Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results

PURPOSE

We evaluated the efficacy of botulinum-A toxin injections into the detrusor muscle in patients with spinal cord injury, detrusor hyperreflexia and urge incontinence resistant to anticholinergic drugs. The purpose of treatment was to suppress incontinence episodes and increase functional bladder capacity.

MATERIALS AND METHODS

Included in our prospective nonrandomized study done at 2 clinics were 31 patients with traumatic spinal cord injury who emptied the bladder by intermittent self-catheterization. These patients had severe detrusor hyperreflexia and incontinence despite a high dose of anticholinergic medication. Pretreatment evaluation included a clinical examination and complete urodynamic investigation. Under cystoscopic control a total of 200 to 300 units of botulinum-A toxin were injected into the detrusor muscle at 20 to 30 sites (10 units per ml. per site), sparing the trigone. Clinical and urodynamic followup was planned for 6, 16 and 36 weeks after treatment. Patients were asked to decrease their intake of anticholinergic drugs during week 1 after treatment.

RESULTS

Of the 21 patients 19 underwent a complete examination 6 weeks after the botulinum-A toxin injections, and 11 at 16 and 36 weeks. At the 6-week followup complete continence was restored in 17 of 19 cases in which anticholinergic medication was markedly decreased or withdrawn. Less satisfactory results in 2 cases were associated with an insufficient dose of 200 units botulinum-A toxin. After the injections overall mean reflex volume and mean maximum cystometric bladder capacity plus or minus standard deviation significantly increased from 215.8 +/- 90.4 ml. to 415.7 +/- 211.1 (p <0.016) and 296.3 +/- 145.2 to 480.5 +/- 134.1 (p <0.016), respectively. There was also a significant decrease after treatment in mean maximum detrusor voiding pressure from 65.6 +/- 29.2 cm. water to 35 +/- 32. 1 (p <0.016). Mean post-void residual urine volume catheterized at the end of the urodynamic examination increased significantly from a mean of 261.8 +/- 241.3 ml. to 490.5 +/- 204.8 (p <0.016). Moreover, autonomic dysreflexia associated with bladder emptying that manifested as a hypertensive crisis during voiding disappeared after treatment in the 3 patients with tetraplegia. Satisfaction was high in all successfully treated patients and no side effects were observed. Ongoing improvement in urodynamic parameters and incontinence was already present in all patients reevaluated at 16 and 36 weeks.

CONCLUSIONS

Botulinum-A toxin injections into the detrusor seem to be a safe and valuable therapeutic option in spinal cord injured patients with incontinence resistant to anticholinergic medication who perform clean intermittent self-catheterization. Successfully treated patients become continent again and may withdraw from or markedly decrease anticholinergic drug intake. A dose of 300 units botulinum-A toxin seems to be needed to counteract an overactive detrusor. The duration of bladder paresis induced by the toxin is at least 9 months, when repeat injections are required.

Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results

PURPOSE

We evaluated the efficacy of botulinum-A toxin injections into the detrusor muscle in patients with spinal cord injury, detrusor hyperreflexia and urge incontinence resistant to anticholinergic drugs. The purpose of treatment was to suppress incontinence episodes and increase functional bladder capacity.

MATERIALS AND METHODS

Included in our prospective nonrandomized study done at 2 clinics were 31 patients with traumatic spinal cord injury who emptied the bladder by intermittent self-catheterization. These patients had severe detrusor hyperreflexia and incontinence despite a high dose of anticholinergic medication. Pretreatment evaluation included a clinical examination and complete urodynamic investigation. Under cystoscopic control a total of 200 to 300 units of botulinum-A toxin were injected into the detrusor muscle at 20 to 30 sites (10 units per ml. per site), sparing the trigone. Clinical and urodynamic followup was planned for 6, 16 and 36 weeks after treatment. Patients were asked to decrease their intake of anticholinergic drugs during week 1 after treatment.

