Distal transradial access for coronary angiography and interventions in everyday practice: data from the TRIANGLE Registry

Background

Transradial access has become the primary route for coronary angiography (CAG) and percutaneous coronary interventions (PCI). Recently a new puncture site more distally on the dorsal side of the hand in the area of the anatomical snuffbox has been developed.

Purpose

With this multicenter registry, we wish to demonstrate the feasibility and safety of the distal transradial access (dTRA) and assess the rate of radial artery occlusion (RAO). As an exploratory endpoint, we compared peri-interventional data between right- and left-radial access and differences between the true anatomical snuffbox (SB) and the distal- dorsal (DD) puncture site.

Methods

Between December 2018 and May 2019 we included all patients into this registry with a planned CAG or PCI via dTRA in three cardiology centers in Germany. Procedural data, puncture success, crossover rate and complications were registered. We examined proximal and distal radial artery patency by ultrasound within 48 h after removal of compression device.

Results

A total of 327 patients were enrolled (mean age: 69 years, male: 69%), in 5 cases bilateral distal puncture was performed, puncture success was high (N=316/332, 95%) and the crossover rate was low (27/332, 8%). The rate of proximal (2/332) and distal (3/332) RAO was low. Major complications were not encountered. The comparison between SB and DD site and left- and right radial access showed no significant differences (see table).

The indication for CAG in 50% of the population was acute coronary syndrome, including 28 patients with ST elevation myocardial infarction (8.4%). Overall PCI rate was 48%. PCI cases did not demonstrate a crossover rate higher than in CAG. PCI on chronic total occlusion (CTO) was performed in 16 cases including bilateral dTRA.

Conclusion

Coronary angiography and interventions via dTRA can be performed with a high rate of success and safety. This data suggests a reduced rate of RAO compared to previous reported data after cannulation via the standard forearm radial artery puncture site. Randomized studies are needed to further investigate these results.

Funding Acknowledgement

Type of funding source: None

Synergistic effects of interleukin-4 or interleukin-13 and tumor necrosis factor-alpha on eosinophil activation in vitro

Increased concentrations of tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-4, and IL-13 have been measured in bronchoalveolar lavage fluid (BALF) of patients with asthma following allergen provocation. In addition, these cytokines have also been reported to activate eosinophils in vitro. Although cytokine interactions have been postulated in the activation of eosinophils, the combined effects of cytokines on eosinophil activation remain poorly understood. Because activation of eosinophils has been regarded as a crucial event in the pathogenesis of asthmatic inflammation, we tested the hypothesis that IL-4 and IL-13 could enhance the effects of TNF-alpha on eosinophil activation. For this purpose, eosinophils from normal donors were purified and cultured in the presence of IL-4 or IL-13 and TNF-alpha. Eosinophil survival and surface expression of CD69 were assessed by flow cytometry. There was a concentration- and time-dependent upregulation in CD69 expression as well as eosinophil survival when eosinophils were incubated with IL-13, IL-4, or TNF-alpha. However, eosinophil viability and CD69 expression increased synergistically when eosinophils were incubated with IL-13 or IL-4 in the presence of TNF-alpha. This synergistic effect of IL-4 and IL-13 on CD69 expression was not limited to TNF-alpha but was also observed with IL-5. Our study provides evidence that IL-4 can activate eosinophils in a similar fashion as does IL-13. Furthermore, this study shows that the addition of IL-4 or IL-13 to TNF-alpha or IL-5 has synergistic effects on eosinophil activation, suggesting that the combined effects of different cytokines present in BALF following allergen provocation can enhance eosinophil activation in vitro.

