A randomized trial of recombinant staphylokinase versus alteplase for coronary artery patency in acute myocardial infarction. The STAR Trial Group

BACKGROUND

Recombinant staphylokinase (STAR) was shown recently to offer promise for coronary arterial thrombolysis in patients with evolving myocardial infarction. The present multicenter randomized open trial was designed to assess the thrombolytic efficacy, safety, and fibrin specificity of STAR relative to accelerated alteplase (recombinant tissue-type plasminogen activator [RTPA]).

METHODS AND RESULTS

One hundred patients with evolving myocardial infarction of < 6 hours' duration and with ST-segment elevation were allocated to accelerated and weight-adjusted RTPA over 90 minutes (52 patients) or to STAR (the first 25 patients to 10 mg and the next 23 patients to 20 mg given intravenously over 30 minutes). All patients received aspirin and intravenous heparin. The main end points were coronary artery patency and plasma fibrinogen levels at 90 minutes. Thrombolysis in Myocardial Infarction (TIMI) perfusion grade 3 at 90 minutes was achieved in 62% of STAR patients versus 58% of RTPA patients (risk ratio, 1.1; 95% CI, 0.76 to 1.5). With 10 mg STAR, TIMI grade 3 patency was 50% (risk ratio, 0.86; 95% CI, 0.54 to 1.4 versus RTPA); with 20 mg STAR, it was 74% (risk ratio, 1.3; 95% CI, 0.90 to 1.8 versus RTPA). Residual fibrinogen levels at 90 minutes were 118 +/- 47% (mean +/- SD) of baseline with STAR and 68 +/- 42% with RTPA (P < .0005). STAR therapy was not associated with an excess mortality or electric, hemorrhagic, mechanical, or allergic complications. However, patients developed antibody-mediated STAR-neutralizing activity from the second week after STAR treatment. As an addendum to the randomized study, 5 patients were given 40 mg STAR over 30 minutes, resulting in TIMI perfusion grade 3 at 90 minutes in 4 patients without fibrinogen breakdown (residual levels at 90 minutes of 105 +/- 8% of baseline).

CONCLUSIONS

STAR appears to be at least as effective for early coronary recanalization as and significantly more fibrin-specific than accelerated RTPA in patients with evolving myocardial infarction.

At equipotent doses, isradipine is better tolerated than amlodipine in patients with mild-to-moderate hypertension: a double-blind, randomized, parallel-group study

1. The objective of this double-blind parallel-group study was to compare the tolerability of isradipine and amlodipine, specifically, the side-effects known to be related to the use of dihydropyridine calcium antagonists. 2. A total of 205 patients with mild-to-moderate essential hypertension were randomized to receive either the sustained-release (SRO) formulation of isradipine (n = 103) or amlodipine (n = 102), both at dosages of 5 mg once daily. Blood pressure measurements were taken at the end of the dosing interval to assess the antihypertensive efficacy of the two drugs. 3. Adverse reactions were assessed in two ways: a) spontaneously reported adverse events were recorded and investigated in depth for severity, duration, relation to the study drug, and outcome; b) a questionnaire was used to elicit specific adverse reactions known to be related to the use of dihydropyridine calcium antagonists which were evaluated for severity, duration, relation to the study drug, and outcome. 4. After 6 weeks of active treatment, both isradipine and amlodipine reduced mean sitting systolic/diastolic blood pressure: from 165.1/100.1 to 145.2/89.7 mm Hg with isradipine; and from 164.1/100.6 to 145.7/90.5 mm Hg with amlodipine. There was no difference in antihypertensive effect between isradipine and amlodipine (95% CI: -3.73 to 4.73 and -1.89 to 3.49 for differences in systolic and diastolic blood pressure, respectively). 5. The number of patients spontaneously reporting adverse events was significantly higher (P = 0.02; 95% CI: 3.1 to 26.7%) with amlodipine (33.3%) than with isradipine (18.4%).(ABSTRACT TRUNCATED AT 250 WORDS)