RESULTS

Of the 21 patients 19 underwent a complete examination 6 weeks after the botulinum-A toxin injections, and 11 at 16 and 36 weeks. At the 6-week followup complete continence was restored in 17 of 19 cases in which anticholinergic medication was markedly decreased or withdrawn. Less satisfactory results in 2 cases were associated with an insufficient dose of 200 units botulinum-A toxin. After the injections overall mean reflex volume and mean maximum cystometric bladder capacity plus or minus standard deviation significantly increased from 215.8 +/- 90.4 ml. to 415.7 +/- 211.1 (p <0.016) and 296.3 +/- 145.2 to 480.5 +/- 134.1 (p <0.016), respectively. There was also a significant decrease after treatment in mean maximum detrusor voiding pressure from 65.6 +/- 29.2 cm. water to 35 +/- 32. 1 (p <0.016). Mean post-void residual urine volume catheterized at the end of the urodynamic examination increased significantly from a mean of 261.8 +/- 241.3 ml. to 490.5 +/- 204.8 (p <0.016). Moreover, autonomic dysreflexia associated with bladder emptying that manifested as a hypertensive crisis during voiding disappeared after treatment in the 3 patients with tetraplegia. Satisfaction was high in all successfully treated patients and no side effects were observed. Ongoing improvement in urodynamic parameters and incontinence was already present in all patients reevaluated at 16 and 36 weeks.

CONCLUSIONS

Botulinum-A toxin injections into the detrusor seem to be a safe and valuable therapeutic option in spinal cord injured patients with incontinence resistant to anticholinergic medication who perform clean intermittent self-catheterization. Successfully treated patients become continent again and may withdraw from or markedly decrease anticholinergic drug intake. A dose of 300 units botulinum-A toxin seems to be needed to counteract an overactive detrusor. The duration of bladder paresis induced by the toxin is at least 9 months, when repeat injections are required.

Percutaneous transluminal therapy of occluded saphenous vein grafts: can the challenge be met with ultrasound thrombolysis?

BACKGROUND

Percutaneous transluminal treatment of a thrombotic vein graft yields poor results. We have previously reported our experience with transluminal percutaneous coronary ultrasound thrombolysis (CUT) in the setting of acute myocardial infarction (AMI). This report describes the first experience with ultrasound thrombolysis in thrombus-rich lesions in saphenous vein grafts (SVGs), most of which were occluded.

METHODS AND RESULTS

The patients (n=20) were mostly male (85%), aged 64+/-4 years old. The presenting symptom was AMI in 2 patients (10%) and unstable angina in the rest. Fifteen patients (75%) had totally occluded SVGs. The median age of clots was 6 days (range, 0 to 100 days). The ultrasound thrombolysis device has a 1.6-mm-long tip and fits into a 7F guiding catheter over a 0.014-in guidewire in a "rapid-exchange" system. CUT (41 kHz, 18 W, </=6 minutes) led to device success in 14 (70%) of the patients and residual stenosis of 65+/-28%. Procedural success was obtained in 13 (65%) of the patients, with a final residual stenosis of 5+/-8%. There was a low rate of device-related adverse events: 1 patient (5%) had a non-Q-wave myocardial infarction, and distal embolization was noted in 1 patient (5%). Adjunct PTCA or stenting was used in all patients. There were no serious adverse events during hospitalization.

CONCLUSIONS

Ultrasound thrombolysis in thrombus-rich lesions in SVGs offers a very promising therapeutic option.

Application of pulsed-Doppler tissue imaging in patients with dual chamber pacing: the importance of conduction time and AV delay on regional left ventricular wall dynamics

Pulsed-Doppler tissue imaging (pDTI) is able to measure myocardial wall velocities (systolic: S; early diastolic: E; late diastolic: A) and their timings. Relationships have been demonstrated between the pre-ejection period and indexes of left ventricular systolic function. This study was designed to examine with pDTI the effects of variations in atrioventricular delay (AVD) (100 ms, 150 ms, 200 ms) on myocardial dynamics and on their timings at the basal interventricular septum (IVS) from an apical approach and at the posterior wall (PW) from the parasternal view. These data were compared with stroke volume measurements recorded from the left ventricular outflow tract. Seventeen patients with dual chamber pacemakers (7 because of complete heart block, 10 with sick sinus syndrome and first-degree AV block) were studied; full atrial and ventricular capture was present at any AVD. These data were also compared with those obtained in 10 age-matched healthy volunteers with comparable heart rates.

