Evolving to a single inhaler extrafine LABA/LAMA/ICS - Inhalation technique and adherence at the heart of COPD patient care (TRIVOLVE)

OBJECTIVE

Incorrect inhaler use and poor treatment adherence have a negative impact on COPD outcomes. This multi-centre, single arm, non-interventional, phase IV study investigated whether inhalation technique, treatment adherence and patient outcomes change in patients who evolve from dual therapy or multiple inhaler triple therapy to single inhaler extrafine triple therapy (beclomethasone dipropionate (BDP, 87 μg), formoterol fumarate (FF, 5 μg) and glycopyrronium (G, 9 μg)) in combination with inhalation technique training.

METHODS

A total of 126 COPD patients were included in the per protocol set. Inhalation technique and treatment adherence were assessed at baseline and at two visits at approximately 3 and 6 months of treatment with extrafine BDP/FF/G. In addition, lung function, symptom score, patient satisfaction and exacerbations (exploratory) were followed up.

RESULTS

Before switching to single inhaler extrafine BDP/FF/G (baseline), any device errors and critical errors were detected for 28.8% and 9.6% of patients, respectively. After switching to BDP/FF/G, the percentage of patients with any device errors decreased to 14.0% (visit 2) and 16.3% (visit 3), without critical errors at the two follow-up visits. Treatment adherence increased from 67.5% at baseline to 75.8% (visit 2) and 80% (visit 3). In addition, lung function, symptom and patient satisfaction scores improved, whilst exacerbation rates substantially decreased.

CONCLUSIONS

This observational study demonstrates that in eligible COPD patients in a real-life setting, the switch from dual therapy or multiple inhaler triple therapy to single inhaler extrafine BDP/FF/G in combination with inhalation technique training is associated with improved inhalation technique and adherence.

Testing the efficacy and safety of BIO101, for the prevention of respiratory deterioration, in patients with COVID-19 pneumonia (COVA study): a structured summary of a study protocol for a randomised controlled trial

Objectives

As of December, 1^st, 2020, coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2, resulted in more than 1 472 917 deaths worldwide and death toll is still increasing exponentially. Many COVID-19 infected people are asymptomatic or experience moderate symptoms and recover without medical intervention. However, older people and those with comorbid hypertension, diabetes, obesity, or heart disease are at higher risk of mortality. Because current therapeutic options for COVID-19 patients are limited specifically for this elderly population at risk, Biophytis is developing BIO101 (20-hydroxyecdysone, a Mas receptor activator) as a new treatment option for managing patients with SARS-CoV-2 infection at the severe stage.

The angiotensin converting enzyme 2 (ACE2) serves as a receptor for SARS-CoV-2. Interaction between ACE2 and SARS-CoV2 spike protein seems to alter the function of ACE2, a key player in the renin-angiotensin system (RAS). The clinical picture of COVID-19 includes acute respiratory distress syndrome (ARDS), cardiomyopathy, multiorgan dysfunction and shock, all of which might result from an imbalance of the RAS. We propose that RAS balance could be restored in COVID-19 patients through MasR activation downstream of ACE2 activity, with 20-hydroxyecdysone (BIO101) a non-peptidic Mas receptor (MasR) activator. Indeed, MasR activation by 20-hydroxyecdysone harbours anti-inflammatory, anti-thrombotic, and anti-fibrotic properties. BIO101, a 97% pharmaceutical grade 20-hydroxyecdysone could then offer a new therapeutic option by improving the respiratory function and ultimately promoting survival in COVID-19 patients that develop severe forms of this devastating disease. Therefore, the objective of this COVA study is to evaluate the safety and efficacy of BIO101, whose active principle is 20-hydroxyecdysone, in COVID-19 patients with severe pneumonia.

Trial design

Randomized, double-blind, placebo-controlled, multi-centre, group sequential and adaptive which will be conducted in 2 parts.

Part 1:

Ascertain the safety and tolerability of BIO101 and obtain preliminary indication of the activity of BIO101, in preventing respiratory deterioration in the target population

Part 2:

Re-assessment of the sample size needed for the confirmatory part 2 and confirmation of the effect of BIO101 observed in part 1 in the target population.

The study is designed as group sequential to allow an efficient run-through, from obtaining an early indication of activity to a final confirmation. And adaptive – to allow accumulation of early data and adapt sample size in part 2 in order to inform the final design of the confirmatory part of the trial.

Participants

Inclusion criteria

Age: 45 and above

A confirmed diagnosis of COVID-19 infection, within the last 14 days, prior to randomization, as determined by PCR or other approved commercial or public health assay, in a specimen as specified by the test used.

Hospitalized, in observation or planned to be hospitalized due to COVID-19 infection symptoms with anticipated hospitalization duration ≥3 days

With evidence of pneumonia based on all of the following:

Clinical findings on a physical examination

Respiratory symptoms developed within the past 7 days

With evidence of respiratory decompensation that started not more than 4 days before start of study medication and present at screening, meeting one of the following criteria, as assessed by healthcare staff:

Tachypnea: ≥25 breaths per minute

Arterial oxygen saturation ≤92%

A special note should be made if there is suspicion of COVID-19-related myocarditis or pericarditis, as the presence of these is a stratification criterion

Without a significant deterioration in liver function tests:

ALT and AST ≤ 5x upper limit of normal (ULN)

Gamma-glutamyl transferase (GGT) ≤ 5x ULN

Total bilirubin ≤ 5×ULN

Willing to participate and able to sign an informed consent form (ICF). Or, when relevant, a legally authorized representative (LAR) might sign the ICF on behalf of the study participant

Female participants should be: at least 5 years post-menopausal (i.e., persistent amenorrhea 5 years in the absence of an alternative medical cause) or surgically sterile; OR

Have a negative urine pregnancy test at screening

Be willing to use a contraceptive method as outlined in inclusion criterion 9 from screening to 30 days after last dose.

Male participants who are sexually active with a female partner must agree to the use of an effective method of birth control throughout the study and until 3 months after the last administration of the investigational product.

