2-Methoxyestradiol--a unique blend of activities generating a new class of anti-tumour/anti-inflammatory agents

The estradiol metabolite, 2-methoxyestradiol (2MEO), is currently being evaluated in Phase II clinical trials for the treatment of solid tumours and is undergoing preclinical evaluation for inflammatory conditions. The anti-proliferative/cytotoxic/pro-apoptotic effects on tumour and endothelial cells have conferred potential on this metabolite for a synergistic impact on tumour growth. Exploitation of this synergy of 2MEO has previously required the combination of well-established cytotoxic agents with newer anti-angiogenic agents. This article reviews the pharmacology of 2MEO and describes the limitations inherent in its residual estrogen receptor affinity. The extent to which the metabolite 2MEO embodies an optimised therapeutic candidate is discussed. The challenges involved in using rational (3D QSAR-based) drug design to optimise the activity profile of analogues of 2MEO to provide additional members of this new class of anti-tumour/anti-inflammatory drug are also outlined.

Distinct factors correlating with adverse cardiac events after major vascular surgery

INTRODUCTION

Cardiovascular complications remain the principal cause of both morbidity and mortality after major vascular surgery. The well-known coincidence between vascular disease and coronary artery disease provided the rationale for a detailed analysis of major perioperative cardiovascular complications in their relation to preoperative and intraoperative parameter

METHODS AND PATIENTS

90 patients scheduled to undergo either femoral-popliteal bypass (n = 74) or repair of an infrarenal aortic aneurysm (n = 16) were prospectively included in the study. All patients had no signs of unstable cardiac disease and required no cardiac testing. Both preoperative and intraoperative parameter were correlated to adverse cardiac events (cardiac death and myocardial infarction -MI).

RESULTS

Univariate analysis identified the following parameter to be significantly related to cardiac complications: prior MI and intraoperative hypertension (systolic blood pressure above 200 mmHg). In contrast perioperative betablocker therapy was revealed to be protective. In multivariate analysis the history of MI and intraoperative hypertension correlated with poor cardiac outcome.

CONCLUSIONS

Our results underline the importance of the individual history in predicting perioperative risk and corroborate the beneficial effects of long-standing beta-blocker therapy. Additionally the significance of stable intraoperative hemodynamic parameter is demonstrated.

Microcirculation and tolerability following i.v. infusion of PGE1 and iloprost: a randomized cross-over study in patients with critical limb ischemia

In a randomized cross-over study, the effect of PGE(1) and iloprost on microcirculation as well as the tolerability was investigated in 36 patients with peripheral arterial occlusive disease stage III and IV according to Fontaine. Patients received PGE(1) and iloprost by single 3-h i.v. infusions on two different days at doses recommended by the manufacturers or in previous studies (PGE(1): first hour 20 microg, next 2h 30 microg each. Iloprost: first hour 0.5 ng/kg/min, next 2h 1.0 ng/kg/min). Transcutaneous oxygen pressure (tcPO(2)) values increased much more with PGE(1). Median tcPO(2) increase over baseline 30 min after the end of infusion was 9 and 2 mmHg for PGE(1) and iloprost, respectively, corresponding to median AUC differences from baseline of 1050 and 210 min mmHg. Because of its exploratory character, the study was not powered to test for significance. Adverse effects occurred in 19.4% (PGE(1)) and 30.6% (iloprost) of patients. Dose reduction was required in 3 patients receiving iloprost (hypotension, nausea, irritation of the infused vein), and in none receiving PGE(1).

DRG-based cost analysis of inpatient conservative treatment of PAD stage III/IV

Hintergrund: In einer von der Deutschen Gesellschaft für Angiologie (DGA) und dem DRG Competence Center, München, durchgeführten prospektiven Studie wurde geprüft, ob die Kosten für eine konservative Behandlung von Patienten mit PAVK Stadium III/IV (DRG F65) im derzeitigen G-DRG-System adäquat abgebildet sind. Methode und Patienten: Im Zeitraum vom 1. September. bis 16. Dezember 2002 wurden an acht angiologischen Zentren in Deutschland insgesamt 704 Patienten mit der DRG F65 (periphere Gefäßerkrankungen) ausgewertet. Neben der Verweildauer im Krankenhaus wurden die Gesamtkosten (Kostenäquivalente) nach einer von der DRG Research Group der Universität Münster entwickelten Methodik berechnet. Darüber hinaus erfolgte ein Vergleich des Studienkollektivs mit einer von InEK veröffentlichten bundesdeutschen Kalkulationsstichprobe für die DRGs F65A/B. Ergebnisse: Es zeigte sich, dass konservativ behandelte Patienten mit einer PAVK Stadium III/IV (DRGs F65A/B) signifikant mehr Kosten verursachen (p < 0,001) und signifikant längere Verweildauern (p < 0,001) aufweisen als Patienten, die wegen anderer Gefäßerkrankungen ebenfalls in die DRG F65 eingruppiert wurden. Gleichzeitig wurde deutlich, dass angiologische Zentren doppelt so viele Patienten mit kritischer Extremitätenischämie behandeln, wie dies im bundesdeutschen Mittel der Fall ist. Die von InEK bislang veranschlagte Vergütung deckt nicht einmal die Hälfte der tatsächlich entstandenen Kosten für die konservative Therapie der PAVK Stadium III/IV. Schlussfolgerung: Um eine leistungsgerechte Vergütung zu gewährleisten, muss – wie von der DGA beantragt – eine neue Basis-DRG für Patienten mit PAVK Stadium III/IV gebildet werden. Andernfalls wird in Zukunft eine adäquate – den Leitlinien entsprechende – konservative Therapie dieser Patienten, die weder operativ noch interventionell behandelt werden können, nicht mehr möglich sein.