Exercise and heart transplantation. A review

Results of heart transplantation as therapy for end-stage cardiac diseases are encouraging not only because of actuarial survival curves but also because of the recovered quality of life for the heart transplant recipient. Although heart transplantation drastically improves the physical capacity of the patients, heart recipients still have a reduced maximal aerobic capacity compared to healthy people. Altered resting and exercise haemodynamics, due to cardiac denervation, are a common finding after orthotopic heart transplantation: increases in heart rate and stroke volume at exercise are first linked with the augmented venous return and later with the increased plasmatic nor-adrenaline level. Maximal heart rate and stroke volume are both reduced when compared to innervated heart. Reduced cardiac output response to exercise therefore results in early anaerobic metabolism, acidosis, hyperventilation and diminished physical capacity. In spite of an altered ventilatory adaptation to exercise, characterised by hyperpnoea in most transplant patients, ventilation is not the limiting factor for exercise in heart recipients without associated obstructive pulmonary disease. Endurance training restores lean tissue, decreases submaximal minute ventilation, increases peak work output, maximal ventilation and peak heart rate. Guidelines for prescribing exercise are not yet standardised due to the limited number of studies on a sufficient cohort of heart recipients. Nevertheless, recommendations similar to those used for persons with coronary heart disease, with modifications due to the denervated heart, seem to be used. The cardiocirculatory and pulmonary capacity of heart transplant recipients allow them to undertake endurance sports activities such as walking, jogging, cycling and swimming, and these should be encouraged.

Efficacy of diclazuril against Eimeria dispersa in turkeys

Diclazuril, a new anticoccidial drug, was tested for its efficacy against Eimeria dispersa in turkeys. A dose-titration study indicated that diclazuril at dosages of 0.5, 1, and 2 ppm in the feed was highly effective in terms of weight gain and suppression of lesions, abnormal droppings, and oocyst shedding.

Effects of isradipine on peripheral hemodynamic reflex responses in mild-to-moderate essential hypertension

In a randomized double-blind, placebo-controlled, crossover study of isradipine (5 mg twice daily), effects on peripheral hemodynamic reflex responses were studied in nine patients (mean age 48 years) at baseline and after six weeks of active treatment. Assessments included vital signs, resting blood flow in the calf and finger (using an electrocardiograph-triggered venous occlusion plethysmograph), reflex responses during isometric exercise and cold pressor resistance, and venous capacitance in the forearm and calf. Isradipine lowered systolic and diastolic blood pressure as well as mean arterial pressure in patients with mild-to-moderate essential hypertension without reflex tachycardia or venoconstriction. All of the reflex responses studied were attenuated. It is concluded that vasodilatation of the peripheral circulation induced by isradipine contributes partially to the blood pressure-lowering effect.

Helminth and protozoan parasites in dogs and cats in Belgium

This study investigates the level of helminthic and protozoal infestation over the last 10 years in strays, well-cared-for dogs and cats. Determination of the prevalence of infections was based either on faecal examination or on worm counts at necropsy. Of 2324 faecal flotations (NaCl sp.gr. 1.20) of stray dogs, 34.2% had eggs or proglottids of one or more worm species consisting of Toxocara canis (17.4%), Toxascaris leonina (10.1%), Uncinaria stenocephala (11.4%), Trichuris vulpis (7.0%) and cestodes (2.1%). Isospora oocysts were observed in 5.2% of the dogs. The data on the distribution of the various worm species in the positive dogs indicate that T. canis eggs were by far the most common (50.9%). Necropsy data from 212 infected dogs indicate that 38.9% were infected with T. canis and 33.7% with T. leonina. The overall prevalence of worm infestation of 246 well-cared-for kennel dogs, based on worm egg counts by the McMaster technique, was 36.1%. Of 30 feline faecal samples examined by flotation, 83.3% were positive for parasites, including Toxocara cati (60%), Ancylostoma tubaeformae (36.6%), Taenia (Hydatigera) taeniaeformis (20%) and coccidia (30%). Toxocara cati was the most frequently found worm species at the necropsy of 25 cats (52%). Toxoplasma was not observed.

Anticoccidial efficacy of diclazuril in pheasants

Diclazuril, a new anticoccidial drug, was tested in young pheasants artificially infected with the three most common pathogenic species of Eimeria, E colchici, E duodenalis and E phasiani. In two replicate experiments each with 40 birds the mortalities in the infected controls were 50 and 25 per cent. Diclazuril was administered in the feed at dose levels of 1, 2 and 4 ppm from the day before the inoculation of coccidia until the end of the test on day 6 after infection. The 1 ppm dose failed to inhibit the development of the parasite completely, as was shown by a reduction of the weight gain of the birds and the output of a small number of oocysts. Diclazuril at 2 or 4 ppm adequately controlled the infection, with weight gains similar to those of the uninfected controls. At all dose levels, mortality, intestinal lesions and diarrhoea were prevented.

