[Tissue plasminogen activator (alteplase) in acute massive pulmonary embolism. A pilot study]

Twenty six patients with acute (less than 5 days) pulmonary embolism (PE) confirmed by bilateral pulmonary angiography with a Miller index greater than 15 were given tissue plasminogen activator (Alteplase) (rt-PA) intravenously (n = 20) or directly into the pulmonary artery (n = 6). The dosage was 100 mg/7 hours (bolus 10 mg + 40 mg/2 hours + 50 mg/5 hours). Heparin (5000 IV as a bolus and 1000 IV/hour) was associated in all cases. The Miller index decreased from 24 +/- 1 (n = 26) before treatment to 12 +/- 1 (n = 25) (p less than 0.001) after 100 mg of Alteplase, and from 25 +/- 0.4 (n = 14) to 22 +/- 0.5 (n = 14) (p less than 0.001) after 50 mg. The mean pulmonary arterial pressures fell from 30 +/- 2 mmHg to 21 +/- 2 mmHg after 50 mg (n = 26) (p less than 0.001) and to 14 +/- 1 (n = 25) (p less than 0.001) after 100 mg of Alteplase. A decrease in mean pulmonary artery pressures (-22%, p less than 0.001) and total pulmonary resistances (-29%, p less than 0.001) was obtained after one hour of thrombolysis in 12 monitored patients. There were no fatalities. Severe haemorrhage occurred in 6 cases. Therefore, Alteplase induced a rapid dissolution of recent intrapulmonary thrombi without inacceptable haemorrhagic complications. Its action could be particularly beneficial in patients with right ventricular failure due to life threatening pulmonary embolism.

Preferential inhibition of mouse hepatic coumarin 7-hydroxylase by inhibitors of steroid metabolizing monooxygenases

Etomidate, metomidate and metyrapone, all potent inhibitors of steroid metabolizing monooxygenases, inhibit preferentially coumarin 7-hydroxylase (COH) amongst several liver microsomal monooxygenase activities from control and pyrazole-treated D2 mice in vitro. SKF-525A, an inhibitor of phenobarbital-inducible monooxygenase activities has a much weaker effect on COH than the other three drugs, even though COH is a phenobarbital-inducible enzyme. Treatment of mice with eto- and metomidate decreases the microsomal COH also in vivo while the other activities remained unchanged (with the exception of 7-ethoxycoumarin O-deethylase (ECDE) in case of metomidate). Despite of the decrease in COH no parallel decrease in the amount of microsomal P450Coh (P450 isoenzyme highly active in the 7-hydroxylation of coumarin) could be found in dot immuno-binding analysis. These data suggest that among several liver microsomal P450 isoenzymes, metyrapone, eto- and metomidate interact preferentially with the P450Coh and that eto- and metomidate may alter selectively the catalytic properties of P450Coh leading to decreased enzyme activity. Two different Ks-values could be found for all three drug in their binding to microsomal cytochrome(s) P450. Based on substrate binding spectra, potassium ferricyanide treatment does not dissociate the complex between reduced P450 and metomidate and does it only partly for etomidate. Furthermore potassium ferricyanide treatment of microsomes does not increase COH after in vivo treatment of mice with eto- and metomidate. These data further suggest that the complex between P450Coh and eto- and metomidate may be particularly strong and independent from the redox state of the haem iron.

Mouse steroid 15 alpha-hydroxylase gene family: identification of type II P-450(15)alpha as coumarin 7-hydroxylase

We identified type II P-450(15)alpha as mouse coumarin 7-hydroxylase (P-450coh). Unlike type I P-450(15)alpha, the other member within the mouse steroid 15 alpha-hydroxylase gene family, type II catalyzed little steroid 15 alpha-hydroxylase activity, yet structurally there were only 11 substitutions between type I and type II P-450(15)alphaS within their 494 amino acid residues (Lindberg et al., 1989), and the N-terminal sequence (21 residues) of P-450coh was identical with that of both P-450(15)alphaS. Induction by pyrazole of coumarin 7-hydroxylase activity correlated well with the increase of type II P-450(15)alpha mRNA in 129/J male and female mice. Pyrazole, on the other hand, was less in males or not effective in females in inducing the 15 alpha-hydroxylase activity and type I P-450(15)alpha mRNA. Expression of type I and II in COS-1 cells revealed that the latter catalyzed coumarin 7-hydroxylase activity at 10 to approximately 14 pmol min-1 (mg of cellular protein)-1. The former, on the other hand, had a high testosterone 15 alpha-hydroxylase but little coumarin 7-hydroxylase activity. It was concluded, therefore, that type II P-450(15)alpha is the mouse coumarin 7-hydroxylase. Identification of type II as the P-450 specific to coumarin 7-hydroxylase activity and characterization of its cDNA and gene, therefore, were significant advances toward understanding the basis of genetic regulation of this activity in mice (known as Coh locus).