2-Methoxyestradiol and analogs as novel antiproliferative agents: analysis of three-dimensional quantitative structure-activity relationships for DNA synthesis inhibition and estrogen receptor binding

2-Methoxyestradiol (2-MEO), a metabolite of estrogen, is an attractive lead compound for the development of novel antitumor and anti-inflammatory agents, because it embodies antiproliferative and antiangiogenic activities in one molecule. However, the affinity of 2-MEO for the estrogen receptor would lead to undesirable side effects. As a prelude to the design of 2-MEO-like compounds with an optimal activity profile, we assayed 2-MEO and a series of analogs for their ability to cause G(1) cell-cycle arrest (by measuring inhibition of DNA synthesis in human cultured airway smooth muscle) and to inhibit binding of [(3)H]estradiol at the estrogen receptor (ER; from rat uterine smooth muscle). One compound, a diacetoxy enediol derivative, was identified with reasonable potency for DNA synthesis (pIC(50) = 5.97) but showed negligible affinity for the ER (pIC(50) < 5). Three-dimensional quantitative structure-activity relationships were developed for these activities using comparative molecular field analysis (CoMFA) techniques. Comparison of optimized CoMFA models revealed distinct structural requirements for DNA synthesis inhibition and ER binding. For example, DNA synthesis inhibition is enhanced by electropositive substitutions in the 2-position below the plane of the steroid A-ring, whereas ER binding is favored by electronegative substitution in this position. Similarly, DNA synthesis inhibition correlates negatively with increased steric bulk in regions clustered around the A and B rings; changes in steric bulk in these regions has little correlation with ER binding. These observations will guide the design of new analogs with improved potency for desired characteristics (e.g., DNA synthesis inhibition) with minimal unwanted activities (e.g., ER binding).

[Initial manifestation of thromboangiitis obliterans as necrotizing colitis]

Necrotizing colitis as primary manifestation of Buerger's disease. We report the disease process of a 41 year old woman, who was referred to our clinic with intermittent claudication of the leg. She has been an excessive smoker since early youth. Three years ago a hemicolectomy was carried out because of a necrotizing colitis. The clinical, angiographic and histologic findings are presented. Finally the frequency of intestinal Buerger's disease and the types of clinical course are discussed.

Differences in treatment and outcome of patients with acute myocardial infarction admitted to hospitals with compared to without departments of cardiology; results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA 1+2) Registries and the Myocardial Infarction Registry (MIR)

AIMS

The specialty of the admitting physician may influence treatment and outcome in patients with acute myocardial infarction.

METHODS AND RESULTS

The pooled data of three German acute myocardial infarction registries: the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) 1+2 studies and the Myocardial Infarction Registry (MIR) were analysed. Patients admitted to hospitals with departments of cardiology were compared to hospitals without such departments. A total of 24 814 acute myocardial infarction patients were included, 9020 (36%) patients at 91 (29.8%) hospitals with departments of cardiology and 15 794 (64%) at 214 (70.2%) hospitals without cardiology departments. There were only minor differences in patient characteristics and prevalence of concomitant diseases between the two types of hospital. The first electrocardiogram was more often diagnostic at hospitals with cardiology departments (71.8% vs 66.5%, P<0.001). Reperfusion therapy and adjunctive medical therapy, such as aspirin, beta-blockers and ACE-inhibitors were used more often at cardiology departments (all P -values <0.001), even after adjustment for confounding parameters. Treatment improved at both types of hospital over time. Admission to a hospital with a department of cardiology was independently associated with a lower hospital mortality (14.2% vs 15.4%, adjusted OR=0.91; 95%CI: 0.83-0.99). Additional logistic regression models showed that the higher use of reperfusion therapy and recommended concomitant medical therapy was responsible for most of the survival benefit at such hospitals.

CONCLUSION

Treatment of acute myocardial infarction patients at hospitals with departments of cardiology was independently associated with a higher use of recommended therapy and a lower hospital mortality compared to hospitals without such departments.

Impact of prehospital delay on mortality in patients with acute myocardial infarction treated with primary angioplasty and intravenous thrombolysis

BACKGROUND

In patients with acute myocardial infarction treated with thrombolysis, longer times to treatment are associated with increasingly worse clinical outcome. This relation may be different for treatment with primary angioplasty.

METHODS

We analyzed the pooled data of the German acute myocardial infarction registries Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) and Myocardial Infarction Registry (MIR) to determine the influence of prehospital delays on hospital mortality rates. Primary angioplasty was performed in 1063 patients and thrombolysis in 7552 patients.

RESULTS

In patients treated with thrombolysis, in-hospital time to treatment was constantly 30 minutes median. In patients treated with primary angioplasty, in-hospital time to treatment increased from 60 minutes median up to 87 minutes median with increasing prehospital delay. Hospital mortality rates slightly decreased with increasing prehospital delays in patients treated with primary angioplasty (P for trend =.02). However, in patients treated with thrombolysis, mortality rate was nonsignificantly increased (P for trend =.11). Logistic regression analysis showed no significant difference in mortality rates between primary angioplasty and thrombolysis for prehospital delays of <3 hours. However, when prehospital delay was >3 hours, thrombolysis was independently associated with a higher mortality rate compared with primary angioplasty.

