Building integrated systems--driving the nitroglycerin truck

Both sides of the bizarre, sadomasochistic relationship between physicians and hospitals bring baggage to the "arranged marriage" of the integrated healthcare system.

Lingual hemorrhage in a patient with hemophilia A complicated by a high titer inhibitor. Management by continuous infusion of monoclonal antibody-purified factor VIII

PURPOSE

The management of oral bleeding in hemophilia A patients with high titer inhibitors can be challenging. Simultaneous administration of activated prothrombin complex concentrates and antifibrinolytic agents is potentially dangerous because both agents have thrombogenic properties. We report sustained control of life-threatening lingual hemorrhage in a hemophilic patient with a high titer inhibitor (100 Bethesda Units/ml) on continuous infusion of a monoclonal antibody-purified factor VIII concentrate (75 U/kg/h).

METHODS AND RESULTS

In vivo hemostasis was achieved without an initial increment in free plasma factor VIII:C. The biphasic nature of recovered factor VIII:C indicated initial antigen-antibody formation, a saturation point, then a rapid rise of free factor VIII in plasma. In vitro, rapid loss of factor VIII activity was noted in mixtures of patient's plasma and purified factor VIII during incubation at 37 degrees C. When an excess of purified factor VIII was added to patient's plasma, a plateau of stable residual factor VIII activity followed the initial loss of factor VIII activity, suggesting a second-order reaction.

CONCLUSION

This type I kinetic response is typical of alloantibodies induced by exposure to factor VIII concentrates.

The reshaping of healthcare. Part 2

Powerful new tools produced by the biotechnology revolution--predictive genetics (and ultimately genetic therapy) and immunotherapy--will eventually make obsolete much of our current armada of crude "halfway" technologies, and enable us to prevent most illness altogether. These advances were discussed in the May/June issue of the Journal. This article addresses their likely impact on healthcare delivery.

Coagulation factor IX: successful surgical experience with a purified factor IX concentrate

The use of plasma-derived coagulation factor concentrates has been marked by the transmission of viral agents. Infusions of factor IX complex concentrates have been additionally complicated by inappropriate thrombosis. Use of these concentrates in the neonate, in those with liver disease, and in surgical patients results in increased risk for this complication. Twenty patients have been infused with a purified coagulation factor IX concentrate for fall-off and recovery studies. A two-compartment model indicated an initial phase half-life of 4.06 +/- 2.86 hr and a beta phase half-life of 20.0 +/- 3.8 hr following the administration of AlphaNine, Coagulation Factor IX (Human). In vivo recovery was 62.7% +/- 13.8%, with an average factor IX coagulant level of 73% +/- 16% at 15 min after the infusion of a mean dose of 45 U/kg. Thirteen previously transfused patients with hemophilia B underwent major orthopedic or general or dental surgery using this purified factor IX. Operative outcomes were excellent in all patients. No excessive bleeding was noted. There was no laboratory or clinical evidence for a disseminated intravascular coagulopathy. The excellent surgical outcomes observed in this multitransfused group with biochemical evidence for active liver disease demonstrates the utility and safety of a purified coagulation factor IX concentrate.

Atypical pulmonary diseases associated with AIDS

We present three patients with pulmonary diseases not usually associated with AIDS. Early recognition and treatment allowed a favorable outcome. The cases are discussed and the literature is reviewed.

Pneumocystis carinii pneumonia complicating multiple myeloma

Pneumocystis carinii pneumonia complicated the course of two patients with multiple myeloma. The diagnosis was established in both cases by bronchoalveolar lavage, which demonstrated the typical pneumocysts. Clinical and roentgenographic improvement in both patients was observed following a course of trimethoprim-sulfamethoxazole. One patient had lymphocyte subsets performed with a CD4/CD8 ratio of 0.8; both patients were HIV antibody-negative by ELISA. Both patients tolerated prophylactic TMP-SMX given concurrently with the subsequent chemotherapy for myeloma. We suggest that the immune defect seen in multiple myeloma may have placed these patients at risk for opportunistic infections such as P carinii pneumonia; however, as opposed to patients with AIDS, our patients tolerated therapy with TMP-SMZ quite well.

