[Pulsed doses of cyclophosphamide in the treatment of Wegener's granulomatosis]

The aim of the study was to analyze the efficacy and toxicity of the therapy with pulse dose of cyclophosphamide in patients with Wegener's granulomatosis. The diagnosis was established in three patients (2 male, 1 female, average age 58.3 years) upon the clinical picture, laboratory-immunologic and histopathologic findings. The initial therapy was conducted by pulse doses of cyclophosphamide (0.6 and 0.8 g/kg), glucocorticoids (0.5 g), repeated plasmapheresis and pulse doses of immunoglobulin (0.4 g/kg). All patients achieved remission with complete recovery of renal function in one patient. The therapy with pulse doses of cyclophosphamide (time-period between pulses from 1 to 3 months), together with glucocorticoids taken orally for 24 months, was continued for the following 18 months. Stable remission (4-15 months) was maintained in all the patients after the immunosuppressive therapy was over. The treatment of Wegener's granulomatosis by cyclophosphamide and glucocorticoid pulse doses with the application of plasmaphereses and immunoglobulin pulse doses in the initial therapy lead to the remission of progressive types of long duration.

[Platelet function]

Platelets are cells which possess broad potential activities in the area of both physiological functions and physiological disorders. The role of platelets in haemostasis with vascular injury is well documented. With vascular and endothelial cell injury, the following sequence of platelet events includes: adhesion, aggregation, secretion. In addition, platelets have a certain role in formation of a permanent haemostatic plug and prolongation of the period of vasoconstriction. There is also the recent evidence of the role of platelets in haemostasis without vessel wall injury. It is evident that platelets play the essential role not only in normal haemostasis but also in wound healing, maintenance of normal plasma homeostasis by endocytosis as well as in inflammation. Platelets play a role in the following pathological events: atherosclerosis, tissue fibrosis, tromboembolism, graft rejection, cancer metastasis. A complete insight into the content of platelet depot organelles, and their functional possibilities requires further research in this area.

Dynamic analysis of the three-phasic vascular response to histamine in coronary circulation

In this work we tried to perform a dynamic analysis of coronary vascular response to histamine, using a simple mathematical analysis as a first step in the better understanding of complex histamine effects on coronary blood vessels of the isolated guinea pig heart. So, we defined more parameters, such as: I and delta I to quantify the intensity of coronary perfusion pressure (CPP) change, T and dt to quantify the time CPP change occurs and D to characterize the intensity and duration of CPP change, i.e. to quantify the dynamics of this change.

[The antiphospholipid syndrome--yesterday, today, tomorrow]

Antiphospholipid syndrome (APLS), is defined as the presence of antiphospholipid antibodies (APLA) associated with clinical phenomena of arterial or venous thrombosis, recurrent spontaneous abortions and thrombocytopenia. APLA represent the family of antibodies of different specificity. They are mostly directed to various anionic phospholipids (cardiolipin, phosphatidylcholine, phosphatidylserine, phosphatidyl acid and phosphatidyl ethanolamine). The part of APLA is directed towards epitope at the structurally changed beta-2-GPI, the so-called anti beta-2-GPI antibodies and the hypothesis was established that the subgroup of APLA was directed towards complex of beta-2-GPI with the phospholipids and oxidized lipoproteins of high and very low density. This could explain the clinically observed association of mutual onset of thrombosis and atherosclerosis. The most frequent target tissues for APLA are endothelial cells, thrombocytes, monocytes, natural anticoagulant system and placenta. APLA can be detected in a serum with one of the following assays: testing of lupus anticoagulant presence, determination of anticardiolipin antibodies (ACLA) concentration by ELISA and by testing the false positivity of VDRL test (standard test for syphilis). The pathological base for so-called vasculopathy in APLS are arterial and venous thrombosis. Clinical manifestations of APLS are mainly the result of blood vessels' occlusion but the thrombotic mass deposition on the surface of the heart valves may also occur. Clinically APLS can be divided into primary and secondary one, and manifestations of the secondary APLS are mainly expressed in the patients with SLE. Some clinical and serological variants of primary APLS were also described. The tendency for thrombotic process as a crucial characteristic of the syndrome and the lack of inflammation, imposes the choice of antithrombotic and anticoagulant therapy.