CONCLUSIONS

Compared with thrombolysis, primary angioplasty is independently associated with a lower mortality rate in prehospital delays of >3 hours. The reason for this may be a time-dependent loss of efficacy to achieve reperfusion for thrombolysis but not for primary angioplasty.

Primary angioplasty versus intravenous thrombolysis in acute myocardial infarction: can we define subgroups of patients benefiting most from primary angioplasty? Results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction Registry and the Myocardial Infarction Registry

OBJECTIVES

We sought to determine the effectiveness of primary angioplasty compared with thrombolysis in clinical practice.

BACKGROUND

In clinical practice, primary angioplasty for the treatment of acute myocardial infarction (AMI) has not yet been proven more effective than intravenous thrombolysis, nor have subgroups of patients been identified who would perhaps benefit from primary angioplasty.

METHODS

The pooled data of two AMI registries--the Maximal Individual TheRapy in Acute myocardial infarction (MITRA) study and the Myocardial Infarction Registry (MIR)--were analyzed. A total of 9,906 lytic-eligible patients with AMI, with a pre-hospital delay of < or =12 h, were treated with either primary angioplasty (n = 1,327) or thrombolysis (n = 8,579).

RESULTS

Despite differences in the patients' characteristics and concomitant diseases between the two groups, the prevalence of adverse risk factors was balanced. Univariate analysis of hospital mortality showed a more favorable course for patients treated with primary angioplasty: 6.4% versus 11.3% (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.43 to 0.67). This was confirmed by logistic regression analysis (multivariate OR 0.58, 95% CI 0.44 to 0.77). Primary angioplasty was associated with a lower mortality in all subgroups analyzed. We observed a significant correlation between mortality and absolute risk reduction (r = 0.82, p < 0.0001) in the different subgroups: as mortality increased, there was an increase in absolute benefit of primary angioplasty compared with thrombolysis.

CONCLUSIONS

These large registry data showed the effect of primary angioplasty to be more favorable than thrombolysis for the treatment of patients with AMI in clinical practice. This effect was not restricted to special subgroups of patients. As mortality increased, the absolute benefit of primary angioplasty also increased.

Primary angioplasty versus no reperfusion therapy in patients with acute myocardial infarction and a pre-hospital delay of > 12-24 hours: results from the pooled data of the maximal individual therapy in acute myocardial infarction (MITRA) registry and the myocardial infarction registry (MIR)

OBJECTIVE

In patients with acute myocardial infarction (AMI), treatment with thrombolysis is superior to no reperfusion therapy only up to 12 hours after the onset of symptoms. There are no data addressing whether this time limit is also justified for treatment with primary angioplasty.

DESIGN

The pooled data of two German ST-segment elevation AMI registries, the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) study and the Myocardial Infarction Registry (MIR), were analyzed.

PATIENTS

Out of 22,749 patients, eight hundred and forty-eight with a pre-hospital delay of > 12 hours and < or = 24 hours were treated with either primary angioplasty (94/848; 11.1%) or no reperfusion therapy (754/848; 88.9%).

RESULTS

Patients treated with primary angioplasty were 10 years younger (59 years versus 69 years; p = 0.001), more often male [72.3% versus 59.9%; odds ratio (OR) = 0.57; 95% confidence interval (CI) = 0.36-0.92] and less likely to be diabetics (17% versus 27.2%; OR = 0.55; 95% CI = 0.31-0.97). Hospital mortality was 8.5% in patients treated with primary angioplasty compared to 17.1% in patients with no reperfusion therapy (OR = 0.45; 95% CI = 0.21-0.95; p = 0.033) and the combined endpoint (death, reinfarction or stroke) occurred significantly less often (11.7% versus 20.3%; OR = 0.52; 95% CI =0.27-1; p = 0.045). However, multiple logistic regression showed only a non-significant trend for lower mortality (OR = 0.54; 95% CI =0.20-1.23) and the combined endpoint (OR = 0.65; 95% CI = 0.29-1.31) in patients treated with primary angioplasty.

CONCLUSIONS

These data show the possibility of a benefit of primary angioplasty over conservative treatment in patients with pre-hospital delays of > 12 up to 24 hours, although multiple logistic regression analysis failed to find significant differences between treatments. This might be due to inadequate study power or a selection bias. These findings encourage further investigation of this subject.

7-Alkyl- and 7-cycloalkyl-5-aryl-pyrrolo[2,3-d]pyrimidines--potent inhibitors of the tyrosine kinase c-Src

7-Substituted-5-aryl-pyrrolo[2,3-d]pyrimidines have been prepared starting from alpha-bromoacetophenones. These compounds represent a novel class of potent inhibitors of the tyrosine kinase pp60(c-Src) with good specificity towards other tyrosine kinases (EGF-R, v-Abl).

7-Pyrrolidinyl- and 7-piperidinyl-5-aryl-pyrrolo[2,3-d]pyrimidines--potent inhibitors of the tyrosine kinase c-Src

7-Heterocyclyl-5-aryl-pyrrolo[2,3-d]pyrimidines represent a new class of highly potent and selective inhibitors of the tyrosine kinase pp60(c-Src).