The experimental toxicology of tramadol: an overview

The experimental toxicological findings of tramadol are reviewed and discussed. Tramadol is a centrally acting analgesic. In acute toxicity studies, LD50 values are estimated to be around 300-350 mg/kg body weight (rat, mouse, oral administration). After intravenous administration the LD50 values ranged from 50 to 100 mg/kg body weight. In subacute and chronic toxicity studies, clinical signs of intoxication are mainly behavioural disorders and convulsions, beginning at dose levels of 25 mg/kg. Clinical pathological alterations or morphological lesions, in particular neuropathological findings were not detected. Overall, the battery of mutagenicity studies shows no evidence of a genotoxic risk to man. Reproductive and developmental toxicity investigations and carcinogenicity studies were without substance-dependent findings. Toxicological and toxicokinetical data of both enantiomers did not show biologically relevant deviations in comparison to the data on tramadol. The toxicological characteristic of this compound is demonstrated.

Mode of antinociceptive and toxic action of alkaloids of Aconitum spec

Extracts of the plant Aconitum spec. are used in traditional Chinese medicine predominantly as anti-inflammatory and analgesic agents, the latter allegedly equally potent as morphine but without any habit-forming potential. As the only pharmacologically active compounds, the C19 diterpenoid alkaloid aconitine, and some of its derivatives, have been proven to be antinociceptive in different analgesic assays, but the mode of action is unknown. To elucidate the mode of action, ten aconitine-like derivatives were investigated with respect to their affinity for voltage-dependent Na+ channels, the action on synaptosomal Na+ and Ca2+ homoeostasis and their antinociceptive, arrhythmogenic and acute toxic properties. Since aconitine is known to bind to site II of Na+ channels, we determined the affinity of the aconitine-like derivatives in vitro to synaptosomal membranes by the [3H]-batrachotoxinin-binding assay and their properties on intrasynaptosomal concentrations of free Na+ and Ca2+ ([Na+]i and [Ca2+]i), both the latter determined fluorometrically with SBFI and Fura-2 respectively. Furthermore, the alkaloids' arrhythmogenic potential was investigated in guinea-pig isolated atria and the antinociceptive action on formalin-induced hyperalgesia and the acute toxic action estimated in mice. The results show that the alkaloids could be divided into at least three groups. The first is characterized by a high affinity to the site II of Na+ channels (Ki about 1.2 microM), the ability to enhance [Na+]i and [Ca2+]i (EC50 about 3 microM), a strong arrhythmogenic action that starts at about 30 nM, an antinociceptive effect (ED50 about 0.06 mg/kg) and high acute toxicity (LD50 values about 0.15 mg/kg). To this group belong aconitine, 3-acetylaconitine and hypaconitine. The second group, with lappaconitine as the only member, has an affinity to Na+ channels an order of magnitude lower (Ki = 11.5 microM), less acute toxicity (LD50 about 5 mg/kg), and a two orders of magnitude lower antinociceptive action (ED50 about 2.8 mg/kg) and lower cardiotoxicity (bradycardia observed at 3 microM). Additionally, lappaconitine suppresses the increase in [Ca2+]i of aconitine-stimulated synaptosomes and increases the excitation threshold of left atria, indicating an inhibition of Na+ channels. The other derivatives, i.e. delcorine, desoxydelcorine, karakoline, lappaconidine, lappaconine and lycoctonine, belong to the third group, which has hardly any effects. They have a low affinity to Na+ channels with Ki values in the millimolar range, show no effect on synaptosomal [Na+]i and [Ca2+]i, no arrhythmogenic potential up to 100 microM, no antinociceptive activity and low toxicity with LD50 values greater than 50 mg/kg. For the investigated alkaloids we suggest two different antinociceptive-like modes of action. Aconitine, hypaconitine and 3-acetylaconitine may induce a block of neuronal conduction by a permanent cell depolarisation, whereas lappaconitine might act like local anaesthetics. However, because of the low LD50/ED30 quotients of 2-6, the antinociceptive-like action of the Aconitum alkaloids seems to reflect severe intoxication rather than a specific antinociceptive action. The structure/activity relationship shows that alkaloids that activate or block Na+ channels have a benzoyl ester side chain in the C-14 or C-4 positions respectively, whereas the other compounds lack this group.