Antiphospholipid syndrome in systemic connective tissue diseases

Clinical manifestation and immunoserological features of secondary antiphospholipid syndrome (SAPS) were analyzed in this paper in 107 patients with systemic connective tissue diseases. In the group of patients with confirmed systemic lupus erythematosus (SLE), antiphospholipid antibodies (aPL) were positive in 43/93 (46.23%), while in 50/93 (53.76%) they were negative. Among aPL positive patients, 33/43 (76.74%) had clinical manifestations of SAPS, while 10 patients (23.26%) were without any clinical manifestations. The most frequent manifestations of SAPS associated with SLE were: arteriovenous thrombosis in 20/43 (46.51%), thrombocitopenia in 15/43 (34.88%) and autoimmune hemolytic anemia in 7/43 (16.27%). In our patients, rare manifestations of SAPS associated with SLE were recurrent fetal loss (1 case), livedo reticularis (1 case), transversal myelitis (2 cases), neuropathy (2 cases) and aseptic endocarditis (Libman-Sacks) (5 cases). Among 7 patients, with Sjögren's syndrome, clinically manifested SAPS was observed in 2, while in other 5 only increased aPL levels were found, as well as in patients with systemic vasculitis-3, MCTD-2 and Sy. Sjögren with vasculitis-1. One RA patient had thrombosis of v. cava inferior. In majority of patients with clinically present SAPS the levels of both examined immunoglobulin isotypes (IgG + IgM) were decreased-21/40 or 52.5%, while isolated increase of IgG was found in 14 (35%) and isolated increase of IgM in 5 (19.22%) patients. In three out of five patients with Libman-Sacks only LA test was positive. This investigation have shown that arterial and venous thromboses are the most common manifestations of SAPS in SLE. Every blood vessel may be involved (from arteriolae to the aorta and from postcapilar venules to the v. cava).

[Dermatopolymyositis and overlap syndromes]

Clinical characteristics and immunoserological features of patients with overlap myositis treated in Clinic for Rheumatology of Military Medical Academy in the period 1978-1996 are presented in the study. Retrospective and partially prospective study included 16 patients with the diagnosis of dermatopolymyositis associated with some other systemic disease of connective tissue (SDCT) in overlap syndrome. There were 12-females of average age 37.33 years and 4 males of average age 52.25 years. Complete laboratory investigation included the determination of muscular enzymes values. Immunoserological analyses were also performed (RF, Le cells, ANA, ICs, immunoglobulins, cryoglobulins and complement), EMNG examination of pelvis and shoulder and pH examination of skin, subcutaneous tissue and muscles. The combination of the diseases was found in 11 patients, 7 were with PSS, 2 with SLE, 1 with RA and one with PAN. Three diseases were associated in 4 patients, SLE and RA in 2, PSS and RA in 1, thyroiditis and sicca complex in 1. Five-fold combination of disease was found in 1 patient. More frequent occurrence of fever, polyarthritis, skin manifestations, Raynoud's phenomenon, the involvement of serosas, lungs and heart, histological finding of skin and/or muscle vasculitis and larger presence of ANA, ICs, hypergammaglobulinemia and hypocomplementemia pointed out the dominant disorder of humoral immunity which was most probably connected with associated SDCT.

A simple morphological score for the quality control of platelet concentrates

The percentage of platelets that retain discoid form correlate with their post-transfusion viability and therefore they may act as a simple indicator for the quality of the stored platelet concentrates (PCs). The morphological score (MS) of platelets, given by Kunicki, requires the index of different forms of platelets: discoid, spherical, starlike and bizarre. In the present study, we intended to clarify whether the morphological score of discoid platelets alone could serve as a method for the estimation of PCs quality. During the first five days after preparation, samples of standard platelet concentrates (SPCs) and of leucodepleted platelet concentrates (LDPCs) were analyzed morphologically by immersion light microscopy using smears stained by the May-Grünwald-Giemsa method. In addition to the MS, an original Modified Morphological Score (MMS), for a population of 200 platelets, was used to count platelets with the discoid shape. The mean MMS ranged (first to fifth day) from 192.6 to 166.6 with SPCs and from 197.2 to 185.4 with LDPCs. There is a significant difference (ANOVA) between: (a) PCs prepared by different techniques (p < 0.01); (b) the quality of the same PCs during the storage (p < 0.0001).