Effect of preinfarction angina pectoris on outcome in patients with acute myocardial infarction treated with primary angioplasty (results from the Myocardial Infarction Registry

Preinfarction angina is associated with better clinical outcome in patients with acute myocardial infarction (AMI) who receive intravenous thrombolysis. This has not been proved in patients with AMI treated with primary angioplasty. We analyzed the data of the prospective multicenter Myocardial Infarction Registry (MIR). Of 14,440 patients with AMI, 774 with a prehospital delay of < or =12 hours were treated with primary angioplasty. Five hundred thirty-two patients (68.7%) had preinfarction angina. Patients with preinfarction angina were slightly older than patients without (63 vs 62 years, p = 0.042), prehospital delay was 1 hour longer (180 vs 120 minutes, p = 0.001), and arterial hypertension was more prevalent (47.6% vs 32.2%, odds ratio [OR] 1.91, 95% confidence intervals [CI] 1.39 to 2.62). There was no significant difference in hospital mortality (5.6% vs 3.3%, OR 1.75, 95% CI 0.79 to 3.87), reinfarction, stroke, or the combined end point of death, reinfarction, or stroke between the 2 groups. Logistic regression analysis showed no association of preinfarction angina with the occurrence of either death (OR 2.21, 95% CI 0.91 to 6.08) or the combined end points (OR 1.10, 95% CI 0.55 to 2.31). There was also no significant difference in mortality (6% vs 5.1%, OR 1.19, 95% CI 0.56 to 2.52), reinfarction, stroke, postinfarction angina, or the combined end points between patients with preinfarction angina within 48 hours compared with patients with preinfarction angina between 49 hours and 4 weeks before the AMI. Thus, the MIR data showed no protective effects of preinfarction angina in patients with AMI treated with primary angioplasty.

Decreasing hospital mortality between 1994 and 1998 in patients with acute myocardial infarction treated with primary angioplasty but not in patients treated with intravenous thrombolysis. Results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) Registry and the Myocardial Infarction Registry (MIR)

OBJECTIVES

We investigated changes in the clinical outcome of primary angioplasty and thrombolysis for the treatment of acute myocardial infarction (AMI) from 1994 to 1998.

BACKGROUND

Primary angioplasty for the treatment of AMI is a sophisticated technical procedure that requires experienced personnel and optimized hospital logistics. Growing experience with primary angioplasty in clinical routine and new adjunctive therapies may have improved the outcome over the years.

METHODS

The pooled data of two German AMI registries: the Maximal Individual Therapy in AMI (MITRA) study and the Myocardial Infarction Registry (MIR) were analyzed.

RESULTS

Of 10,118 lytic eligible patients with AMI, 1,385 (13.7%) were treated with primary angioplasty, and 8,733 (86.3%) received intravenous thrombolysis. Patients characteristics were quite balanced between the two treatment groups, but there was a higher proportion of patients with a prehospital delay of >6 h in those treated with primary angioplasty. The proportion of an in-hospital delay of more than 90 min significantly decreased in patients treated with primary angioplasty over the years (p for trend = 0.015, multivariate odds ratio [OR] for each year of the observation period = 0.84, 95% confidence interval [CI]: 0.73-0.96) but did not change significantly in patients treated with thrombolysis. Hospital mortality decreased significantly in the primary angioplasty group (p = 0.003 for trend; multivariate OR for each year = 0.73, 95% CI: 0.58-0.93). However, for patients treated with thrombolysis, hospital mortality did not change significantly (p for trend 0.175, multivariate OR for each year: 1.02, 95% CI: 0.94- 1.11).

CONCLUSIONS

Compared with thrombolysis the clinical results of primary angioplasty for the treatment of AMI improved from 1994 to 1998. This indicates a beneficial effect of the growing experience and optimized hospital logistics of this technique over the years.

Transfer of patients with acute myocardial infarction for primary or acute angioplasty from hospitals without the facilities to perform angioplasty. Results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) Registry and the Myocardial Infarction Registry (MIR)

In patients with acute myocardial infarction (AMI) admitted at hospitals without angioplasty facilities there are some subgroups of patients which seem to profit from a transfer to primary or acute angioplasty. However, current clinical practice at such hospitals is unknown. We analyzed the pooled data of the German acute myocardial infarction registries MITRA and the MIR. Angioplasty was not available at 221/271 hospitals (81.5%). Out of 14,487 patients with acute myocardial infarction admitted to these hospitals, 50.1% (7,259/14,487) received thrombolysis at the initial hospital and 3.6% (523/14,487) were transferred. Out of the transferred patients, 55.3% (289/523) were treated with primary angioplasty and 44.7% (234/523) received a combination of thrombolysis and angioplasty. The proportion of transferred patients increased from 1.1% in 1994 to 5.5% in 1998 (p for trend = 0.001). One hundred and four hospitals (47.1%) never transferred patients. Patients transferred for primary angioplasty (289 patients) were compared to patients treated with thrombolysis at the initial hospitals (7,259 patients). Multivariate analysis showed the following independent predictors for transfer of patients for primary angioplasty: contraindications for thrombolysis (OR = 17.9), a non-diagnostic first ECG (OR = 4.0), pre-hospital delay > 6 hours (OR = 2.5), unknown symptom onset of the acute myocardial infarction (OR = 2.0) and anterior wall acute myocardial infarction (OR = 1.6). Heart failure at admission was the only independent predictor not to transfer patients (OR = 0.40). In Germany only 47.1% of hospitals without angioplasty facilities transfer patients with acute myocardial infarction to primary or acute angioplasty. The proportion of transferred patients increased from 1.1% in 1994 to 5.5% in 1998. Contraindications for thrombolysis were the strongest predictor to transfer patients to primary angioplasty.