(Note: medically acceptable methods of contraception that may be used by the participant and/or partner include combined oral contraceptive, contraceptive vaginal ring, contraceptive injection, intrauterine device, etonogestrel implant, each supplemented with a condom, as well as sterilization and vasectomy).10.

Female participants who are lactating must agree not to breastfeed during the study and up to 14 days after the intervention.

11.

Male participants must agree not to donate sperm for the purpose of reproduction throughout the study and until 3 months after the last administration of the investigational product.

12.

For France only: Being affiliated with a European Social Security.

Exclusion criteria

Not needing or not willing to remain in a healthcare facility during the study

Moribund condition (death likely in days) or not expected to survive for >7 days – due to other and non-COVID-19 related conditions

Participant on invasive mechanical ventilation via an endotracheal tube, or extracorporeal membrane oxygenation (ECMO), or high-flow Oxygen (delivery of oxygen at a flow of ≥16 L/min.).

Participant is not able to take medications by mouth (as capsules or as a powder, mixed in water).

Disallowed concomitant medication: Consumption of any herbal products containing 20-hydroxyecdysone and derived from Leuzea carthamoides; Cyanotis vaga or Cyanotis arachnoidea is not allowed (e.g. performance enhancing agents).

Any known hypersensitivity to any of the ingredients, or excipients of the study medication, BIO101.

Renal disease requiring dialysis, or known renal insufficiency (eGFR≤30 mL/min/1.73 m2, based on Cockcroft & Gault formula).

In France only:

Non-affiliation to compulsory French social security scheme (beneficiary or right-holder).

Being under tutelage or legal guardianship.

Participants will be recruited from approximately 30 clinical centres in Belgium, France, the UK, USA and Brazil. Maximum patients’ participation in the study will last 28 days. Follow-up of participants discharged from hospital will be performed through post-intervention phone calls at 14 (± 2) and 60 (± 4) days.

Intervention and comparator

Two treatment arms will be tested in this study: interventional arm 350 mg b.i.d. of BIO101 (AP 20-hydroxyecdysone) and placebo comparator arm 350 mg b.i.d of placebo. Administration of daily dose is the same throughout the whole treatment period. Participants will receive the study medication while hospitalized for up to 28 days or until a clinical endpoint is reached (i.e., ‘negative’ or ‘positive’ event). Participants who are officially discharged from hospital care will no longer receive study medication.

Main outcomes

Primary study endpoint:

The proportion of participants with ‘negative’ events up to 28 days.

‘Negative’ events are defined as respiratory deterioration and all-cause mortality. For the purpose of this study, respiratory deterioration will be defined as any of the following:

Requiring mechanical ventilation (including cases that will not be intubated due to resource restrictions and triage).

Requiring extracorporeal membrane oxygenation (ECMO).

Requiring high-flow oxygen defined as delivery of oxygen at a flow of ≥16 L/min.

Only if the primary endpoint is significant at the primary final analysis the following

Key secondary endpoints will be tested in that order:

Proportion of participants with events of respiratory failure at Day 28

Proportion of participants with ‘positive’ events at Day 28.

Proportion of participants with events of all-cause mortality at Day 28

A ‘positive’ event is defined as the official discharge from hospital care by the department due to improvement in participant condition.

Secondary and exploratory endpoints:

In addition, a variety of functional measures and biomarkers (including the SpO2 / FiO2 ratio, viral load and markers related to inflammation, muscles, tissue and the RAS / MAS pathways) will also be collected.

Randomization

Randomization is performed using an IBM clinical development IWRS system during the baseline visit. Block-permuted randomization will be used to assign eligible participants in a 1:1 ratio.

In part 1, randomization will be stratified by RAS pathway modulator use (yes/no) and co-morbidities (none vs. 1 and above).

In Part 2, randomization will be stratified by centre, gender, RAS pathway modulator use (yes/no), co-morbidities (none vs. 1 and above), receiving Continuous Positive Airway Pressure/Bi-level Positive Airway Pressure (CPAP/BiPAP) at study entry (Yes/No) and suspicion of COVID-19 related myocarditis or pericarditis (present or not).

Blinding (masking)

Participants, caregivers, and the study team assessing the outcomes are blinded to group assignment. All therapeutic units (TU), BIO101 b.i.d. or placebo b.i.d., cannot be distinguished in compliance with the double-blind process. An independent data-monitoring committee (DMC) will conduct 2 interim analyses. A first one based on the data from part 1 and a second from the data from parts 1 and 2. The first will inform about BIO101 safety, to allow the start of recruitment into part 2 followed by an analysis of the efficacy data, to obtain an indication of activity. The second interim analysis will inform about the sample size that will be required for part 2, in order to achieve adequate statistical power.

Numbers to be randomised (sample size)

Number of participants randomized: up to 465, in total

Part 1: 50 (to obtain the proof of concept in COVID-19 patients).

Part 2: 310, potentially increased by 50% (up to 465, based on interim analysis 2) (to confirm the effects of BIO101 observed in part 1).

Trial Status

The current protocol Version is V 10.0, dated on 24.09.2020. The recruitment that started on September 1^st 2020 is ongoing and is anticipated to finish for the whole study by March2021.

Trial registration

The trial was registered before trial start in trial registries: EudraCT, No. 2020-001498-63, registered May 18, 2020; and Clinicaltrials.gov, identifier NCT04472728, registered July 15, 2020.

Full protocol

The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-020-04998-5.

Inotropic therapy for cardiac low output syndrome: comparison of hemodynamic effects of dopamine/dobutamine versus dopamine/dopexamine

OBJECTIVE

To examine the effects of a therapy with dopexamine/dopamine in comparison with a regimen of dobutamine/dopamine on the outcome of patients with profound cardiogenic shock.