Identification and characteristics of a novel mitochondrial 5'-nucleotidase in rat liver

In rat liver mitochondria there exists an AMP-dephosphorylating activity which converts external 5'-AMP to adenosine. It exhibits a pH optimum of 7.5 and a Km(AMP) of 0.085 mM. Furthermore, this activity is stimulated by magnesium (Km = 0.5 mM) and seems to be not affected by low concentrations of ATP or ADP. From the characteristics of the enzyme the existence of a 5'-nucleotidase in rat liver mitochondria which is localized on the outer surface of the inner mitochondrial membrane was concluded. The enzyme may be important for the production of cellular adenosine.

Biosynthesis of complement C4 messenger RNA in normal human kidney

Complementary DNA (cDNA) probes were used to investigate the extrahepatic production of the major histocompatibility complex (MHC)-linked complement components C4, factor B and C2 in various normal human tissues. The presence of the corresponding messenger RNA (mRNA) was tested by Northern blot analysis. Complement C4 mRNA was found in liver, and with high intensity also in normal kidneys. In contrast, no C2 mRNA and only very low amounts of factor B mRNA could be detected in the kidney. Slot blot hybridization was performed to quantitate the amount of C4 mRNA, and the intensity of C4 mRNA hybridization in the kidney samples was about 25% compared with liver RNA. C4-specific transcripts were not present in isolated glomeruli but in the renal interstitium. Other human tissues, such as tonsil, spleen, thymus, brain, lung and peripheral mononuclear cells, contained no C4 mRNA. Low amounts of C4 mRNA were found in colon, thyroid gland, lymph node and breast carcinoma. The results obtained with lung, where C2 mRNA was found but no C4 mRNA, further indicate an independent, tissue-specific regulation of the class III gene expression. The results, showing that the complement C4 genes are transcribed very efficiently in normal human kidney, suggest a direct role of complement C4 in renal pathogenesis.

Molecular biology of the HLA-B27 locus

The molecular biology of the HLA-B27 locus is reviewed. The HLA-B27 gene itself does not differ between healthy individuals and ankylosing spondylitis patients. Several unique features of the HLA-B27 molecule have been identified and one epitope was proposed to cross-react with bacterial proteins.

Left frontal lobe in verbal associative learning: a slow potential study

In the present experiment pairs of words had to be memorized. The words were either meaningful or meaningless. The experimental design compares conditions of preestablished learning (L-) with active learning (L+). The effects of these two factors, "semantic content (S)" and "learning (L)", on the slow potential shifts accompanying presentation and processing of the verbal material were tested. In the memorizing tasks, the two words were given in a fixed temporal sequence. A slow negative potential shift having a maximum in parietal leads emerged within the inter-stimulus-interval. Its amplitudes were larger in the learning tasks (L+) than in conditions of pre-established learning (L-). This difference of amplitudes may reflect different levels of attention: In L-, the second word could be anticipated, but not in the L+ tasks. After the presentation of the second item, learning tasks (L+) were characterized by a slow negative potential shift in the recordings of the left dorso-lateral frontal lobe. It is assumed that this potential shift may indicate an importance of the left frontal lobe in the elaborative encoding of verbal material.

[Left ventricular hypertrophy in arterial hypertension]

Arterial hypertension is frequently and at an early stage complicated by left ventricular hypertrophy, i.e. an increase in muscular mass due to the proliferation of myofibrillae. This in fact is a physiological mechanism aimed at maintaining systolic function and systemic blood flow rate. Left ventricular hypertrophy may be associated with myocardial alterations, such as increase of collagen, abnormalities of diastolic function, reduced contractility, increased cell excitability and disorders of coronary perfusion. It is responsible for a higher risk of cardiovascular mortality. Antihypertensive treatments, therefore, must not only bring blood pressure down to normal values, but also reduce the myocardial mass. In order to avoid a detrimental effect on coronary reserve, it is highly desirable that arterial hypertension and left ventricular hypertrophy regress simultaneously. Regression of the myocardial hypertrophy associated with arterial hypertension is observed with most antihypertensive drugs, except vasodilators that act directly on the vascular smooth muscle, probably due to stimulation of the sympathetic system. Diuretics also have an inconstant beneficial effect on left ventricular hypertrophy. When a choice has to be made between two drugs that have the same antihypertensive activity, it is the one that also brings about an early and lasting regression of myocardial hypertrophy which must be prescribed.