Safety and efficacy of eptifibatide vs placebo in patients receiving thrombolytic therapy with streptokinase for acute myocardial infarction; a phase II dose escalation, randomized, double-blind study

AIMS

Thrombolytic therapy restores coronary patency in patients with acute myocardial infarction, although normal perfusion (TIMI 3 flow) is not achieved in all patients. In an attempt to improve TIMI 3 flow, a combination of full-dose streptokinase, aspirin and escalating dosages of a platelet glycoprotein IIb/IIIa receptor blocker, eptifibatide, vs placebo were tested.

METHODS AND RESULTS

A bolus of 180 microg. kg(-1)of eptifibatide was administered in each group, followed by a 72 h continuous infusion of 0.75 (44 patients), 1.33 (n=45) and 2.00 microg. kg(-1). min(-1)(n = 30); 62 patients received placebo. Normal perfusion (TIMI 3 flow) at 90 min was observed in 31% of placebo patients compared to 46, 42 and 45% in the ascending eptifibatide groups (44% for combined eptifibatide groups, P = 0.07). Patency (TIMI 2 and 3 flow combined) increased from 61% (placebo) to 78% for the combined eptifibatide groups (P = 0.02). Reocclusion was infrequent. No differences were observed in TIMI flow grades among eptifibatide groups. Major and minor bleeding was increased and occurred mainly at the arterial puncture site.

CONCLUSION

A combination of full dose streptokinase with different eptifibatide regimens enhanced coronary perfusion, but bleeding risk was excessive. Additional trials are needed with different dosage regimens to determine the optimal combination of fibrinolytic agents and platelet glycoprotein IIb/IIIa receptor blockers.

Tyrosine kinase inhibition in bone metabolism

Inhibition of tyrosine kinase signaling has become increasingly important as a therapeutic approach for a variety of diseases, initially for cancer, but also for inflammatory and non-malignant hyperproliferative diseases (psoriasis) amongst others. Recently, inhibitors of the tyrosine kinase c-Src, have for the first time been shown to reduce bone loss after estrogen withdrawal in an animal model of osteoporosis. Here we review the current state of knowledge on the effects of tyrosine kinase inhibition on bone metabolism with a particular emphasis on inhibitors of c-Src.

Substituted 5,7-diphenyl-pyrrolo[2,3d]pyrimidines: potent inhibitors of the tyrosine kinase c-Src

5,7-Diphenyl-pyrrolo[2,3d]pyrimidines represent a new class of highly potent inhibitors of the tyrosine kinase c-Src (IC50 < 50 nM) with specificity against a panel of different tyrosine kinases. The substitution pattern on the two phenyl rings determines potency and specificity and provides a means to modulate cellular activity.

[Fibrinolytic, revascularizing therapy of peripheral arterial occlusive disease]

Thrombo-embolic events are the primary or secondary cause for occlusions of peripheral arteries. The systemically applied fibrinolysis rarely resulted in revascularization. The local application of plasminogen activators leads to better results. Combined with interventionally techniques 70-80% of the acute und subacute occlusions can be opened an the necessity of angio-surgical interventions can be reduced by about 50%. The technical procedure of the local fibrinolysis and the dosages of the applied activators are presently not standardized. Therefore the results of 13 reports between the years 1995-1998 including 4 prospective studies are not comparable. According to the present experiences, acute und subacute incomplete ischemia syndromes are to be seen as indication for local lysis. Especially for patients whose constitution is not optimal for surgery, local fibrinolysis is an alternative to surgical revascularization. Further studies are necessary to optimize the therapy.

[Cardiovascular risk in arterial vascular surgery reconstruction]

Perioperative cardiac complications can limit the outcome after major vascular surgery where the underlying severe coronary artery disease is considered to be the main source. We describe the results of a prospective study including 201 patients undergoing elective vascular surgery. After looking at the encouraging low complication rate (mortality 0.99%, non-fatal myocardial infarction 2.98%, cardiac complications 9.95%) we would recommend the discussed diagnostic strategy. Specialized and expensive cardiac testing should be reserved for a few cases.

[Acute myocardial infarction in Germany between 1996 and 1998: therapy and intrahospital course. Results of the Myocardial Infarction Registry (MIR) in Germany]

The "Myocardial Infarction Registry" in Germany (MIR) is a multicenter and prospective registry of consecutively included, unselected patients with acute myocardial infarction. The purpose of MIR is to document the actual praxis of decision making and prescribing of an optimized infarction therapy in AMI patients. Optimized infarction therapy is defined as the combination of reperfusion therapy and ASS, betablocker, and ACE inhibitor.14,598 patients with acute myocardial infarction were included between 12/96 and 5/98 in 217 hospitals throughout Germany. 68% of the patients were male; mean age was 67 years. The prehospital delay time was 195 minutes in median, the first ECG was diagnostic in 66% of the patients. A reperfusion therapy was applied in 46.1% of the patients (thrombolysis 36.2%, primary PTCA 9.9%). During the acute phase, the following adjunctive therapy was used: ASS in 90.3%, betablockers in 53.8%, and ACE inhibitors in 52.5%. Intrahospital mortality was 15.4%. Compared to hospitals without cardiologists, the hospitals with cardiologist had a lower intrahospital mortality (13.8% versus 16.1%; p < 0.001). Reasons are the more frequent use of a reperfusion therapy by cardiologists (54.3% versus 42.3%; p < 0. 001) and the availability of a catheter laboratory with PTCA facilities.A lower intrahospital mortality was associated with each therapy of the optimized infarction therapy: reperfusion therapy (odds ratio 0.7; 95% CI: 0.5-0.8), ASS (odds ratio 0.6; 95% CI: 0. 5-0.8), betablocker (odds ratio 0.6; 95% CI: 0.5-0.7) and ACE inhibitor (odds ratio: 0.5; 95% CI: 0.4-0.7). However, patients with poor initial prognosis - such as cardiogenic shock, hypotension and/or bradycardia - could not benefit from the orally adjunctive therapy. This fact may have led to an overestimation of the influence on intrahospital mortality. In representative communal German hospitals, a reperfusion therapy in combination with an optimized adjunctive therapy in patients with acute myocardial infarction is associated with a reduction in intrahospital mortality. Compared to previous registries, the application of betablockers and ACE inhibitors was clearly increased. Reasons could be the participation in a quality registry, the obligation to document why a therapy has not been given and repeated and intensified education of the treating physicians.Thus, the mainly communal hospitals in Germany are increasingly following recommendations about the early treatment of acute myocardial infarction. Myocardial infarction registries such as MIR reflect daily prescribing habits in hospitals and describe the implementation of the results of randomized trials into daily routine.