MATERIAL AND METHODS

Twenty patients presenting with an acute cardiogenic shock assisted with mechanical ventilation, being refractory to a therapy with dopamine alone were analyzed. After persistence of low cardiac output syndrome (cardiac index <2.5 l/min/m2) was confirmed, patients were treated either with receiving dopexamine (2 microg/kg/min) (group 1) or dobutamine (6 microg/kg/min) (group 2) in combination with dopamine (6 microg/kg/min) for 24 hrs. Hemodynamic parameters, urine production and clinical outcome were measured at intervals throughout the study. The groups were similar with respect to demographics and risk factors and there were no significant differences in the supportive treatment and hemodynamics at baseline.

RESULTS

The dopexamine treated patients had lower myocardial oxygen consumption (9310+/-2243 mmHg O2/sec vs. 10621+/-2552 mmHg O2/sec) and lower mean arterial pressure (66+/-11 mmHg vs. 71+/-10 mmHg) after the 24 hrs treatment interval, but no one of the changes reached statistical significance. No differences were found between the two groups for other variables and the overall clinical outcome.

CONCLUSION

The present study revealed that neither substance is superior in the treatment of cardiogenic shock, even if the effect on myocardial consumption and the reported beneficial effects on renal and splanchnic functions might favour the use of dopexamine under certain circumstances.

Inotropic therapy for cardiac low output syndrome: comparison of hemodynamic effects of dopamine/dobutamine versus dopamine/dopexamine

OBJECTIVE

To examine the effects of a therapy with dopexamine/dopamine in comparison with a regimen of dobutamine/dopamine on the outcome of patients with profound cardiogenic shock.

MATERIAL AND METHODS

Twenty patients presenting with an acute cardiogenic shock assisted with mechanical ventilation, being refractory to a therapy with dopamine alone were analyzed. After persistence of low cardiac output syndrome (cardiac index <2.5 l/min/m2) was confirmed, patients were treated either with receiving dopexamine (2 microg/kg/min) (group 1) or dobutamine (6 microg/kg/min) (group 2) in combination with dopamine (6 microg/kg/min) for 24 hrs. Hemodynamic parameters, urine production and clinical outcome were measured at intervals throughout the study. The groups were similar with respect to demographics and risk factors and there were no significant differences in the supportive treatment and hemodynamics at baseline.

RESULTS

The dopexamine treated patients had lower myocardial oxygen consumption (9310 +/- 2243 mmHg O2/sec vs. 10621 +/- 2552 mmHg O2/sec) and lower mean arterial pressure (66 +/- 11 mmHg vs. 71 +/- 10 mmHg) after the 24 hrs treatment interval, but no one of the changes reached statistical significance. No differences were found between the two groups for other variables and the overall clinical outcome.

CONCLUSION

The present study revealed that neither substance is superior in the treatment of cardiogenic shock, even if the effect on myocardial consumption and the reported beneficial effects on renal and splanchnic functions might favour the use of dopexamine under certain circumstances.

Distal embolic protection during percutaneous intervention of aorto-coronary venous bypass grafts: The FIRST Trial

OBJECTIVE

Interventions in aorto-coronary venous bypass grafts (CABG) can cause acute procedural complications due to distal embolization of debris. In the FIRST (First European Investigation Regarding the Systematic use of the TriActiv device) multicenter trial the distal endovascular protection system TriActiv (Kensey Nash) was evaluated during intervention of CABG.

METHODS

195 patients in 17 centers in Germany with significant disease of a vein graft were enrolled. Inclusion and exclusion criteria were comparable to the SAFER trial.

RESULTS

Acute procedural success was achieved in 98% of cases. Aspirated debris was found in 96.5% of patients. Primary endpoints (MACE at 30 days) occurred in 8.7% of all pts. (ITT). No patient died and 7.2% of patients suffered from MI. The rate of early revascularization was 1.5%. Secondary endpoints (MACCE at 30 days) were found in 9.2% and at hospital discharge in 8.7% of patients.

CONCLUSIONS

The TriActiv system is safe and effective. Normal post procedural flow can be preserved and the MACE rate is with 8.7% considerably low. The FIRST trial supports the growing belief that PCI of CABG should be performed with protection systems.

Relationship between therapeutic time intervals and intermediate term left ventricular systolic function in patients treated with facilitated percutaneous coronary intervention for acute myocardial infarction

BACKGROUND

The concept of initiating fibrinolytic therapy in patients who cannot undergo immediate percutaneous coronary intervention (PCI) in the setting of acute ST-segment-elevation myocardial infarction (STEMI) has been proposed as a strategy to improve outcomes. However, evidence supporting the use of this strategy is not conclusive, and the results of recent randomized controlled trials are apparently contradictory. Probably, the time points of administration of the adjunctive thrombolytics and antiplatelet agents and the time loss until coronary intervention have a major influence on the discrepancy of outcomes in different trials. Therefore, the relationship between therapeutic time intervals and outcome in patients treated with facilitated PCI has been analyzed.

METHODS

In this single center retrospective study, 131 patients with STEMI were treated with a combined pharmaco-mechanical reperfusion strategy using half-dose r-tPA combined with a glycoprotein (GP) IIb/IIIa antagonist prior to PCI. Specific time points were recorded for each patient, including the time of symptom onset, the time of first medical contact, the start of intravenous thrombolysis, the time of administration of the GP IIb/IIIa antagonist and the start of coronary intervention. We then examined the relationship between the time delay from symptom onset to the initiation of various steps of treatment and the residual myocardial damage as expressed by the severity of both global and regional myocardial dysfunction calculated from a left ventriculography study performed 3 months later.

RESULTS

The median time from symptom onset to the first medical contact, with 25th and 75th percentiles in parentheses, was 1.25 h (0.75, 3), from symptom onset to initiation of thrombolytic therapy 2.25 h (1.25, 3), to initiation of GP IIb/ IIIa inhibitor therapy 3.5 h (2, 5.69), and to the start of coronary intervention 4.81 h (2.85, 7.91). The time between symptom onset and initiation of both thrombolytic therapy and coronary intervention was significantly related to the global ejection fraction and to the extent of regional hypokinesia at the 3-month follow-up (p<0.05). The time to the initiation of GP IIb/IIIa inhibitors was only significantly related to the global ejection fraction (p<0.05), while the time to the first medical contact did not show a similar relationship (p>0.05). Furthermore, we observed a significant relationship between the infarct-related artery (IRA) patency at the initial angiogram and the residual regional myocardial damage at follow-up; normokinesia at follow-up was found in 61.3% of patients with an initially patent IRA and in 41.2% of patients with an initially occluded IRA, whereas severe hypokinesia was found in 13.8% and 37.3%, respectively (p<0.05).