RESULTS

Optimal atrial contribution to left ventricular filling and, consequently, best systolic performance were achieved when AVD was programmed such that a mean interval of 77 ms was allowed between the end of the A wave and the beginning of the S wave, similar to what was measured in the healthy control group by pDTI.

CONCLUSION

The noninvasive measurement of timings of the cardiac cycle by pDTI is helpful to determine the optimal AVD in individual patients.

APP RNA splicing is not affected by differentiation of neurons and glia in culture

Amyloid precursor protein (APP) gene expression was investigated in primary cultures of neurons, astrocytes, microglial cells and oligodendrocytes. Neurons from various rat brain regions, as well as oligodendrocytes, contained RNA encoding APP695, while astrocytes and microglial cells expressed high levels of RNAs for APP770 and APP751. It was studied whether the cell type-specific regulation of APP gene expression could be modified by induction of cellular differentiation in vitro. While neuronal differentiation of PC12 cells has been shown to correspond with an altered pattern of APP splicing, in the primary cultures neither the time in culture nor a treatment of the cells with appropriate differentiation factors affected this pattern.

Cortical astrocytes activated by basic fibroblast growth factor secrete molecules that stimulate differentiation of mesencephalic dopaminergic neurons

In reactive gliosis, astrocytes undergo morphological and biochemical changes which can be mimicked in vitro by treatment with bFGF (basic fibroblast growth factor) or cAMP. To investigate the influence of activated cortical astrocytes on central nervous system (CNSD) neurons, we studied the effect of the supernatant from bFGF-treated astrocytes on the development of dopaminergic neurons from rat mesencephalon. Conditioned medium of untreated astrocytes stimulated dopamine uptake of mesencephalic cultures. After activation of astrocytes with bFGF this effect was greatly enhanced. It was significantly more potent than stimulating effects of other neurotrophic factors. The supernatant of these astrocytes increased the biochemical differentiation but not the survival of dopaminergic neurons in our cell culture system. Trypsin digestion and gel chromatography revealed that the activity was due to one or several proteins with molecular mass above 5 kDa. We excluded the participation of several factors known to be produced by astrocytes or that are neurotrophic for substantia nigra cultures. In particular, we provide evidence that bFGF, BDNF, NT-3, Il-1, Il-6, S100 beta and alpha 2-macroglobulin were not involved in the effect of the conditioned medium. In vitro stimulation of astrocytes therefore triggers the expression of currently uncharacterized factors which influence the biochemical differentiation of mesencephalic dopaminergic neurons, the cells that degenerate in Parkinson's disease.

Acute occlusion in multiple lesion coronary angioplasty: frequency and management

Among 3,548 patients undergoing a percutaneous transluminal coronary angioplasty procedure, 714 had multilesion angioplasty (1,550 lesions) in a single session. Acute occlusion occurred in 22 patients (3.1%) and 29 lesions (1.9%). The patients were classified into a group undergoing multivessel angioplasty (348 patients, 785 lesions) and a group undergoing multilesion single vessel angioplasty (366 patients, 765 lesions). The rate of acute occlusion was similar in both patient groups. The multivessel angioplasty group had a 2.9% rate per patient (n = 10) and a 1.7% rate per vessel; the multilesion single vessel group had a 3.3% rate per patient (n = 12) and a 2.1% rate per lesion. Five of the 10 patients from the multivessel group with acute occlusion, but only 1 of the 12 patients with occlusion in the single vessel multilesion group, required emergency open heart surgery. No patient in either group died as a consequence of coronary angioplasty. Occlusion occurred during angioplasty in 15 of the 22 patients, and 1 to 24 h after angioplasty in 7 of 22 patients. In the group with multivessel angioplasty, acute occlusion during the procedure was mainly linked with hypotension during the second vessel dilation, whereas in this group with delayed vessel closure and in the multilesion single vessel group, existence of intimal tearing constituted the most important factor for acute occlusion (12 of 16 patients). Closure of vessel per major coronary system was evenly distributed in the multivessel group, whereas significantly more left circumflex vessels closed in the single vessel multilesion group (6.1% versus 1.3% in the left anterior descending coronary artery and 1.1% in the right coronary artery; p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Pertussis toxin inhibits angiotensin II-mediated phosphatidylinositol breakdown and ADP-ribosylates a 40 Kd protein in cultured smooth muscle cells