Comparative results of thrombolysis treatment with rt-PA and urokinase: a pilot study

BACKGROUND

The aim of the following prospective study was to investigate whether patients benefited from locoregional lysis treatment of recent deep leg vein thrombosis after 1 year.

PATIENTS AND METHODS

The prospective study included 69 patients aged between 22 and 58 years, in whom recent lower leg vein and popliteal vein thromboses were diagnosed by phlebography. Patients were randomized to one of three treatment groups: one group was treated for a maximum of 7 days with full heparinization and daily dose of 20 mg rt-PA administered locoregionally over a period of 4 hours; a second group received 100,000 IU/h urokinase locoregionally for a maximum of 7 days, in addition to full heparinization; and in the third group (control group), intravenous heparin infusions after PTT constituted the only form of treatment. All patients were given phenprocoumon from day 7 and received compression treatment. Before treatment began and before the course of phenprocoumon started, phlebography and colour duplex sonography examinations were carried out. After 12 months, follow-up duplex sonography was conducted to evaluate the reflux times over the popliteal vein and the degree of patency of the deep leg veins.

RESULTS

Complete lysis was achieved in 6 of 22 patients in the recombinant tissue plasminogen activator (rt-PA) group and in 11 of 22 patients in the urokinase group. At follow-up examination after 12 months, there were serious post-thrombotic changes in 14 of 22 patients in the rt-PA group, in 9 of 22 patients in the urokinase group and in 15 of 22 patients in the group of patients who received no lysis treatment.

CONCLUSION

Patients with recently formed thromboses in the lower leg and popliteal veins who underwent 7 days of locoregional lysis treatment with urokinase demonstrated significantly fewer clinical symptoms of post-thrombotic syndrome after 1 year than those who received locoregional treatment with rt-PA over a similar period or a control group treated with anticoagulants only.

A rare complication with an Anthéor vena cava filter

A case of an embolization of an Anthéor vena cava filter into the pulmonary artery with disastrous exit 9 days after placement is described. The possible reasons are discussed.

[Ultrasound angiography in diagnosis of deep venous thrombosis and post-thrombotic syndrome. A prospective comparative study]

PURPOSE

Aim of the present study was to establish the value of ultrasound angiography compared with colour duplex sonography and phlebography in the diagnosis of deep venous thrombosis of the leg and insufficiency of the perforating vein.

METHOD

Sixty-two patients with deep venous thrombosis of the leg and 30 patients with post-thrombotic syndrome and perforating vein insufficiency underwent diagnostic examination by colour duplex sonography, ultrasound angiography and phlebography. Endoscopic varicose surgery was taken as the gold standard for diagnosis of perforating vein insufficiency.

RESULTS

In the diagnosis of deep venous thrombosis, the specificity of colour duplex sonography was 92% in the thigh, 100% in the popliteal area and 89% in the lower leg. Colour angiography showed higher specificity. 95%, in the lower leg. In a diagnosis of perforating vein insufficiency, accuracy specificity of the three procedures was 60% for colour duplex sonography, 47% for phlebography and 80% for ultrasound angiography.

CONCLUSIONS

The diagnosis of venous thromboses in the lower leg can be further improved by means of ultrasound angiography. Ultrasound angiography is the best method for demonstrating insufficiency of the perforating vein.

Beta-blockers and nitrates in patients with peripheral arterial occlusive disease: long-term findings

METHODS

The effect of 6 months' administration of celiprolol, atenolol and isosorbide dinitrate on peripheral arterial occlusive disease (PAOD), double-blind and placebo-controlled, was investigated in 56 patients with chronic ischaemic heart disease and stage IIb PAOD, using as criteria the walking distance and the change in resistance index in the femoral artery. The placebo group consisted of 14 patients with chronic ischaemic heart disease and the same stage of PAOD.

RESULTS

Patients on 50 mg/day atenolol showed a significant reduction in both pain-free and maximal walking range compared with the controls. In contrast, those taking 200 mg/day celiprolol and those on 80 mg/day isosorbide dinitrate demonstrated significant increases in pain-free and maximal, walking distance compared with the control group. The colour duplex sonographically measured Doppler flow through the femoral artery showed a significant decrease both in the patients taking celiprolol and in those on isosorbide dinitrate, while in those receiving atenolol the resistance index increased significantly.

CONCLUSIONS

The study shows that the beta-adrenoceptor blocker celiprolol also possesses a nitrate-like vasodilatory property and can be used in patients with chronic ischaemic heart disease and impaired peripheral arterial blood flow.