CONCLUSION

In patients with STEMI treated with a facilitated PCI strategy using half dose r-tPA in combination with a glycoprotein IIb/IIIa receptor blocker, the 3-month global and regional residual myocardial dysfunction is significantly related to the time elapsed between the onset of symptoms and the start of both fibrinolytic therapy and coronary intervention.

Symptoms and signs of an acute myocardial ischemia caused by chemotherapy with Paclitaxel (Taxol) in a patient with metastatic ovarian carcinoma

INTRODUCTION

Paclitaxel (Taxol) is an anticancer agent used for the treatment of breast and ovarian cancer. The major side effects are bone marrow suppression, alopecia, polyneuropathy and cardiac toxicity like bradycardia, myocardial infarction, congestive heart failure and cardiac death.

SETTING

Intensive care unit (ICU) of a university hospital.

PATIENT

We report on a 58-years-old woman with a metastatic ovarian carcinoma who had chest pain, nausea and collapse during their first Taxol infusion. The infusion was stopped and the patient was submitted to the intensive care unit (ICU) to exclude an acute coronary syndrome.

RESULTS

The electrocardiography (ECG) showed a third-degree heart block and ST elevation in II, III and avF. In the initial and in the control laboratory investigation values of cardiac enzymes (creatininkinase and Troponine T) remained normal. The control ECG after 30 minutes turned back to normal. After one day the patient was submitted back to a normal ward.

CONCLUSION

Symptomatic bradyarrhythmia and clinical sign of an myocardial infarction are rare but important cardiac side effects in patients treated with Taxol. Those patients should be under intensive care unit until patients conditions improve and acute myocardial ischemia has been excluded.

[Acute coronary syndrome after diclofenac induced coronary spasm]

We report about a 67-year old man, who was submitted to our clinic with acute coronary syndrome. The cardiac catheterization showed a proximal thrombus in the left anterior descending (LAD). The other coronary arteries did not have significant lesions. After percutaneous transluminal coronary angioplasty with stent-implantation into the proximal LAD the patient remained clinically stable. Cardiac enzymes confirmed no myocardial necrosis. Three days after the acute coronary syndrome the patient developed a podagra, which was treated with colchicinum, diclofenac and local cooling. Five hours after initial therapy the patient developed severe symptoms of angina pectoris and electrocardiographical signs of an acute posterior and anterior myocardial infarction. Immediate coronary angiography demonstrated extended vasospasm of the right coronary artery. Intracoronary application of verapamil and nitroglycerin resolved the coronary spasm. The patient reported about a self-indicated application of diclofenac six hours before hospital admission. This case demonstrates that oral application of diclofenac can provoke coronary vasospasm.

[Bland-White-Garland syndrome in an adult]

We report about a 47-year-old woman, who presented with a history of cardiac failure. Echocardiography showed an impaired left ventricular function, clinically significant mitral regurgitation and pulmonary hypertension. Diagnosis of a Bland- White-Garland syndrome was made by coronary angiography. Subsequent therapy consisted of ligation of the anomalus origin of the left coronary artery, implantation of a Mammaria interna graft to the left coronary artery and replacement of the mitral valve by a mechanical prosthesis. One year after operation, left ventricular function was still impaired. At a 3-year follow-up, left ventricular function improved continuously.

[The role of stress-echocardiography in diagnostics of hemodynamically significant coronary artery stenosis and determination of indications for myocardial revascularisation.]

In 118 patients dobutamine (n=108) or exercise (n=10) stress-echocardiography and coronary angiography were carried out within time interval of 4 weeks. Retrospective analysis of data obtained showed that sensitivity and specificity of stress echocardiography for detection of more than 70% coronary artery stenosis was 75 and 71%, respectively. No significant reduction of sensitivity or specificity was found in any clinical group. Negative result of stress echo in most of the cases evidenced for continuation of conservative therapy while positive result in 66% of cases attested necessity of myocardial revascularization. Detection of stress induced disturbances of local myocardial contractility could be used as a proof of hemodynamic significance of 50-70% coronary artery stenosis.

[Pullback atherectomy. An alternative procedure in the treatment of coronary stenosis and in-stent restenosis]

Optimized directional coronary atherectomy (DCA) has shown significantly superior acute and long-term results compared to conventional balloon angioplasty (BA). Nevertheless DCA has remained a niche application due to specific procedural aspects. The pullback atherectomy catheter (PAC), developed to retrieve atheromatous plaque material, is an alternative debulking device. We report on clinical and angiographic experience in 55 consecutive patients, in whom de novo lesions (35 pts) as well as instent restenoses (17 pts) were treated. The minimal luminal diameter (MLD, mm) rose after PAC and additional BA from 1.06 +/- 0.53 to 2.68 +/- 0.48 and from 1.10 +/- 0.48 to 2.55 +/- 0.49 mm, respectively. A stenosis reduction from 69 +/- 13 to 19 +/- 16 and from 64 +/- 15 to 16 +/- 10%, resp., could be documented. After 3-6 months a complete angiographic follow-up showed MLD values of 2.01 +/- 0.69 and 1.88 +/- 0.61 mm. Nine of 35 (26%) vs. 5 of 17 (29%) pts developed significant restenosis at the treated site (diameter stenoses > 50%). Stent implantation was necessary to achieve an optimal acute angiographic result or due to dissection in 17 vs. 5 pts. Major cardiac events did not occur; however, two restenosed coilstents were removed by PAC. With the pullback atherectomy catheter, a safe and effective alternative device is available for the treatment of coronary lesions and also of in-stent restenosis. Promising short and acceptable long-term results are comparable to those of other debulking procedures.

