMP strongly inhibited the ADP- or thrombin-evoked calcium mobilization from intracellular stores in normal platelets, this agonist-evoked calcium response was not inhibited by the cGMP analog in cGMP-dependent protein kinase-deficient platelets. The results demonstrate a defect in the nitrovasodilator-/cGMP-regulated signal transduction system in human platelets from some patients with myeloproliferative disorders, and underscore that a cGMP-dependent protein kinase regulatory system, distinct from that of cAMP-dependent protein kinase or other cGMP-dependent effectors is operative in normal human platelets.

Low density lipoproteins inhibit endotoxin activation of monocytes

Human serum and low density lipoproteins (LDLs) were shown to inactivate endotoxin (lipopolysaccharide [LPS]) by testing the effect of LPS interactions with serum or LDL on the activation of human monocytes. Sera and LDL preparations from four patients with familial hypercholesterolemia were used to demonstrate the inhibition of LPS from inducing interleukin-1 release. Before LDL removal by immunoapheresis, the patients' sera were able to inactive approximately fivefold more LPS than after LDL removal. The LPS-inactivating capacity lost during apheresis could essentially be retrieved in the LDL-rich eluate from the immunoadsorption columns. Because patients were treated frequently with immunoapheresis, their LDL levels before LDL removal were not markedly elevated. These patients' sera before LDL removal were shown to inactivate amounts of LPS comparable to those inactivated by the sera from three healthy volunteers. LDL prepared by ultracentrifugation showed similar LPS inactivation as LDL prepared by immunoapheresis. We conclude that the inhibition of LPS-induced monocyte activation by human serum is dependent to a large extent on the LDL fraction. LDLs were demonstrated to inhibit LPS from inducing interleukin-1 release by human monocytes.

[Combined surgical-orthodontic palatine suture expansion in adulthood]

A method of surgical support of a rapid maxillary expansion is described. Specific osteotomies are performed on the attached region of the maxillary zygomatic process and the dorsal and middle part of the hard palate. The results of 14 patients are demonstrated. Almost all patients underwent surgical correction of sagittal and/or vertical jaw relations after a subsequent harmonization. This surgical orthodontic expansion proved to be an efficient and low pain method of preoperative correction of transverse maxillary deficiencies and facilitated the following skeletal surgery.

Quantitative investigation on the urinary excretion and metabolism of 3,4-dimethoxyphenylethylamine in schizophrenics and normal individuals

A quantitative method for the detection of DMPEA in urine was developed. It is based on the fluorometric determination of DMPEA in the form of its phosphopyridoxyl derivate. The limit of detection is 2 microgram DMPEA per 1 g creatinine. The DMPEA content was measured in urine from healthy persons, from schizophrenics, and from psychiatric patients without schizophrenia hospitalized with the schizophrenics. From each person five to ten 24-hr urine samples were investigated. DMPEA could be found neither in schizophrenics nor in controls or healthy persons. Finally, the urinary excretion of parenterally applied 14C-DMPEA was determined in three healthy volunteers and in three rats. In man about 25% of the label was excreted as DMPEA. The main metabolite in urine was homoveratric acid. Both compounds were excreted as conjugates.