Digitoxin intoxication with lethal outcome

A 65-year old woman with known history of reactive depression and failed suicide attempts ingested 7 mg digitoxin at 09.00 h. After vomiting 4 hours later, she reported the drug intake to her husband who thereupon summoned a physician. Arriving at 16.00 h, the physician was informed about the suicide attempt, but failed to initiate any specific measures. After a second doctor's visit at 22.00 h, the patient was rushed to hospital in a moribund state. In spite of a gastric lavage, treatment with activated charcoal and insertion of a transvenous pacemaker, the patient died at 23.45 h with signs of total atrioventricular block. Digitalis fab fragments could not be administered in time. A calculation based on the plasma digitoxin concentration of 212 ng.ml-1 measured at 23.00 h indicated that nearly the entire ingested dose had been absorbed. Thus, neither the vomiting nor the gastric lavage eliminated significant amounts of the drug which had left the stomach without delay. Under these circumstances, the failure to initiate timely therapy with specific digitalis fab fragments ultimately contributed to the lethal outcome.

Comparison of tissue plasminogen activator and urokinase in the local infiltration thrombolysis of peripheral arterial occlusions

Recanalization of the vascular lumen by means of local fibrinolysis is of major importance in the treatment of peripheral arterial occlusive disease. While urokinase and streptokinase have been extensively used for local fibrinolysis, there have been few studies of infiltration thrombolysis with genetically engineered tissue plasminogen activator (rt-PA). The aim of the investigation reported here was to establish whether there is any difference between urokinase and rt-PA in the short- and long-term outcome of local fibrinolytic therapy. One-hundred twenty patients (70 men, 50 women) with acute or subacute femoral (n = 21), femoropopliteal (n = 33), popliteal (n = 13) or popliteocrural (n = 53) thrombotic occlusions were randomized to local lysis using urokinase or rt-PA, and 6 months later follow-up investigations took place. Recanalization of thrombotically occluded vessels, particularly in the lower leg, was found more frequently, and after treatment of shorter duration, with rt-PA. Large local haematomas occurred in 8% of cases in the urokinase group and 15% in the rt-PA group. No serious haemorrhages were encountered in either group. Six months after treatment, the rt-PA group showed lower rates of Fontaine stage III and IV disease and amputation than the urokinase group, with a higher number of patients in Fontaine stage IIb. This study shows that local lysis with rt-PA yields better results than urokinase, not only in the short term but also 6 months later.

[Are beta-blockers generally contraindicated in patients with peripheral arterial occlusive disease?]

Ninety patients with chronic ischemic heart disease and stage IIb peripheral arterial occlusive disease were investigated to determine the effect of celiprolol, atenolol and isosorbide dinitrate on peripheral arterial blood flow. Walking distance and the resistance index in the femoral artery were measured before and after 3 months medication and compared with the findings in controls (30 patients with chronic ischemic heart disease and stage IIb peripheral arterial occlusive disease) who received placebo. Patients with peripheral arterial occlusive disease who were treated with atenolol 50 mg/day demonstrated significant decreases in both pain-free and maximal walking distance. In contrast, the walking distances in those given celiprolol 200 mg/day and those who received isosorbide dinitrate 80 mg/day did not differ from the distances in control subjects. The Doppler flow through the femoral artery, as measured by color duplex sonography, showed a significant decrease in resistance index, both in patients given celiprolol and in those given isosorbide dinitrate. In patients treated with atenolol the resistance index rose significantly. The results of this study confirm that the beta-adrenoceptor blocker celiprolol exerts a supplementary vasodilatory action resembling that of nitrates and hence can be used in patients with chronic ischemic heart disease and impaired peripheral arterial perfusion.

Non coded C alpha, alpha-disubstituted amino acids. X-ray diffraction analysis of a dipeptide containing (S)-alpha-methylserine

The crystal and molecular structure of the fully protected dipeptide Boc-Val-(S)-alpha-MeSer-OMe has been determined by X-ray diffraction techniques. Crystals grown from ethyl acetate/n-pentane mixtures are tetragonal, space group I4(1), with cell parameters at 295 K of a = 15.307(2), c = 18.937(10)A, V = 4437.1A3, M.W. = 332.40, Z = 8, Dm = 0.99 g/cm3 and Dx = 0.995 g/cm3. The structure was solved by application of direct methods and refined to an R value of 0.028 for 1773 reflections with I > or = 3 sigma (I) collected on a CAD-4 diffractometer. Both chiral centers have the (S) configuration. The dipeptide assumes in the solid state an S shape. The urethane moiety is in the cis conformation, while the amide bond is in the common trans conformation. The conformational angles phi 1, psi 1 of the Val and phi 2, and psi 2 of the (S)-alpha MeSer fall in the F region of the phi-psi map. The isopropyl side chain of the Val residue has the (t, g-) conformation, while the Ser side chain has a g+ conformation. The hydrogen bond donor groups are all involved in intermolecular H-bond interactions. Along the quaternary axis the dipeptide molecules are linked to each other with the formation of infinite rows.

[Value of color-coded duplex sonography in diagnosis of extracranial vascular changes]

72 patients at the age of 44 to 76 years with transitory ischaemic attacks which happened and for a short time reversible deficits, respectively, were diagnosed both conventionally duplex-sonographically and with the colour-coded duplex sonography under the question of vascular stenotic process in the region of the cervical vessels. After the ultrasound examination within two weeks an angiography was performed. As a result was shown that in 10 patients with an angiogram without pathological findings by means of the colour-coded duplex sonography in 3 cases plaque formations could be proved which could be clearly diagnosed only by colour marking.