Endoluminal beta-radiation therapy for the prevention of coronary restenosis after balloon angioplasty. The Dose-Finding Study Group

BACKGROUND

Beta radiation is effective in reducing vascular neointimal proliferation in animals after injury caused by balloon angioplasty. However, the lowest dose that can prevent restenosis after coronary angioplasty has yet to be determined.

METHODS

After successful balloon angioplasty of a previously untreated coronary stenosis, 181 patients were randomly assigned to receive 9, 12, 15, or 18 Gy of radiation delivered by a centered yttrium-90 source. Adjunctive stenting was required in 28 percent of the patients. The primary end point was the minimal luminal diameter six months after treatment, as a function of the delivered dose of radiation.

RESULTS

At the time of follow-up coronary angiography, the mean minimal luminal diameter was 1.67 mm in the 9-Gy group, 1.76 mm in the 12-Gy group, 1.83 mm in the 15-Gy group, and 1.97 mm in the 18-Gy group (P=0.06 for the comparison of 9 Gy with 18 Gy), resulting in restenosis rates of 29 percent, 21 percent, 16 percent, and 15 percent, respectively (P=0.14 for the comparison of 9 Gy with 18 Gy). At that time, 86 percent of the patients had had no serious cardiac events. In 130 patients treated with balloon angioplasty alone, restenosis rates were 28 percent, 17 percent, 16 percent, and 4 percent, respectively (P=0.02 for the comparison of 9 Gy with 18 Gy). Among these patients, there was a dose-dependent enlargement of the lumen in 28 percent, 50 percent, 45 percent, and 74 percent of patients, respectively (P<0.001 for the comparison of 9 Gy with 18 Gy). The rate of repeated revascularization was 18 percent with 9 Gy and 6 percent with 18 Gy (P=0.26).

CONCLUSIONS

Intracoronary beta radiation therapy produces a significant dose-dependent decrease in the rate of restenosis after angioplasty. An 18-Gy dose not only prevents the renarrowing of the lumen typically observed after successful balloon angioplasty, but actually induces luminal enlargement.

Immunoglobulin A and secretory immunoglobulin A in the bronchoalveolar lavage from patients after lung transplantation

Secretory immunoglobulin A (sIgA) is the most important Ig on mucosal surfaces. In bronchoalveolar lavage (BAL) fluid, sIgA is mainly produced by bronchus-associated lymphoid tissue (BALT). The presence of pre-formed antibodies against donor tissue in kidney transplantation is associated with hyperacute rejection, indicating a humoral (antibody-mediated) reaction. In heart and liver transplantation, humoral rejection has also been documented. The goal of this study was to evaluate the role of IgA in patients after lung transplantation. An enzyme-linked immunosorbent assay was established to determine the levels of sIgA, IgA, and total protein in the lavage. IgA and sIgA were both detectable in BAL from transplanted lungs. IgA and sIgA levels were both higher during episodes of infection than during episodes of rejection or during the control episodes. The level of IgA during episodes of rejection equaled the level of IgA during the control episodes. The level of sIgA was significantly decreased during episodes of acute rejection (1.8 +/- 1.0 microg/mL) when compared with the control (7.2 +/- 1.0 microg/mL; p = 0.013). This study demonstrates that BALT retains the ability to produce Ig even after lung transplantation. The levels of IgA and sIgA and their ratio do not contribute to the differentiation between rejection and infection in lung-transplanted patients.

Pericardiocentesis: differential aspects of a common procedure

OBJECTIVE

To evaluate the risk and effectiveness of pericardiocentesis in primary and repeat cardiac tamponade.

DESIGN

Retrospective analysis.

SETTING

Intensive care unit in a medical university hospital.

PATIENTS

Sixty-three consecutively admitted patients with cardiac tamponade.

INTERVENTIONS

In all patients pericardiocentesis was performed via the subxiphoid pathway after echocardiographic detection of the pericardial effusion.

MEASUREMENTS AND RESULTS

There was no adverse event in patients undergoing primary pericardiocentesis, which was sufficient to resolve pericardial effusion in 51 of 63 patients (81%). However, repeat pericardiocentesis necessitated by the recurrence of symptomatic pericardial effusion yielded suboptimal results in 10 of 12 patients (83%).

CONCLUSION

Pericardiocentesis is the treatment of choice for primary symptomatic pericardial effusion. In recurrent pericardial effusion surgical approaches appear to be preferable.

[Effect of exercise tolerance test on hemostasis in patients with and without coronary heart disease]

BACKGROUND

Physical exercise leads to an elevated coagulation activity with a possibly disturbed hemostatic balance. Therefore patients with coronary heart disease have a potentially increased risk of thromboembolic events after a bicycle exercise tolerance test, that is frequently performed for diagnostic reasons.

PATIENTS AND METHODS

Patients with angiographically known coronary heart disease (Group I: n = 49; age 59 years; male = 42, female = 7) were investigated in comparison to a healthy cohort (Group 2: n = 51; age 53 years; male = 44, female = 7) to study the influence of a standardized exercise tolerance test on hemostatic variables. Blood samples were taken before and after exercise.

RESULTS

No significant changes were found for any investigated parameter between both groups. However, 3 parameters did change significantly within the groups: factor VIII rose in Group 1 from 132 to 156% and in Group 2 from 106 to 136% and the von Willebrand factor rose in Group 1 from 230 to 249% and in Group 2 from 228 to 247%. An elevated fibrinolytic potential was found with an increase of plasminogen-alpha 2-antiplasmin in Group 1 from 251 to 401 micrograms/l and in Group 2 from 247 to 350 micrograms/l.

CONCLUSION

The findings underline the clinical presumption that exercise tolerance test does not increase the risk for thromboembolic complications in patients with coronary heart disease in comparison to patients without coronary heart disease, as long as the exercise tolerance test is performed in a standardized way and under aerobe conditions.