Diclazuril, a new broad-spectrum anticoccidial for chickens. 3. Floor-pen trials

Diclazuril is a benzeneacetonitrile showing great promise as a broad-spectrum anticoccidial agent for chickens, turkeys, and rabbits. The high anticoccidial activity of diclazuril in chickens, as first reported in dose-titration studies and battery trials, was confirmed in three floor-pen trials. The efficacy was demonstrated against six major pathogenic species of Eimeria after artificial infection with one or more species. The experimental data indicated that diclazuril, at dose levels of .5, .75, 1, and 2 ppm, had a high anticoccidial activity in terms of preventing mortality, suppressing or reducing lesion scores, and allowing for normal weight gains as well as productivity. The performances obtained with diclazuril was generally comparable with that of salinomycin at 60 ppm and that of lasalocid at 90 ppm.

Efficacy of diclazuril in the prevention and cure of intestinal and hepatic coccidiosis in rabbits

The efficacy of diclazuril against intestinal and hepatic coccidiosis was studied in artificially infected rabbits. Prophylaxis against intestinal coccidiosis was evaluated using a mixed infection of Eimeria intestinalis, Eimeria magna and Eimeria perforans. Continuous medication in the feed at 1 p.p.m. was 100% effective in reducing oocyst output and faecal scores, and weight gain and feed efficiency were normal. Hepatic coccidiosis induced by Eimeria stiedai was prevented at 0.5 and 1 p.p.m. as shown by negative oocyst counts, normal liver weight, absence of liver lesions, and normal body-weight gain and feed efficiency. Medication at 1 p.p.m. for 7 consecutive days during the prepatent phase of hepatic coccidiosis resulted in large reductions in oocyst counts and lesion scores with a normal liver weight and growth performance. Diclazuril at 1 p.p.m. in the feed prevented both intestinal and hepatic coccidiosis in rabbits and can be advocated for safe mass medication.

Efficacy of diclazuril against turkey coccidiosis in dose-titration studies

Diclazuril, a new anticoccidial drug, was tested for its efficacy in turkeys against single Eimeria infections. Dose-titration studies indicated that diclazuril at dosages of 0.1, 0.5, 1, and 2 ppm was highly effective against the major pathogenic species-E. adenoeides, E. gallopavonis, and E. meleagrimitis-in terms of weight gain and suppression of lesions, abnormal droppings, and oocyst shedding.

Efficacy of diclazuril against turkey coccidiosis in a floor-pen experiment

Diclazuril, a new anticoccidial drug, was tested for its efficacy in turkeys against mixed Eimeria infections. A floor-pen trial indicated that diclazuril at dosages of 0.5 ppm and 1 ppm in the feed was highly effective against the major pathogenic species E. adenoeides, E. gallopavonis, and E. meleagrimitis in suppressing intestinal and cecal lesions and oocyst shedding. Weight gain and feed conversion improved, particularly at 1 ppm.

Diclazuril, a new broad spectrum anticoccidial drug in chickens. 2. Battery trials

Battery trials have confirmed the broad spectrum anticoccidial activity of diclazuril as previously reported in dose titration studies. The advocated dose level of 1 ppm in the diet demonstrated excellent activity against the economically most important Eimeria species. At this dose level, body weight gains were comparable to those of uninfected, unmedicated controls and the oocyst production was negative in most species. Lesion scores and dropping scores were nil or highly reduced. An E. maxima-147 strain, less sensitive to ionophores, also responded well to diclazuril. It was concluded that diclazuril is a promising anticoccidial for the control of all species of coccidia that cause losses to the poultry industry.

Efficacy of flubendazole against gastrointestinal and lung nematodes in pigs

Three trials were carried out on landrace pigs of various ages to assess the anthelmintic efficacy of flubendazole. The pigs were either artificially infected with Metastrongylus apri or naturally or artificially infected with the gastrointestinal nematodes Ascaris suum, Oesophagostomum dentatum or Hyostrongylus rubidus. For mass medication of young pigs and fatteners a dose regimen of 30 ppm flubendazole in the feed for 10 consecutive days was 100 per cent effective against the four nematode species. For individual medication a single dose of 5 mg/kg bodyweight administered in a small amount of feed was also 100 per cent effective. No side effects were observed.