[Reiter's syndrome--analysis of 187 patients]

The study included 187 patients with positive diagnosis of Reiter's syndrome (RS) examined and treated in the Clinic of Rheumatology of Military Medical Academy in the period of 26 years (1970-1995). There were 176 males and 11 females (16:1) aged from 12 to 65 (average age 28.5) years. The disease diagnosis was made upon the clinical finding of at least two of four RS main features: acute urogenital or enteral infection, arthritis, ophthalmic and mucocutaneous changes. Family disease occurrence was noticed in 5, and juvenile type in 6 patients. HLA-B27 antigen was present in 81.5% patients. In 74.3% patients the urogenital disease type was determined, in 18.2% enterocolitic and in 7.5% initial causative agent was not discovered. Three or two RS main signs were present in approximately same number of patients (42.2% and 42.6%) while all the four disease signs were found in 15% patients. Acute or subacute course was found in 43.8%, recurrent in 34.2% and chronic in 22% patients. Clinically, the disease was revealed in locomotor system, most frequently as the asymmetric oligoartritis localized in lower extremities. Sacroiliac arthritis, partial or more frequently asymmetric mutual, radiologically confirmed, was present in 18.2% patients. Only one patient was with sacroiliitis without peripheral arthritis, pain in heel was present in 31.5%, and dactilitis, more frequently in the feet, in 13.9% patients. Radiological changes were found in 51.8% patients, most frequently in sacroiliac joints and heel bone. Chlamydia trachomatis or genital mycoplasma were isolated in synovial fluid of 33.3% (6/18) patients. The most frequent urogenital change was urethritis (56.7), ophthalmic--conjunctivitis (46.5), and mucocutaneous--balanitis (12.3). Positive damage of heart and kidneys by primary disease was found in 2, i.e. 4 patients, and possible in 7, i.e. 14 patients. No differences in RS clinical demonstration among sexes were observed. Besides conventional therapy, in only 26 (13.9%) patients were applied drugs out of the basic group, so as the radiation synovectomy and surgical methods of treatment.

[A manic syndrome after cerebral trauma: case report]

This case report describes a 17-year-old female patient in whom a clinical picture of manic syndrome developed four days after craniocerebral trauma. The diagnostic procedure comprised neuropsychological, neurophysiological and neuroanatomical examination. The diagnosis revealed discrete organicity on the level of psychic functions, whereas magnetic resonance imaging revealed changes of the right hemisphere. One case cannot reveal the etiology of affective disorders after cerebral injuries, but gathered results point to the possibility of causal connection between craniocerebral trauma and manic syndrome.

[Cyclosporin A in the treatment of Behçet's disease]

The results of Cyclosporin A treatment of 15 patients with Behçet's disease were examined in the study--9 females (aged from 32 to 34 years, mean 33 years) and 12 males (aged from 25 to 55 years, approximately 34.33 years). Among them, the majority were with chorioretinitis (10/15 or 66.6%). Besides chorioretinitis two patients were simultaneously with iridocyclltis, while in three the whole nervous system was affected (meningoencephalitis, simultaneously pyramidal syndrome with the signs of extrapyramidal lesion and consciousness disorder in one patient). In one patient myocarditis was revealed, and the one was with deep aphtous ulcer. The approximate daily dose was 5 mg/kg in 13 patients, and 7.5 mg/kg/d in 2 patients. For that, the level of the drug in blood elevated from 79 to 380 ng/ml, approximately 170 ng/ml. The effect was favourable in 12 patients (complete restraint of the disease evolution), partial in 2 patients (slowing of the disease course) while it was incomplete in one patient for the interruption of the therapy 15 days after its beginning.

[Fibronectin--a multifunctional glycoprotein]

Fibronectin is an ubiquitous glycoprotein that plays an important role in many biological processes. Plasma and cellular fibronectins are similar, but not identical molecular structures. Cellular fibronectin has ED1 and ED2 components that do no exist in plasma fibronectin. Human plasma fibronectin is a high molecular weight (440-530 kD) glycoprotein, consisting of two nearly identical subunits disulfide-bridged close to their C-terminal ends. Tetrapeptide "RGDS" and polypeptide "CS1" are receptors for cell surface integrins. Numerous receptors for macromolecules enable to bridging of fibronectin to the fibrin, heparin, factor XIIIa, plasminogen, tissue type plasminogen activator, collagen, bacterial and virus glycoproteins. Cellular fibronectin is a component of the fibrillar extracellular matrix compartment and basal membrane of all tissues that are involved in the tissue modelling in embryogenesis and tissue remodelling in wound healing. Plasma fibronectin is involved in the mechanisms of immune defence, immune surveillance and hemostasis.