Endoscopy in the diagnosis of gastrointestinal Mycobacterium avium-intracellulare infection

Two cases of mycobacterium avium-intracellulare (MAI) infection in association with acquired immunodeficiency syndrome (AIDS) are presented to highlight the distinctive upper gastrointestinal endoscopic appearances: 2 X 4 mm diameter, white nodules with intervening erythema and hemorrhagic erosions covered the mucosa of the second part of the duodenum. Histological evaluation of these nodules revealed diffuse expansion of the lamina propria by macrophages that contained numerous intracellular and extracellular acid-fast organisms. We conclude that endoscopy with endoscopic biopsy may represent the most rapid and sensitive diagnostic tool available in this disease.

Widespread dissemination of Pneumocystis carinii infection in a patient with acquired immune deficiency syndrome receiving long-term treatment with aerosolized pentamidine

Patients with acquired immune deficiency syndrome (AIDS) may be infected with many opportunistic pathogens, the most common of which is Pneumocystis carinii. P. carinii infection typically presents as a subacute pneumonia. However, rare cases of localized, extrapulmonary, and disseminated disease have been described. Standard therapy for P. carinii is systemically administered trimethoprim-sulfamethoxazole or pentamidine. These agents, however, frequently are associated with serious adverse effects. More recently, aerosolized pentamidine has been proposed as an alternative treatment for those who cannot tolerate standard therapy and as primary and secondary prophylaxis. Inhaled pentamidine is effective, but it is not without hazards. The authors describe a patient with AIDS who received long-term treatment with aerosolized pentamidine and yet died as a result of widely disseminated P. carinii infection.

Hickman catheter-induced thoracic vein thrombosis. Frequency and long-term sequelae in patients receiving high-dose chemotherapy and marrow transplantation

One hundred sixty-eight bone marrow transplant recipients and 49 patients who received high-dose chemotherapy were evaluated for symptomatic thrombosis after Hickman catheter placement. The timing of thrombotic complications was different between these two groups, with the transplant group having a significantly lower thrombus-free survival by 28 days after catheter placement. By 100 days after placement the thrombus-free survival rates of the two groups were similar. The platelet count at time of catheter placement was significantly lower in the nontransplant group, and the thrombus-free survival was longer in patients whose catheter was placed when their platelet count was less than 150,000, suggesting that thrombocytopenia delays thrombotic complications. Placement of two Hickman catheters resulted in a 12.9% thrombosis rate (21 of 162 patients) and was significantly more likely to be associated with thrombosis than placement of one catheter. Long-term follow-up evaluation of patients treated without successful fibrinolytic therapy showed no residual symptoms of venous obstruction. In those patients presenting with concomitant catheter obstruction resulting from thrombosis, low-dose fibrinolytic therapy was successful in restoring catheter function 70% of the time. Placement of two Hickman catheters is associated with an inordinate incidence of thrombosis. Thrombocytopenia at the time of catheter placement may delay this complication. Thrombotic catheter obstruction can be treated successfully with low-dose fibrinolytic therapy. Even without fibrinolytic therapy, catheter-induced subclavian vein thrombosis rarely causes long-term disability.

Aspergillus infection of the central nervous system in patients with acquired immunodeficiency syndrome

Infections of the central nervous system in patients with the acquired immunodeficiency syndrome are common. Of the many microorganisms that have been implicated, infection with Aspergillus is rare. We describe three patients with Aspergillus infection of the nervous system. Two patients had cerebral lesions due to Aspergillus flavus, and one patient had Aspergillus fumigatus infection of the spinal cord. Diagnosis of the infections was difficult, and therapy appeared to be ineffective.