Aconitum sp. alkaloids: the modulation of voltage-dependent Na+ channels, toxicity and antinociceptive properties

Alkaloids from Aconitum sp., used as analgesics in traditional Chinese medicine, were investigated to elucidate their antinociceptive and toxic properties considering: (1) binding to Na+ channel epitope site 2, (2) alterations in synaptosomal Na+ and Ca2+ concentration ([Na+]i, [Ca2+]i), (3) arrhythmogenic action of isolated atria, (4) antinociceptive and (5) acute toxic action in mice. The study revealed a high affinity group (Ki 1 microM) and a low affinity group (Ki 10 microM) of alkaloids binding to site 2. The compounds of the high affinity group induce an increase in synaptosomal [Na+]i and [Ca2+]i (EC50 3 microM), are antinociceptive (ED50, 25 microg/kg), provoke tachyarrhythmia and are highly toxic (LD50 70 microg/kg), whereas low affinity alkaloids reduce [Ca2+]i, induce bradycardia and are less antinociceptive (ED50 20 mg/kg) and less toxic (LD50 30 mg/kg). These results suggest that the alkaloids can be grouped in Na+ channel activating and blocking compounds, but none of the alkaloids seem to be suitable as analgesics because of the low LD50/ED50 values.

[Four-week intravenous toxicity study of montirelin hydrate (NS-3) in dogs followed by 4-week recovery test]

A repeated dose toxicity study of montirelin hydrate (NS-3), a new drug for the treatment of disturbance of consciousness, was conducted in beagle dogs. The dogs were given the drug intravenously for 4 weeks at doses of 0 (control), 0.0002, 0.002, 0.02, 0.2, 2 and 20 mg/kg in males and 0, 0.2, 2 and 20 mg/kg in females. After discontinuation of the treatment, a 4-week recovery test was also conducted in the 0 and 20 mg/kg groups. No deaths related to the treatment were observed. There were no changes in body weight gain, and food and water consumptions. Nasal discharge was seen in all dose groups. Salivation, emesis and hypoactivity were observed in the 0.2 mg/kg group and over. Licking chops were seen in the 2 and 20 mg/kg groups. Trembling and agitated/restless behavior were seen in the 20 mg/kg group. Electrocardiographic examination revealed elevated heart rate in the 0.2 mg/kg group and over. Ophthalmoscopic and hematologic examinations, and urinalysis failed to show any abnormalities attributable to the treatment. Blood chemical examination disclosed increases in T3 level in the 2 and 20 mg/kg groups of males and in T4 level in the 0.2 mg/kg group and over of males. There were no pathological findings attributable to the treatment. The changes mentioned above were satisfactorily reversible. The nasal discharge seen in the 0.02 mg/kg group and below was considered to be of no toxicological significance. These results show that the NOAEL of montirelin hydrate is 0.02 mg/kg for 4-week repeated dose toxicity in dogs.

Local skin reactivity after induction of Shwartzman reaction in rabbits

A local Shwartzman response was elicited in rabbits by an intradermal injection of the Salmonella typhosa endotoxin lipopolysaccharide (LPS) followed 24 hours later by an intravenous challenge injection with zymosan. After the intravenous challenge, necrotizing vasculitis developed in the prepared skin sites which was characterized by microthrombi, accumulation of neutrophil granulocytes, fibrin deposition and extravasation of red blood cells. Evans' blue extravasation into the altered tissue was significantly reduced, and histologically, the intensity of the Shwartzman reaction in the skin was reduced by pretreatment with thalidomide and dexamethasone. The mechanism of reduction of an LPS-induced local Shwartzman reaction by thalidomide is discussed.