Negative cortical DC shifts preceding and accompanying simultaneous and sequential finger movements

Cortical DC shifts preceding and accompanying the execution of five different bimanual motor tasks were analysed in 20 subjects. All tasks required repetitive flexions and extensions of the two forefingers for a period of at least six seconds. The temporal and spatial structures organization varied in the different tasks: (1) Simultaneous agonistic performance (forefinger flexion on both sides), (2) simultaneous antagonistic performance (e.g. flexion of the right, extension of the left forefinger), (3) sequential agonistic performance, (4) sequential antagonistic performance, (5) uncoordinated flexions and extensions of the two forefingers. Compared to (1) and (2), conditions (3) and (4) included a temporal delay between the performance of the two forefingers; compared to (1) and (3), conditions (2) and (4) required the subjects to perform movements of opposite directions with their two forefingers. Effects of the temporal factor (T; simultaneous vs. sequential) and the spatial factor (S; agonistic vs. antagonistic) on cortical DC shifts were investigated. The voluntary initiation of each motor task was preceded by a Bereitschaftspotential (BP). The performance of the complex tasks (1-4) was accompanied by a slow negative DC potential shift (N-P). In general, the BP did not differ depending on the temporal or spatial structures of the tasks (1-4). However, amplitudes of N-P (i.e. during tasks) were influenced by the temporal factor with significantly larger amplitudes in sequential than in simultaneous tasks. This difference was not a global phenomenon in all recordings but was selectively found in the recordings over the fronto-central midline.(ABSTRACT TRUNCATED AT 250 WORDS)

DC-potential shifts and regional cerebral blood flow reveal frontal cortex involvement in human visuomotor learning

In the present study, two different physiological parameters were measured to describe brain activity related to visuomotor learning: performance-related DC-potential shifts and regional cerebral blood flow (rCBF) by Tc-99m HMPAO brain SPECT (Single Photon Emission Computerized Tomography). Visuomotor learning was required in a conflicting situation: a visual target moved on a screen and had to be tracked by moving the right hand in an inverted fashion (IT), e.g. movements of the target to the right side required hand movement to the left and vice versa. Compared to a normal, non-inverted control task (T), IT required the development of a novel motor program and the prevention of returning to routine direct pursuit. These additional demands in IT caused a relative hyperperfusion in regions including the middle frontal gyri, frontomedial cortex (including the supplementary motor area, SMA), right basal ganglia (caudate-putamen) and left cerebellum. Correlations of rCBF values between the middle frontal gyrus and basal ganglia may indicate a functional relation between these two brain structures. Visuomotor performance was accompanied by slow negative DC-potential shifts. In frontal and to a lesser degree in central recordings, amplitudes of DC-negativity were larger in IT than they were in T. This additional frontal negativity covaried with the success of learning. Results substantiate, now using a dual approach, previous suggestions that the frontal lobe plays an important role in visuomotor learning.

Suppressive effects of transdermal clonidine administration on contact hypersensitivity reactions in guinea pigs

In the present study, immunopharmacological effects of clonidine-TTS on allergic contact dermatitis (ACD) to non-related, established contact sensitizers were investigated in guinea pigs. First, to evaluate the hypotensive effect of clonidine-TTS in guinea pigs, intra-arterial blood pressure was recorded. After 4 days of treatment with one (or two) TTS per animal, a reduction of arterial blood pressure from 71 +/- 1 to 51 +/- 2 mm Hg was observed. We subsequently assessed the effects of clonidine-TTS on contact hypersensitivity reactions to 2,4-dinitrochlorobenzene (DNCB) and 4-ethoxymethylene-2-phenyl-oxazolone (Ox). This study indicates that clonidine-TTS suppressed the elicitation of contact hypersensitivity reactions. The observed immunosuppressive effect of clonidine may account for the relatively weak hypersensitivity reactions to this drug in experimental animal studies. Further studies are needed to determine whether such findings are of relevance to the clinical use of clonidine in patient populations.