Angiotensin II causes an increase of inositol phosphate production in cultured vascular smooth muscle cells from rat aorta. Pretreatment of the cells with pertussis toxin attenuates this effect. Pertussis toxin ADP-ribosylates a protein of about 40 kD in a crude membrane fraction. These data demonstrate the possible involvement of a GTP-binding protein (G-protein) in the angiotensin II-induced activation of phosphoinositidase in vascular smooth muscle cells.

Pharmacokinetics of an extended-release dosage form of molsidomine in patients with coronary heart disease

Molsidomine (N-carboxy-3-morpholino-sydnonimine-ethylester; Cassella-Riedel Pharma GmbH, Frankfurt/M. FRG) has an antianginal effect for up to 3-5 h after oral administration of 2 mg Corvaton [1]. Plasma levels of the parent drug can be measured during this interval. A new galenic formulation (Corvaton retard) has been developed to prolong the duration of the therapeutic action and to improve patient compliance. The present study was carried out to establish whether the in vitro dissolution profile of the tablet was reflected in vivo, thus permitting prediction of plasma molsidomine levels in patients with coronary heart disease.

Stress testing in persons above the age of 65 years: applicability and diagnostic value of a standardized maximal symptom-limited testing protocol

A standardized symptom-limited stress test on a bicycle ergometer in semisupine position is examined in regard to its applicability in patients over the age of 65. The test protocol allows for exercise at full capacity in the elderly. Its value for diagnosis of coronary heart disease is equivalent with its value in the younger patients' group. In 167 patients above 65 years, there occurred only one case of pulmonary rales with exercise, no other complication could be observed (0.568%). Standardized, symptom-limited stress testing appears to be a simple, highly diagnostic and safe method for testing exercise capacity or diagnosing coronary heart disease in the elderly as in younger persons.

[A case of chronic pulmonary hypertension after fenfluramine intake]

A case of primary vascular pulmonary hypertension (PVPH) in a 53-year old woman (160 cm, 90 kg) is reported. She first complained of symptoms of breathlessness on exertion 2-3 months after completion of three courses of fenfluramine (Ponderax). The courses began in October 1977 and ended in May 1978. Despite persisting symptoms no relevant clinical findings were obtained. The patient was admitted to this hospital after complaining of short syncopal attacks on exertion, in November 1981. Typical signs of PVPH were now demonstrable, with a resting pulmonary pressure of 98/45 mm Hg. Clinical findings showed a similarity to those obtained in patients suffering from aminorex-induced PVPH, although fenfluramine shows some biological differences to aminorex. A causality between the development of PVPH and fenfluramine intake is probable on the basis of the patient's history, but it cannot be proven.

[Assessment of the results of aorto-coronary bypass surgery with the technetium 99m pyrophosphate scintigram (author's transl)]

In 40 patients with angiographically-documented coronary artery disease, technetium 99m pyrophosphate (99mTc-PYP) myocardial scintigrams were obtained prior to and four to six weeks after aorto-coronary bypass surgery. In the majority of patients, preoperative and postoperative exercise testing with simultaneous pulmonary artery pressure recordings was performed. In 22 of 30 patients with preoperatively increased 99mTc-PYP myocardial activity, no tracer accumulation could be found postoperatively. In the latter patients, there was also a significant increase in exercise capacity and lessening of ischemic ST-segment depression in the exercise ECG. In the remaining eight patients in whom increased tracer accumulation was found to persist postoperatively, there was no improvement in exercise capacity. In ten patients with no myocardial tracer accumulation preoperatively, unchanged myocardial scintigrams and a significant decrease of the ischemic ST-segment depression in the exercise ECG were seen postoperatively except in one patient with perioperative myocardial infarction. These results were also partially confirmed by repeated coronary angiography and ventriculography. Patent bypass grafts were associated with regional improvement in left ventricular function. The results indicate that postoperative absence of myocardial tracer accumulation appears due to amelioration of preexisting myocardial ischemia at rest. Thus, in the assessment of the results of aorto-coronary bypass surgery, the 99mTc-PYP scintigram offers an important diagnostic potential.