The beagle dog as a predictor of gastrointestinal findings in humans caused by the prostacyclin analogue taprostene

Beagle dogs were exposed orally to the prostacyclin analogue taprostene for four weeks. Dose levels of 200-3000 micrograms/kg body weight/day were used. Specific activity of taprostene on the digestive system compared to other species is reported. It is characterized by hypermotility of the gastrointestinal tract resulting in intestinal invagination in some animals. Gastrointestinal symptoms occurred also after intravenous administration indicating a systemic stimulating effect on smooth muscles. Concerning reversible gastrointestinal side effects in humans after intravenous infusion of prostacyclin the results of this subacute toxicity study indicated that the dog is an adequate and sensitive species for preclinical testing of prostacyclins.

A quantitative method for measuring antipsoriatic activity of drugs by the mouse tail test

Topical treatment of the mouse tail with antipsoriatic drugs enhances orthokeratotic cell differentiation in the epidermal scales. We developed a new evaluation system for this test which allows quantification of drug efficacy. Drugs were applied topically, once daily, 5 times a week, for 2 weeks. Two hours after the last treatment the animals were sacrificed, longitudinal sections of the tail skin were made and prepared for histological examination (hematoxylin-eosin staining). As indicator of orthokeratosis (OK), the length of the granular layer per scale was measured microscopically with a semiautomatic image evaluation unit and related to the total scale length (= % OK per scale). Drug activity was defined by the increase in the total length of orthokeratotic regions, 100% activity corresponds to a granular layer extending over the whole scale length. In this model dithranol and retinoic acid dose-dependently increased orthokeratosis up to 75 and 79%, respectively. Beech tar, in a concentration of 5% induced a 19% increase in orthokeratosis. Morphometric quantification by image analysis of the conversion of parakeratotic into orthokeratotic regions in mouse tail scales induced by topical drug treatment seems to be a suitable and reliable procedure to investigate new drugs from which antipsoriatic activity may be expected.

Immunohistological detection of Saruplase (recombinant single-chain urokinase-type plasminogen activator) in normal rat tissue

Saruplase--a recombinant single-chain urokinase-type plasminogen activator was identified immunohistochemically in normal rat tissue after intravenous administration by means of a polyclonal antibody. For this purpose, rat tissues were fixed in various ways (liquid nitrogen, ethanol, formaldehyd solution). Saruplase could be detected by the PAP method, streptavidinbiotin system and indirect immunofluorescence in the kidney (proximal tubule), liver (hepatocytes, Kupffer cells) and spleen (reticular cells). Saruplase was not localized in the rat endothelium. It is discussed that the rat-specific receptors for urokinase-type plasminogen activator on endothelial cells cannot bind Saruplase due to the extreme species specificity.

The hemodynamic effects of triglycyl-lysine-vasopressin (Glypressin) in patients with parkinsonism and orthostatic hypotension

The hemodynamic effects of triglycyl-lysine-vasopressin (TGLVP) were investigated in a single-blind study in seven patients with chronic orthostatic hypotension and parkinsonism. Blood pressure, heart rate, and stroke volume were measured in the supine position before and after bolus injection of either placebo or TGLVP (5.0, 7.5, or 10.0 micrograms/kg of body weight). After 40 min in the supine position, the patients were head-up tilted to 45 degrees for 20 min. All patients underwent four tilt studies with different medication. The TGLVP increased supine blood pressure by approximately 25% and total peripheral resistance by approximately 46%, and reduced heart rate by approximately 13%. No changes in supine stroke volume or cardiac output were seen. The TGLVP slightly reduced the relative fall in blood pressure and increased heart rate during the tilt. After TGLVP, blood pressure levels during tilt were similar to supine levels prior to medication. The TGLVP did not change the effects of tilt on stroke volume or cardiac output. Only few and mild side effects were experienced and no cardiotoxic effects were observed. In conclusion, TGLVP showed marked blood pressure effects of very small doses in this category of patients. The clinical effects of TGLVP and other vasopressor-specific analogs of vasopressin should be tested in these patients.