Analyse des Thrombin-Markers F 1+2 in der Einstellungsphase der oralen Antikoagulation

In der initialen Behandlungsphase der oralen Antikoagulation kommt es, abhängig von der gewählten Aufsättigungsdosis, zu Verschiebungen im Hämostase-gleichgewicht. In der stabilen Phase der oralen Antikoagulation ist die INR ein verläßlicher Parameter für die Einstellung. In der initialen Einstellungsphase aber, in der es 2-4 Tage nach Erreichen des angestrebten INR durch Protein-C-Ab-fall noch zur Hyperkoagulabilität kommen kann, ist das Prothrombinfragment F 1 +2 ein zusätzlicher wertvoller Parameter, um abzuschätzen, in wie weit eine Gerinnungsaktivierung vorliegt. In dieser Phase, in der die INR schon im angestrebten Bereich liegt, F 1 +2 aber noch erhöht ist, kann es zu Thrombosen kommen. Der zu diesem Zeitpunkt noch nicht im angestrebten Bereich befindliche Prothrombinfragmentspiegel sollte dann dazu veranlassen die überlappende Heparinisierung noch fortzusetzen.

Belastungs-EKG induziert kein erhöhtes thromboembolisches Risiko bei Patienten mit koronarer Herzerkrankung

Eine Steigerung der Gerinnungsaktivierung, wie sie durch körperliche Aktivität hervorgerufen werden kann, ist für Patienten mit koronarer Herzerkrankung von besonderer Bedeutung, da sie durch thromboembolische Ereignisse besonders gefährdet sind. Zur Frage, ob eine definierte Fahrradergometrie mit einem erhöhten thromboembolischen Risiko verbunden ist, wurden bei 49 Patienten (Gruppe 1) mit und 51 Patienten (Gruppe 2) ohne KHK vor und nach Belastung verschiedene Parameter des Hämostasesystems bestimmt. Die ermittelten Parameter ließen keine signifikanten Unterschiede zwischen den Gruppen vor und nach Belastung erkennen. Es fanden sich jedoch signifikante Änderungen innerhalb der Gruppen: Die Faktor-VIIl-Aktivität stieg in Gruppe 1 von 132 auf 156% und in Gruppe 2 von 106 auf 136%. Der Von-Willebrand-Faktor stieg in Gruppe 1 von 230 auf 249% und in Gruppe 2 von 228 auf 247%. Als Zeichen einer gesteigerten Fibrinolyse fand sich eine Steigerung des Plasmin-alpha-2-Antiplasmin-Komplexes in Gruppe 1 von 251 auf 401 μg/l und in Gruppe 2 von 247 auf 350 μg/l. Damit geht für Patienten mit KHK von einer Fahrradergometrie, durchgeführt in standardisierter Form und in aerober Stoffwechsellage kein erhöhtes thromboembolisches Risiko aus.

A case of Behçet's syndrome presenting with Dieulafoy's ulcer

Behçet's syndrome represents a multisystemic disease with vasculitic changes. We here describe a patient with Dieulafoy's ulcer and oral, genital and bronchial mucosal lesions who met the criteria of incomplete Behçet's syndrome. The rare observation of Behçet's syndrome presenting with Dieulafoy's ulcer in our patient raises the question as to whether this type of ulcer, usually caused by a developmental malformation of a submucosal gastric artery, may occasionally be due also to submucosal aneurysms that result from a vascular inflammation.

Multiple coronary artery-left ventricular fistulae: haemodynamic quantification by intracoronary Doppler ultrasound

Multiple coronary artery-left ventricular fistulae involving all three major coronary arteries are extremely rare. Clinical findings are heterogeneous but include a history of typical or atypical angina pectoris in most cases. Coronary arteriography in a 65 year old woman who presented with chest pain at rest revealed multiple fine fistulae arising from the left anterior descending, left circumflex, and right coronary arteries. Left-to-left shunt was estimated by measurements of coronary artery flow velocity with intravascular Doppler ultrasound.

Coagulation activation in patients undergoing directional coronary atherectomy

Restenosis is a major problem of percutaneous transluminal coronary angioplasty (PTCA) and related procedures. To better understand the underlying pathophysiologic mechanisms, coagulation and fibrinolytic variables were analysed prospectively in 35 patients after directional coronary atherectomy (DCA) and in 20 control patients undergoing diagnostic heart catheterisation and coronary angiography. Blood samples were taken before and 1 h, 24 h and 48 h after the procedure. No subacute thrombosis or unstable angina were documented in any patient. In 8 out of these 35 patients late restenosis was diagnosed during follow-up angiography 3-6 months after DCA. In these 8 patients prothrombin fragments (F1 + 2) rose from 0.7 to 0.9 nmol/l (P < 0.01) and thrombin-antithrombin III complexes (TAT) from 2.9 to 6.0 micrograms/l (P < 0.01), but not significantly in 27 patients without restenosis and in the control patients. In patients with late restenosis plasminogen activator inhibitor (PAI-1) also increased from 2.4 to 4.9 U/ml (P < 0.05) 24 h after DCA while there were no significant changes in patients without restenosis and in control patients. D-Dimer/TAT ratio reflecting the balance between clotting activation and fibrinolysis was significantly lower after 24 h in restenosis patients. The findings suggest that coagulation activation and hypofibrinolysis during 48 h after DCA might be associated with the development of late restenosis.

[Endomyocardial biopsy--helpful in differential diagnosis between myocarditis and dilated cardiomyopathy. A case report]

Endomyocardial biopsy is an established technique to distinguish between myocarditis and dilated cardiomyopathy. Even when clinical symptoms for myocarditis are lacking, immunohistologic findings may establish a clear diagnosis. For treatment, however, an early diagnosis is mandatory. We report on a 44 year old patient who was admitted with the echocardiographic diagnosis of dilated cardiomyopathy. He underwent diagnostic angiocardiography and endomyocardial biopsy. The latter demonstrated an active myocarditis. At the time of read-mission, 2 weeks later, the patient had deteriorated. Now, additional to a symptomatic therapy, prednisolone, azathioprine and human immunoglobulin G were given and patient conditions improved dramatically. The use of endomyocardial biopsy seems recommendable in order to define patients diagnosis and their results may be necessary to decide patients therapy.