[Clazuril: a new anticoccidial agent for pigeons]

The effectiveness of clazuril (Appertex), a new anticoccidial agent for the treatment of pigeons is described in the present study. Clazuril, a benzene-acetonitrile derivative, is administered in a single dose. In laboratory studies, 121 carrier pigeons infected with E. labbeana and E. columbarum were treated once with clazuril in gelatin capsules at dose levels of 10 mg, 5 mg, 2.5 mg, 1.25 mg, 0.63 mg or with a placebo. When a single dose of 2.5 mg and higher was administered, all faecal samples became negative for oocysts within seven days after treatment. In the field studies, 1531 young and full-grown carrier pigeons, from 116 infected dove-cotes, were treated with 1 tablet of 2.5 mg clazuril. Seven days after treatment, the faecal samples of 105 dove-cotes were negative for oocysts of E. Labbeana and E. columbarum; in six dove-cotes, infection was also virtually reduced to zero. Performance in racing was not affected by treatment and side-effects were not observed.

Anthelmintic efficacy of flubendazole paste against nematodes and cestodes in dogs and cats

Small dogs and cats, naturally infected with nematodes and cestodes, were used in a critical test under laboratory conditions to determine the palatability and efficacy of flubendazole as a past formulation. Subsequently, a control test in dogs was conducted under field conditions. A 4.4% past formulation was given at a dosage of 22 mg/kg of body weight once a day for 2 or 3 consecutive days. In a critical test in dogs, the efficacy against Toxocara canis was 97.4% after a 2-day administration and 100% after 3 days. Toxascaris leonina seemed to be the most susceptible worm species, since either 2 or 3 treatments were 100% active. The efficacy against Uncinaria stenocephala was 97.5% after 2 treatments; the same dose level for 3 days improved the efficacy to 100%. The efficacy was 100% for the removal of Trichuris vulpis after a daily dosage for 2 days and 96.7% after 3 days. One of 2 dogs infected with Taenia pisiformis was cleared of the infection after a 2-day treatment, and 3 of 4 dogs were cleared after a 3-day regimen. All cats were cleared of Toxocara cati after 2 or 3 days of treatment. One of 2 cats infected with Hydatigera taeniaeformis was cleared of the infection after a 2-day treatment; a 3-day treatment in 7 cats was 100% effective. The results in the laboratory test in dogs were confirmed under field conditions by a control test, based on the reduction of eggs per gram of feces count after treatment. The paste formulation was well accepted by all dogs and cats without any side effects.

Bradycardia, ventricular pauses, syncope, and sports

16 athletic patients were examined because of syncope, Stokes-Adams attacks, or both. The life-threatening condition required pacemaker implantation in 7 patients. 8 of the 9 other subjects became symptom-free after stopping heavy physical training. 37 top-ranking athletes underwent 24 h Holter monitoring. Pauses longer than 2 s occurred in 19% and resulted from sinus arrest. The longest pause lasted 2.5 s. Second-degree atrioventricular block was noted in 13%.

Inhibitory effects of pirenzepine on muscarinic stimulation of rat pancreas

The binding properties and pharmacological effects of pirenzepine were compared to those of atropine in isolated pancreatic acini and pancreatic membranes of rats. In the first preparation, pirenzepine and atropine blocked [N-methyl-3H]scopolamine ([3H]NMS) binding, pirenzepine being 110 times less potent than atropine (KD for pirenzepine 0.38 microM and for atropine 3.5 microM). A similar difference in potency was observed with respect to carbamylcholine stimulation of amylase secretion (IC50 for pirenzepine 4.5 microM and for atropine 30 nM) and calcium efflux (IC50 for pirenzepine 2.8 microM and for atropine 4 nM). Correspondingly, in rat pancreatic membranes, the KD values for pirenzepine and atropine were 250 and 1.5 nM, respectively. These data are compatible with the hypothesis that the in vitro antimuscarinic effect of pirenzepine on the rat pancreas is linked to the occupancy of a single homogeneous class of receptors with a low affinity for the antagonist.

Treatment of Trichuris suis infections in pigs with flubendazole

A severe outbreak of Trichuris suis infection in piglets is described. Fifteen per cent of the animals died and the morbidity, characterised by weight loss and diarrhoea, was over 50 per cent. The severity of symptoms observed in naturally infected pigs was related to the number of whipworms. A chemotherapeutic trial was worked out with flubendazole mixed in food for naturally infected and artificially infected piglets. Flubendazole at 30 ppm for five consecutive days controlled the infection in the pigs. Immature T suis in artificially infected pigs were also controlled at the same dose administered for 10 consecutive days.