[Experiences with the Günther filter]

In the investigation 17 patients with lung embolism being cared for with a Guenther-filter were post-observed during a period up to two years. Early complications after the implantation of the Guenther-filter did not occur in any case. Late complications after the implantation of the Guenther-filter were dislocations, deformations of the filter and breaks of the spokes. In the result of the post-observation the Guenther-filter application despite its easy handling should be regarded very critically.

[Early complications after acute cerebrovascular insufficiency]

In the present paper the courses of the disease of 117 patients who due to an acute cerebrovascular insufficiency were admitted to the angiological department of a Dresden county hospital in the period from January 1989 to June 1990. Early complications which were frequently observed were urinary tract infections, pneumonias and recidivations of insult. On the basis of the results of examination can be confirmed that the prognosis is decisively determined by the ability of mobilisation during the first days.

[Results of using EEG and carotid angiography for evaluating cerebrovascular insufficiency]

In the cerebrovascular disease the EEG can give references at localisation, extension and course. The ability of statement is increased by methods of provocation and activation. On 35 patients with cerebrovascular insufficiency can be indicated that there are good correlations between changes on the large cerebral supply vessels and changes of the EEG, in particular in the carotid pressure trial.

[Doppler sonography in the diagnosis of extracranial vascular changes]

On account of cerebrovascular insufficiencies or asymptomatic vascular noises which had taken place 45 patients were examined by means of Doppler sonography and after this by means of angiography. The judgement of the common carotid artery, the internal and external carotid arteries, the vertebral artery, the subclavian artery and the supratrochlear artery were involved into the ultrasound investigation. The sensitivity of the supratrochlear compression test was 50% in the diagnosis of high-degree stenoses and occlusions of the internal carotid artery, whereas the sensitivity of the complete ultrasound investigation way about 80%. The advantages and disadvantages of the ultrasound Doppler sonography investigation are discussed.

Conformational studies on host-guest peptides containing chiral alpha-methyl-alpha-amino acids. Comparison of the helix-inducing potential of alpha-aminoisobutyric acid, (S)-2-ethylalanine and (S)-2-methylserine

The conformational behaviour of host-guest peptides of the type Ac-Ala-Xxx-Ala-Ala-Xxx-Ala-Ala-Xxx-Ala-Ala-NH-PEGM (Xxx = alpha-aminoisobutyric acid (Aib), (S)-2-ethylalanine ((S)-Iva), (S)-2-methylserine ((S)-alpha-MeSer)) has been studied by CD spectroscopy in CF3CH2OH, CH3OH, and water and by i.r. spectroscopy in CHCl3 and in the solid state. In this way the relative helix-inducing potential of the two chiral alpha-methyl-alpha-amino acids (S)-Iva and (S)-alpha-MeSer could be established in comparison to the strong helix-former Aib. The results show that (S)-Iva exerts a comparable helix-inducing effect as Aib, making this amino acid a valuable complementary tool for the stabilization or induction of helices. No significant helix-promoting effect was observed for (S)-alpha-MeSer in polar solvents; however, the i.r.-spectroscopic data in CHCl3 and in the solid state point to a helical conformation under these conditions. Possible reasons for the different behaviour of (S)-Iva and (S)-alpha-MeSer are briefly discussed.

[Transcutaneous and intracutaneous pO2 measurements in the assessment of peripheral arterial occlusive diseases]

The purpose of the study was to compare the results of intra- and transcutaneous pO2-measurements of patients suffering from an arterial occlusive disease of the lower extremities (Fontaine I-IV) with that of 20 healthy volunteers. The measurements were performed by one transcutaneous and two intracutaneous pO2-electrodes on the dorsum of the foot. As reference we used the ratio pf/pft of the venous occlusion plethysmography of the calf. Already at rest the transcutaneous pO2 allows a significant separation of healthy persons and patients of Fontaine II. After a 3-minute ischemic period the greatly changed time parameters 'delay-time', 'half-time of the pO2 increase' as well as the 'pO2 recovery time' permit a significant separation of Fontaine III from healthy persons and Fontaine II. The findings show that both methods complete one another. The value of a local pO2 measurement for an individual therapy control is emphasized.

[Thrombolytic treatment of peripheral arterial circulatory disorders with streptokinase]

The purpose of these investigations is to refer to the possibility of the reconstructive treatment of arterial obstructions by means of streptokinase. New application methods improved the chances of success of fibrinolysis. They run about 50%. The local application of smaller doses of streptokinase confines the contraindications to a certain extent. Obstruction in the pelvic area which are not older than three months and such ones in the femoropopliteal part up to 6 weeks are to be regarded as indication to the fibrinolysis. In the care of patients with arterial obstructive diseases importance should, therefore, be attached to the fact that thrombotic shifts should be recognized in time an the possibility of a fibrinolytic therapy is tested within the periods mentioned.

[Rheologic problems of microcirculation and consequences of drug therapy for sudden deafness]

Microcirculation depends on the undisturbed functioning of the vessel walls as well as of the blood cells and plasma. Flow troubles are always highly complex. Viscosity of blood and plasma is of particular clinical interest, and so are the flexibility of red blood cells including the haemoconcentration and the physiology of coagulation. The authors concentrated on the "local hyperviscosity syndrome", which is one of the primary problems in disturbances of microcirculation, as the basis for their treatment of sudden deafness by fibrinolysis with streptokinase.