[Pulmonary artery pressure measurement for assessment of bioavailability of isosorbide dinitrate and pentaerythritol tetranitrate (author's transl)]

In a double-blind cross-over study with 9 patients suffering from ischemic cardiomyopathy with cardiac failure, the effect of 3 different drug preparations on pulmonary artery pressure (PA-pressure) was studied. Iso-Ameritrat is a new drug-combination consisting of a sweet-tasting wrap containing 2.5 mg Isosorbide Dinitrate (ISDN) and of a bitter-tasting core containing 10 mg Pentaerythritol Tetranitrate (PETN) and 200 mg Meprobamate. A statistically significant decrease of PA-pressure values could be observed already 3 minutes after administration of Iso-Ameritrat. Within the next minutes this decrease even augmented and lasted over the whole period of measurement (30 minutes). After administration of the second drug preparation (Ameritrat), containing 10 mg PETN and 200 mg Meprobamate in the core, but not any nitrate in the wrap a slight but also statistically significant decrease of PA-pressure values could be documented. Therefore a sublingual resorption of PETN can be assumed. The precise beginning of the effect of PETN couldn't be assured, but it must be within 5 minutes. A thir preparation, containing only 200 mg Meprobamate in the bitter tasting core caused no significant decrease of PA-pressure values.

[Measurement of pulmonary artery pressure at rest during volume loading for assessment of ventricular function in coronary artery disease (author's transl)]

Measurements of pulmonary artery (PA) pressure at rest with volume loading of the heart was carried out in a semirecumbent position by standardized positioning of the legs (Positioning test) in 44 patients with angiographically-proven severe coronary artery disease (CAD). The patients reacted differently and were accordingly assigned to one of the three following groups: Group I (23 patients) with normal PA pressures values showed normal results on ventriculography and accordingly, a normal ejection fraction. Group II (13 patients) showed a pathological increase in PA pressure by volume loading. Ventriculography showed hypo- or akinetic areas, with accordingly reduced ejection fraction already at rest. Group III (8 patients) showed pathological PA pressure values already at rest, in accordance with the ventriculographic existence of larger akinetic areas and a marked reduction in ejection fraction. Coronary morphology per se showed no correlation with PA pressure behaviour during volume loading at rest. Therefore, PA pressure measurement in the standardized positioning test can give a relatively accurate estimation of the functional state of the left ventricle, while statements about coronary morphology in CAD are not permissible.

[Report of a family with Holt-Oram syndrome (author's transl)]

Report of a family where the typical symptomatology of Holt-Oram syndrome can be documented over three generations. Holt-Oram syndrome is an autosomal-dominantly inherited disease, characterized by cardiac malformation, mainly septal defects, av-conduction disturbances, malformations of the upper limbs, mainly the radial ray and sometimes by vascular hypoplasia. According to the literature, these symptoms can be seen in variable expressivity in the family reported. Differential diagnosis of the entity and genetic counsel of symptomatic patients and their normal relatives are discussed.

[The accuracy of 201 thalium scintigraphy of the heart under conditions of stress (author's transl)]

The results of 201 thalliumszintigraphy under stress condition in patients with coronary heart disease with or without myocardial scars have not been uniform. We could show that pathologic stress szintigrams were only found in patients with a singular stenosis in one branch of the left coronary artery. In all those cases who had similar stenosis in both branches of the left coronary artery the stress szintigram appeared to be unchanged or normal. Therefore an unchanged stress szintigram allows no conclusion on the condition of the coronary arteries. A normal stress szintigram can be found as well in patients with normal coronary arteries as in patients with severe coronary heart disease. The examination of 201 thallium szintigrams under stress conditions therefore needs some critical evaluation.