The use of purified clotting factor concentrates in hemophilia. Influence of viral safety, cost, and supply on therapy

Treatment of hemophilia, although greatly improved in recent years, continues to be problematic owing to infectious complications of blood product replacement therapy. This report examines the therapeutic options presently available for the treatment of hemophilia, focusing on the potential for repeated viral exposure to influence the progression of infectious disease, decreased risks of viral transmission with blood products produced using newer viral inactivation procedures, higher economic costs of newer blood products, and the current inadequate supply of blood products in the United States.

Fatal pericarditis due to Mycobacterium avium-intracellulare in acquired immunodeficiency syndrome

A 27-year-old white male homosexual with AIDS presented 19 months after the initial diagnosis with persistent fever, marked dyspnea at rest, and severe substernal pain in the chest. A pericardial friction rub was auscultated, and an effusion was demonstrated echocardiographically. Pericardiocentesis yielded 220 ml of serosanguinous fluid. Special stains of the fluid for microorganisms were negative. A mycobacterial infection was suspected, and therapy with multiple antimycobacterial agents was initiated. Cultures of the fluid eventually yielded MAI. Despite therapy, cardiac function declined, and the patient died two months after presentation. Autopsy confirmed the diagnosis of chronic pericarditis due to MAI. Pericarditis due to MAI should be included in the differential diagnosis of cardiac dysfunction in patients with AIDS.

Abnormal fibrinolysis in healthy male cigarette smokers: role of plasminogen activator inhibitors

The extrinsic fibrinolytic system and its response to cigarette smoking was studied in five healthy male smokers 35-45 years old. Tissue plasminogen activator (t-PA) release in response to venous occlusion was intact both at 8:00 A.M. and 3:00 P.M. Acutely smoking two cigarettes neither stimulated fibrinolysis nor changed levels of t-PA or plasminogen activator inhibitors. Functional plasminogen activator inhibitor (PA-I) levels and euglobulin lysis times were higher in the smoking group than in a control group matched for age, sex, and body mass. Antigenic levels of PA-I 1, the PA-I derived from vascular endothelial cells and platelets, were similar in both groups. While smoking did not acutely alter fibrinolysis in chronic smokers, these individuals had a high frequency of abnormal fibrinolysis characterized by high levels of PA-I activity. This abnormality is due to either high specific activity of PA-I 1 or to the presence of other antigenically distinct plasminogen activator inhibitors. Abnormal fibrinolysis may be one mechanism contributing to the thrombotic diathesis of cigarette smokers.

Reversible agranulocytosis related to azidothymidine therapy

Hematopoietic toxicity from Zidovudine (AZT) is fairly common, resulting in a requirement for red cell transfusions in up to 25% of patients. Reversible agranulocytosis occurred following approximately 1 week of AZT therapy in a man with AIDS. He recovered from the episode without incident. There was no evidence for underlying bone marrow dysfunction or an adverse drug reaction. Careful monitoring of AZT therapy continues to be of great importance.

Pulmonary emboli in patients receiving chemotherapy for non-Hodgkin's lymphoma

Combination chemotherapy has dramatically improved the prognosis of patients with intermediate and high grade histologic subtypes of non-Hodgkin's lymphomas. Treatment-related complications, however, are considerable, and a common problem encountered is respiratory distress or respiratory insufficiency. Usually these difficulties have been attributed to infectious etiologies or to chemotherapy-induced interstitial fibrosis, most often involving bleomycin. We describe five patients presenting with respiratory problems several weeks after the initiation of chemotherapy. These patients, who represent 3 percent of all patients treated with a single bleomycin-containing regimen for intermediate or high grade non-Hodgkin's lymphoma, were all initially thought to have chemotherapy-induced interstitial fibrosis but were found on subsequent evaluation to have pulmonary emboli. Of the three patients in whom pulmonary emboli were diagnosed antemortem, two had symptoms suggestive of pulmonary emboli and all were successfully treated and remained well and free of lymphoma for over 24 months. Two additional patients were diagnosed at autopsy. We suggest that pulmonary emboli may contribute significantly to the morbidity and mortality of patients undergoing chemotherapy for non-Hodgkin's lymphoma and recommend that patients presenting with respiratory difficulties be evaluated for pulmonary emboli.