The prostacyclin analogue taprostene and recombinant human superoxide dismutase increase the permanent survival rate of endotoxemic rats

The permanent survival rate of endotoxemic rats was studied. In 40 untreated control rats the survival rate 7 days after the endotoxin administration was 33%. The survival rate was increased to 40% with recombinant human superoxide dismutase (r-HSOD), to 55% (p less than 0.05) with the prostacyclin analogue Taprostene and to 70% (p less than 0.01) with the combination of r-HSOD and Taprostene (20 rats for each treatment group). r-HSOD and Taprostene provide significant and permanent protection in rat endotoxic shock.

Post-mating non-infectious hydrometra in BALB/c: Bom mice

Post-mating non-infectious hydrometra and hydrovagina of unknown aetiology, leading to a scrotum-like swelling of the perineum, was observed during an experiment on BALB/c: Bom mice. There was a closure of the vulva with accumulation of secretions of uterine glands under high pressure in both uterus and vagina. The mice were otherwise clinically healthy, gained body weight normally, but were incapable of breeding. The morbidity was approximately 1% and the disease could not be transmitted to other females.

A fluorescent histochemical investigation of the rat submandibular gland after ligation of the excretory duct and isoproterenol treatment

Fluorescent histochemical investigations were carried out on the adrenergic terminal plexus in the salivary gland of the rat 24 hours, 72 hours, and 14 days after ligation of the main excretory duct and the concomitant administration of isoproterenol (IPR, 60 mg/kg body weight subcutaneously). The atrophy of the salivary gland occurring after ligation was also present after the concomitant administration of IPR which induces amylase secretion and DNA synthesis in intact salivary glands. The adrenergic fibres in the atrophic gland exhibited an intensive fluorescence of the adrenergic terminal plexus after IPR treatment. Thus the presynaptic elements remain intact, although the acini are atrophic, and the reason for the absence of the stimulus response probably lies in the effector cells.

Light-microscopic and fluorescent histochemical investigations on the salivary glands of rats after isoproterenol treatment

The effect of isoproterenol (IPR) on the salivary glands of the rat were investigated after single and repeated administration of 80 mg/kg body weight subcutaneously. Adrenergic nerve fibres were demonstrated with the aid of formalin-induced fluorescence, and cholinergic fibres by means of the acetylcholinesterase reaction. After a single dose of IPR the acini of the submandibular and parotid glands were depleted and then hypertrophic and hyperplastic. Large scattered cells with retained secretory granules transiently occurred after three days' treatment. They were identified as cells which degenerated mainly during mitosis. The distribution pattern of the autonomic nerve fibres in both glands adjusted to the changes preformed by the acini in the course of treatment. After long-term treatment there was a distinct loss of fibre structures and intensity of fluorescence. Thus it can be concluded that the autonomic fibres degenerate. The effect of IPR on the proliferation kinetics of the salivary glands is discussed. The fluorescent histochemical results are compared with the electron-microscopic findings in autonomic nerves reported in the literature.

Morphological findings in spontaneously hypertensive rats in comparison with findings after experimental renal hypertension

The morphological findings in spontaneously hypertensive rats (SHR) were compared with the findings after experimental renal hypertension. In addition the effect of an arteriosclerogenic diet was investigated. Cardiac hypertrophy occurred in all types of hypertension. During the course of renal hypertension there was also hypertrophy of the tunica media of the arterial vessels of the heart, kidneys, mesenterium, and orta. Degenerative changes in the vascular walls occurred when nephrectomized rats were given a diet containing 2% cholesterol and 1% cholic acid. This produced intima lipoidosis after seven to eleven weeks. The intensity seemed to be dependent on the degree of hypertension and the duration of the experiment.

Wasting syndrome in neonatal mice after administration of salivary gland homogenate

A wasting syndrome, similar to that occurring after cortisol treatment, was induced in neonatal mice by means of the daily i.p. administration of salivary gland homogenate: 24 h after a single injection of the homogenate, profuse cell necrosis was observed in the thymic cortex, 48 h later the cortex was devoid by lymphocytes. It is hypothesized that the submandibular glands of mice contain substances which are capable of inducing a cortisol-like effect.