Cortical slow potentials in verbal and spatial tasks--the effect of material, visual hemifield and performing hand

Fifteen right-handed students voluntarily initiated the tachistoscopic presentation of visual stimuli containing either verbal (abstract words) or spatial (stereogeometric figures) material. Subjects had to reproduce stimulus material which had been presented either in their right or their left hemifield of vision by writing or drawing, either with their right or their left hand. Material-specific effects were found during the reproduction period: amplitudes of the performance-related negative potential shifts were larger in parietal and occipital recordings (P4, O1, and O2) when drawing as compared to writing. The opposite was true in frontal and left central leads (F3, F4, and C3) where writing was associated with larger negative amplitudes than drawing. Although subjects were informed about the nature of the forthcoming stimulus before voluntarily initiating the task, material-specific effects were missing in the preparation period. The performing hand had an influence on potentials in central leads, whereas hemifield of vision had no effect on preparation- and performance-related slow potential shifts.

[Diagnosis of primary hyperaldosteronism. Apropos of 3 cases]

Primary hyperaldosteronism (HA1) represent a rare etiology of arterial hypertension (less than 1%). It concerns, most of the time, aldosterone-producing adenomas or bilateral adrenal hyperplasias although intermediate forms have been reported. The diagnosis of HA1 is based on simple examinations, especially systematic measurement of kaliemia in every hypertensive patient with a normal sodium diet before treatment. The elevation of aldosterone blood levels associated with a low plasma renin activity confirms the autonomous nature of the hormonal secretion which is dissociated from the renin-angiotensin system. Study of the ratio aldosterone blood level/ARP and the captopril test are particularly useful in borderline cases. Once the diagnosis of HA1 is made, a topographic analysis may be undertaken; tomodensitometry and adrenal scintigraphy are currently the examinations of choice in the diagnosis of adrenal tumors. Due to biological, morphological and topographic factors, aldosterone-producing adenomas may be identified with a great deal of certainty: surgical excision ensures a cure in a large majority of cases. The treatment of bilateral hyperplasias remains medical.

Monitoring of heparin therapy with the activated partial thromboplastin time and chromogenic substrate assays

Heparin therapy was monitored with the activated partial thromboplastin time (APTT) and with chromogenic substrate assays (factor Xa and factor IIa inhibition) in 100 plasma samples from 47 patients. Heparin concentrations were classified as being below, within or above a defined therapeutic range (TR; 0.2-0.55 units heparin/ml). In a first group of patients (A), all three assays allocated the plasma heparin levels to the same concentration interval with respect to the TR. The most frequent diagnoses in group A were uncomplicated arterial or venous thromboembolism, myocardial infarction with limited tissue necrosis, cardiac surgery without major complications and successfully treated infectious disease. In a second group of patients (B), the results of APTT suggested higher heparin concentrations with respect to the TR than the chromogenic assays. Predominant diagnoses were severe infectious diseases, severe liver disorders, extensive myocardial infarction and postoperative complications after cardiac surgery. The discrepancy between heparin concentrations determined by either APTT or the chromogenic substrate assays is most likely due to a non-heparin related prolongation of APTT caused by the underlying disease.

[Primary leiomyosarcoma of the pulmonary artery. Apropos of a case]

A case of leiomyosarcoma of the pulmonary artery in a 64-year old man without previous cardiovascular disease is reported. The clinical picture, which comprised episodes of paroxysmal dyspnoea associated with acute cor pulmonale, suggested pulmonary embolism. Radioisotope perfusion study and pulmonary angiography seemed to confirm this diagnosis, but no improvement was obtained with a prolonged thrombolytic treatment. The presence of a median mass at CT led to exploratory thoracotomy and to the finding of a tumour in the pulmonary artery, which turned out to be a leiomyosarcoma. The disease rapidly took an unfavourable course. Comparison of this case with data from the literature showed that primary tumours of the pulmonary artery are extremely rare, that they are diagnosed with difficulty and often at a late stage and that their prognosis is usually very sombre.