[201-Thalium scintigraphy of the myocardium under conditions of rest and exercise (author's transl)]

The results of 201-Thallium myocardial scintigraphy at rest and after stress conditions in 30 patients are discussed. Among those there were 4 patients without cardiac disease, 7 patients with anterior wall scars after transmural infarction, and 19 patients with coronary heart disease and at least one coronary stenosis greater than 75%. The obtained results were compared to findings in coronary angiography and perfusion scintigraphy. The noninvasive method of 201-Thalliumscintigraphy shows a good correlation to the results of invasive investigations when performed at rest and under stress conditions. It enables greater sensivity and specifity in selection of patients with coronary heart disease compared to stress electrocardiography alone.

Comparison of supine and sitting body position during a triangular exercise test. I. Experiences in healthy subjects

A comparison of haemodynamic parameters is performed during a triangular exercise test on bicycle ergometer in respect of studying the influence of supine and sitting body position. At the maximal symptom-limited work load reached the heart rate is on the average 9.2% higher, the arterial systolic pressure 16.1% and the cardiac output 17.2% less in the sitting body position (P less than 0.001). On the opposite the pulmonary artery pressure during work is of slightly but not significantly higher level in the sitting position than in the supine. This phenomenon is explained by a prevailing of the beta-adrenergic tonus in our untrained subjects, while total sympathetic stimulation seems to be comparable in both body positions.

[Scintigraphic studies on the influence of coronary-effective drugs on myocardial perfusion during rest]

A hemodynamically effective coronary stenosis causes in the myocardial scintigram a maldistribution of the albumin particles within the corresponding myocardial regions. During exercise or after medicamental vasodilatation the differences in regional myocardial perfusion are amplified. Various scintigraphic pictures can be shown in a double-scintigram investigation using particles labelled by different radionuclides before and after vasodilatation. According to the method of double-scintigraphy the influence of coronary active media (dipyridamol, nitroglycerin, nifedipine) on regional myocardial perfusion is investigated. Because of its long-acting vasodilatation dipyridamol leads to a malperfusion in poststenotic myocardial areas. A similar vasodilatation effect combined with reduced activity in the second perfusion scintigram can be noticed after injection of contrast medium. In contrast to the drugs described above comparable scintigraphic changes after nitroglycerin and nifedipine are due to a different myocardial perfusion pattern, which is only showing a relative malperfusion in the poststenotic regions. At rest neither nitroglycerin nor nifedipine is able to normalize the regional myocardial perfusion.

[Plasma renin activity in essential hypertension: different short- und long-term effects of diuretics (author's transl)]

In an acute clinical trial 12 patients with essential hypertension on a standardized sodium and potassium dietary intake were given either amilorid (10 mg daily, orally) or potassium canrenoate (200 mg daily, i.v.) for two days. Either treatment caused a significant decrease in blood pressure and an increase in plasma renin activity (PRA). The aldosterone excretion rate was elevated only in the patients receiving amilorid. Furthermore potassium retention and sodium loss were more pronounced in the amilorid group. Long-term treatment (up to 14 weeks) with amilorid (10 mg daily), spironolactone (200 mg daily) or chlortalidone (50 mg daily) significantly lowered the blood pressure of patients with essential hypertension. Plasma potassium and PRA rose significantly in patients receiving either amilorid or spironolactone. However, after three weeks of therapy the mean PRA returned to the pretreatment level in patients on amilorid while it remained persistently elevated in the spironolactone group. On the other hand, chlortalidone caused potassium loss and persistent elevation of PRA. A possible relationship between the changes in plasma potassium levels and PRA in response to diuretics is discussed.

A rapid technique for preparation of human fetal and adult skeletal material

The techniques described above have been found to provide a rapid method of human skeletal preparation, with advantages of speed and applicability to fresh, fixed, or partially decomposed skeletal materials. While other techniques which can be used include the traditional use of Dermestidae beetle colonies, a five-step anatomical procedure, and other combinations of chemical solvents, the antiformin technique appears to have advantages useful to those involved in forensic medicine.