Chylous cardiac tamponade in acute pancreatitis

A 47-year-old woman with acute necrotizing pancreatitis developed sudden cardiorespiratory arrest and needed resuscitation. A pericardial effusion was found, and 350 ml of a white nontransparent milky fluid was aspirated that contained 1020 mg triglycerides/100 ml. The diagnosis of chylous cardiac tamponade was made. Absence of amylase in the chylous effusion militates against the popular hypothesis that lymphatic transport of exocrine digestive enzymes from the inflamed pancreas produces the frequent intrathoracic serosal effusions in acute pancreatitis. The data of our patient rather suggest that these effusions result from the leakage of pancreatic inflammatory exudates through the diaphragm which, apparently, may even result in the loss of pericardial and adjacent thoracic lymph vessel integrity. Although pericardial tamponade is a rare complication, it should be considered if otherwise unexplained circulatory deterioration occurs in a patient with acute pancreatitis.

[The thrombophilic status of patients with inflammatory diseases]

BASIC PROBLEM AND OBJECTIVE OF STUDY

Inflammatory reactions are taken to be nonspecific defensive measures of the organism and are associated with complex changes at cellular and humoral level. Activation of blood coagulation plays an important part in this, especially as it is accompanied by an increased risk of thromboembolism. It was the aim of this investigation to assess this risk by measuring sensitive markers of coagulation activation.

PATIENTS AND METHODS

Biochemical markers of coagulation activation (prothrombin-fragment F1 + 2 and thrombin-antithrombin III complex [TAT]) and fibrin formation (D-dimer) were measured in 130 patients (61 men, 69 women; mean age 56.9 [20-89] years). 44 had pneumonia, 44 bronchitis and 42 urinary tract infections. A healthy control group for comparison consisted of 11 men and 15 women (mean age 48.7 [23-79] years).

RESULTS

F1 + 2, TAT and D-dimer were significantly increased, compared with the controls, in all three patient groups (P < 0.01). The greatest rises occurred in the patients with pneumonia: F1 + 2: median 1.2 vs 0.6 nmol/I, TAT: 6.2 vs 2.1 micrograms/l and D-dimer 2476 vs 223 ng/ml.

CONCLUSION

These findings underline the importance of consistent thrombosis prophylaxis in patients with inflammatory disease, especially those at an increased risk.

Early postoperative flow rates after internal thoracic artery grafting for the left coronary artery system

OBJECTIVE

The low perioperative flow rates of internal thoracic artery (ITA) conduits have been regarded as a limitation of their use in critical coronary situations with a high myocardial blood demand. To clarify whether these restrictions are justified, early postoperative flow rates were determined.

METHODS

Following bilateral ITA grafting, 48 of 106 patients (April 1993-September 1994) underwent recatheterization. Subsequent to control angiography between days 8 and 12, 20 of these patients were studied by intravascular Doppler techniques applied for ITA grafts supplying the left anterior descending artery (LAD) and branches of the circumflex system (CX) (n = 20). Doppler spectral analysis allowed for determination of the average peak velocity and diastolic-systolic velocity ratio. Vascular diameters were assessed by simultaneously performed quantitative angiography and mean flow rates were calculated. All parameters were recorded at rest and following selective stimulation with nitroglycerin (0.2 mg) and papaverine (12.5 mg) to evaluate the graft flow capacity.

RESULTS

Baseline values of average peak velocity at rest were 24.6 +/- 11.5 cm/s for ITA-LAD conduits and 21.9 +/- 6.8 cm/s for ITA-CX pedicles. Following dilative stimulation with papaverine, a significant increase in average peak velocities were obtained for both locations (ITA-LAD: 47.3 +/- 17.1 cm/s, ITA-CX: 42.3 +/- 11.8 cm/s). The application of nitroglycerin had a similar effect (ITA-LAD: 42.6 +/- 15.3 cm/s, ITA-CX: 40.3 +/- 10.7 cm/s). The vascular diameters of ITA conduits remained unchanged on nitroglycerin stimulation, whereas papaverine effected significant dilatation in both locations. Flow rates at rest were not significantly different (ITA-LAD: 51.0 +/- 34.2 ml/min, ITA-CX: 44.7 +/- 16.4 ml/min) and maximal flow increase was observed following papaverine stimulation of the LAD conduits (116.1 +/- 90.6 ml/min). Dilative stimulation effected an increase in diastolic-systolic velocity ratios from average values at rest in a range between 34% and 41.7% for both groups and substances.

CONCLUSIONS

The basic blood flow in functioning ITA grafts appears to be similar in conduits supplying the LAD and marginal branches. Flow rates between 50 and 60 ml/min at rest should meet myocardial demands, even in the LAD position. Increased flow rates were predominantly based on higher flow velocities with an increased diastolic flow proportion. Enlargement of the graft diameter may exert additional effects, at least following papaverine stimulation at a particular concentration.

[Pseudo-stenosis caused by vessel wall invagination during interventional treatment of 2 coronary vessels in a patient]

We report on a 59-year-old man who underwent a combined procedure of directional coronary atherectomy (DCA) and PTCA of significant lesions of the right coronary artery (RCA) and the left circumflex artery (LCX). Already after positioning of a standard guide wire in the right coronary artery a new excentric "pseudo-stenosis" was observed in the proximal part of the right coronary artery. Since the patient remained symptom free, a 7F DCA catheter was introduced to the stenotic area in the mid RCA, which led to an extension of the narrowing, involving the total segment proximal to the DCA catheter. Directional coronary atherectomy was performed without complications. Removal of the catheter, after successful DCA, and administration of intracoronary nitroglycerin did not relieve the proximal narrowing, which disappeared spontaneously after the guide wire was pulled out. During PTCA of the left circumflex using a standard guide wire and a 3.0 mm Monorail balloon catheter, a similar tight narrowing of the origin of the LCX was observed, which could also not be influenced by vasodilator drugs, but relieved after wire removal. Until now, this phenomenon has only been described for the right coronary artery. The reason underlying intimal folding is a shifting of the intimal layer against the medial layer of the vessel wall. Our observation firstly describes this phenomenon of "pseudo narrowing" in two different vessels in one patient. We, like other authors before, recommend that interventional therapy of these pseudo-lesions should be avoided.