[Our experience in the treatment of painful shoulder syndrome by Streptofil]

Streptofil is a biological product obtained from streptococcus beta haemoliticus, with molecular weight of 700 D and antigenic properties. It has anti-inflammatory, antibacterial and reparative effects. The objective of our study was to test the Streptofil therapy effect on painful shoulder syndrome. Testing included 73 patients. One ml of Streptofil was used locally in the projection of m. supraspinatus insertion five days a week; treatment lasted 3 weeks in average. Therapy effect estimate was made according to Constant and Murley method. As full clinical effect we considered pain loss and complete function restitution (score 90-100) and incomplete reduction or loss of pain and incomplete function recovery (score less than 90). Control radiography was performed only in patients with calcification tendinitis. In 46% of patients tendon calcification had disappeared. Full clinical effect was achieved in 80% of the patients in whom tendon calcification disappeared after therapy, and in 58% of those in whom it remained. This finding coincided with results obtained in the group of patients without tendon calcification.

[Principles of the current therapy in autoimmune diseases]

Presented are principles of systemic connective tissue diseases therapy (SCTD) based on data from literature, our experience and reported at international meetings held in Europe during last years special attention has been paid to the advances and perspectives in the treatment of rheumatoid arthitis (RA) and systemic lupus erythematosus (SEL).

[The antiphospholipid syndrome in systemic connective tissue diseases]

The aim of the study was to prove the incidence of antiphospholipid syndrome (APS) in systemic connective tissue disease (SCTD), especially in systemic lupus erythematosus (SLE) and to find out serologic markers of APS. Of 94 patients with SCTD followed up in the last three years 80 had SLE, 7 Sjogren's syndrome, 3 systemic vasculitis, 2 combined systemic connective tissue disease, 1 rheumatoid arthritis, 1 Sjogren's syndrome with vasculitis. Antiphospholipid antibodies (ApSt) were determined by ELISA method. In 31 of 80 patients with SLE (38.07%) antiphospholipid antibodies were proved. In lo of 31 (32.26%) signs of systemic lupus or the presence of APS markers have not been found, while 21 of 31 (67.74%) had some of clinical manifestations of APS (most commonly thrombocytopenia or vascular thrombosis) with evolution of the basic disease. Among our patients with SLE the most common finding was IgG antibody isotype-in 14 or 66.66% of cases. In 5 of 7 patients with Sjogren's syndrome ApAt were proved without clinical evolution of the basic disease and APS. Only 2 of 7 patients of this group showed, together with more increased ApAt, mild evolution of the basic disease and manifestation of APS (livado reticularis and recurrent venous thrombosis).

[Importance of immunomorphometric evaluation of the size and number of megakaryocytes in normal and pathologic bone marrow]

The aim of the present study was to evaluate the significance of immunomorphometric assessment of megakaryocyte size and number in normal and pathologic human bone marrow. Thus, we compared morphometric characteristics of megakaryocytes in 56 bone marrow trephine biopsies stained by immunohistochemical and conventional techniques. Morphometric results showed that precise megakaryocyte size in normal and pathologic samples can be calculated even by using conventional staining technique, but only employing specific stereological corrections. Immunomorphometric evaluation revealed populations of "small" megakaryocytes (< 14 microns), "morphologically unrecognized" by conventional staining technique (promegakaryoblasts in normal and stimulated as well as micromegakaryocytes in pathologic bone marrow). In patients with normal and stimulated megakaryocytopoises percentage of "small" megakaryocytes was generally low (10.6% and 14%, respect.); so, megakaryocyte number was similar in immunohistochemically and conventionally stained sections. In contrast, percentages of "small" megakaryocytes were significantly higher in patients with stem cell disorders (namely, myelodisplastic syndrome and chronic granulocytic leukaemia), as compared to controls (35.3% in MDS; 22.9% in CML and 10.6% in controls). In those patients megakaryocyte numbers were more sensitively detected by immunohistochemistry than by conventional staining.