Sequential calcium and phosphorus balance studies in preterm infants

Forty-six infant boys less than 1500 g at birth and less than 32 weeks gestation were fed enterally from birth until day 47. Cohorts were given milk formula varying in calcium and phosphorus content: group A, calcium 45 mg/dL, phosphorus 33 mg/dL; group B, calcium 85 mg/dL, phosphorus 33 mg/dL; group C, calcium 125 mg/dL, phosphorus 33 mg/dL; group D, calcium 125 mg/dL, phosphorus 50 mg/dL; and group E, calcium 125 mg/dL, phosphorus 64 mg/dL. Three-day balance studies were begun at days 10, 20, 30, and 40. Calcium net absorption and retention were influenced by postnatal age and calcium intake. Calcium retention best approached intrauterine accretion rates in group C. Phosphorus was well absorbed irrespective of the calcium content of the milk. Phosphorus retention increased with increments in the calcium content of the milk. Increasing the phosphorus content of the milk (groups D and E) resulted in no overall change in calcium absorption and retention but some increments in phosphorus retention.

[Comparative study of the effects of verapamil and propranolol therapy in 16 cases of obstructive hypertrophic myocardiopathy]

In a randomized, double-blind, cross-over study with plasma drug assays, 16 patients (11 men, 5 women; mean age 48.56 +/- 3.61 years) presenting with hypertrophic obstructive cardiomyopathy confirmed by echocardiography, left ventriculography and left intraventricular gradient measurement were treated with verapamil 480 mg/day or propranolol 320 mg/day. Both treatments produced functional improvement (p less than 0.01) which was more distinct with verapamil (NS). No changes in cardiothoracic index, echocardiographic parameters and Sokolow's index were observed. Mean total heart work during exercise, which was 1,197.27 +/- 135.89 watts before treatment, increased to 1,260.91 +/- 146.60 watts under propranolol (NS) and to 1,344.09 +/- 171.06 watts under verapamil (NS). Maximum heart rate during exercise, which was 162.3 +/- 3.46 beats/min before treatment, was reduced to a greater extent by propranolol (122.1 +/- 6.6 beats/min; p less than 0.001) than by verapamil (147.7 less than 5.08 beats/min; p +/- 0.01). The two treatments did not significantly modify ventricular arrhythmia, arterial and capillary pulmonary pressures, mean aortic pressure and left ventricular end-systolic pressure. Cardiac index, unchanged under verapamil, fell from 2.98 +/- 0.16 1 X min-1 X m-2 to 2.60 +/- 0.11 1 X min-1 X m-2 under propranolol (p less than 0.05). The left intraventricular gradient present in 5 patients at rest and during exercise, was reduced by both drugs. The gradient under isoprenaline (n = 16), which was 162.07 +/- 18.77 mmHg before treatment, fell to 93.86 +/- 24.48 mmHg with propranolol (p less than 0.05) and to 128.86 +/- 18.22 mmHg with verapamil (p less than 0.05). Left ventricular ejection fraction, mean circumferential fibre shortening speed and compliance coefficient remained unchanged under both drugs (NS). Left ventricular diastolic function, evaluated by radioisotope angiography in the last 9 patients, was most often improved by verapamil (NS). Verapamil was better tolerated generally and by the heart than propranolol. No correlation was observed between plasma verapamil levels and clinical results. Low plasma propranolol levels were often noted in non-responders, suggesting a need for treatment with high doses. It is concluded that at the dosage level used in this study propranolol and verapamil were equally effective, but there were individual variations in best response to one or the other of these two drugs.

[Monitoring heparin therapy by thrombin time and activated partial thromboplastin time--a comparison]

In 106 plasma samples obtained from patients on heparin therapy, monitoring by 2 methods (activated partial thromboplastin time and thrombin clotting time--APTT and TT) was compared. All patients in whom APTT indicated markedly higher plasma heparin concentrations than the TT were critically ill (group B): their main diagnoses included severe infectious disease, severe liver disease and extensive myocardial infarction. Patients with lesser discrepancies between the results of APTT and TT did not suffer from such severe conditions (group A). Cardiac surgery without major postoperative problems, limited myocardial infarction and uncomplicated thromboembolism were the main diagnoses in this group. In group B, non-heparin related prolongation of APTT was thought to be the main factor responsible for the overestimation of plasma heparin concentrations by this test. We conclude that in patients with severe infectious disease, liver disease or extensive tissue necroses (i.e. myocardial infarction), APTT cannot be recommended for laboratory monitoring of heparin therapy.