Chromogenes Substrat als Antidot gegen den Thrombininhibitor Ro 46-6240?

Anhand von In-vitro-Untersuchungen wird gezeigt, daß ein chromogenes Substrat (Chromozym TH der Firma Boehringer/Mannheim) die gerinnungshemmende Wirkung des neuen Thrombininhibitors Ro 46-6240 (Firma Hoffmann-LaRoche/ Grenzach-Wyhlen) zumindest partiell antagonisieren kann. Der hier beschriebene Antidoteffekt eines chromogenen Substrats gegenüber einem Thrombininhibitor könnte seine Erklärung darin finden, daß eine Substratkompetition des Thrombins im Testsystem gegenüber Fibrinogen, Thrombininhibitor und chromogenem Substrat vorliegt. In Tierversuchen müßte weiterhin geklärt werden, ob die beschriebene Antidotwirkung tatsächlich durch den Thrombininhibitor verursachte Blutungskomplikationen vermindern kann oder ob nur ein In-vitro-Phänomen vorliegt, das in vivo wenig Relevanz hat.

[Directional coronary atherectomy: effect of vessel size on primary results and long-term results]

Of 325 consecutive patients undergoing DCA, 263 patients with 277 stenoses were successfully treated with DCA alone and had angiographic follow-up 3-6 months later. Depending upon the initial reference diameter (RD) patients were divided into two subgroups: group I (n = 159) with a RD > 3 mm and group II (n = 104) showing a RD < or = 3 mm. In contrast to other series DCA was predominantly performed with 7F atherectomy devices using balloon inflation pressures of approximately 5 atm. Angiographic data including the minimal luminal diameter (MLD), percentage of stenosis (%D) and reference diameter (RD) were assessed by quantitative computer-assisted analysis before (pre), after (post) DCA and at a 3-6 months angiographic follow-up (FU). The percentage of diameter stenosis pre/post/FU in group I was 59.9 +/- 12.6%/18.4 +/- 12.8%/29.8 +/- 17.6%, and in group II 55.6 +/- 10.8%/17.8 +/- 12.3%/33.7 +/- 16.1% with a net gain at FU of 1.0 +/- 0.89 mm for group I and 0.86 +/- 0.66 mm for group II. Based on an angiographic restenosis criterion of at least 50% diameter obstruction at FU and or recurrence of symptoms warranting interventional re-treatment of the target lesion, the incidence of restenosis in group I was 20.6% and in group II 28.0% (p: n.s.). There was no significant difference between the two groups concerning complications. Our data show that DCA leads to a satisfying long-term result.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hemodynamic effects of non-ionic iomeprol 350 and ionic diatrizoate 370 during levocardiography and coronary angiography--double-blind randomized comparison of 2 contrast media]

A double-blind randomized study was performed in 49 patients to compare the hemodynamic changes induced by two contrast agents: non-ionic low osmolar lomeprol 350 (IO, n = 25) and ionic high osmolar Diatrizoat 370 (DIA, n = 24). We observed significant changes in hemodynamic parameters after laevocardiography with DIA: a decrease in LVSP from 125 +/- 14 to 113 +/- 14 mmHg, a decrease in mean aortic pressure from 96 +/- 9 to 84 +/- 10 mmHg and in max dp/dt from 2086 +/- 628 to 1861 +/- 654 mm Hg/sec. LVEDP increased from 13 +/- 5 to 17 +/- 6 mmHg and cardiac output from 5.9 +/- 1.2 to 7.7 +/- 1.2 l/min. Heart-rate also rose slightly, but insignificant. IO did not alter these parameters. After selective coronary angiography both groups did not differ significantly in systolic aortic pressure, but DIA caused a drop in diastolic aortic pressure after 10 to 15 sec and a bradycardia in the first five sec, in contrast to IO. These effects can be explained by a cardiodepressive action of contrast agents on left ventricular function, an increase in circulating volume and a reduced peripheral vessel resistance. Differences between both agents are probably due to their different osmolality. IO is a safe contrast agent, compatible in contrast to DIA. In patients with borderline left-ventricular function, IO is preferable, it exerts only very slight effects on cardiovascular function.

Time course of left ventricular function and coronary patency after saruplase vs streptokinase in acute myocardial infarction. The PRIMI Trial Study Group

As part of a prospective randomized double-blind trial (PRIMI) to study the early patency rate of the infarct-related artery after saruplase (INN for recombinant unglycosylated full-length human single-chain urokinase-type plasminogen activator) vs streptokinase in a subgroup of patients, left ventricular function was compared between both treatment groups at 90 min and 24 h after thrombolysis and at discharge, and ventricular function was related to the coronary perfusion grade. Despite a higher patency rate in the saruplase group 60 min after initiating thrombolysis, neither global ejection fraction nor hypokinesia at the infarct site were significantly different between the treatment groups at any of the three time points when function was measured. Hypokinesia at the infarct site remained almost equally severe throughout the study in patients with perfusion grade O, I, and II, and was consistently significantly milder in patients with perfusion grade III. In contrast, in patients with perfusion grade II there was a significant drop in hyperkinesia at the opposite wall at 24 h after thrombolysis and before discharge despite unchanged wall motion at the infarct site. Although patients treated with saruplase had a higher patency rate in the infarct related vessel shortly after the start of thrombolysis, no difference was found in left ventricular function compared to patients treated with streptokinase. Complete reperfusion (TIMI grade III) seems to be a prerequisite for left ventricular function recovery after thrombolysis, whereas only an occluded vessel (TIMI grade O and I) seems to be related to a longer lasting hyperkinesia at the opposite wall.