Screening bioactive compounds from Danggui-shaoyao-san for treating sodium retention in nephrotic syndrome using bio-affinity ultrafiltration

ETHNOPHARMACOLOGICAL RELEVANCE

Danggui-shaoyao-san (DSS), a representative formula of Traditional Chinese Medicine (TCM) for promoting blood circulation and diuresis (Huo-Xue-Li-Shui) therapy, has been used to clinically nephrotic syndrome (NS) and relieve nephrotic edema.

AIM OF THE STUDY

To explore the effects and mechanisms of DSS in improving sodium retention and to identify the bioactive compounds from DSS.

MATERIALS AND METHODS

DSS prescriptions were disassembled into Yangxue-Huoxue (YXHX) and Jianpi-Lishui (JPLS). A nephrotic rat model was induced with puromycin aminonucleoside (PAN), and the effects on urinary sodium excretion, urinary plasmin(gen) content, and plasmin activity of DSS, YXHX, and JPLS extracts were assessed. The inhibitory effects on urokinase-type plasminogen activator (uPA) and plasmin activity of extracts were evaluated in vitro. Bio-affinity ultrafiltration and high-performance liquid chromatography quadrupole time-of-flight mass spectrometry (BAU-UPLC-Q/TOF-MS) were used to rapidly screen and qualitatively analyze the uPA/plasmin affinity compounds from DSS extract. Additionally, uPA/plasmin inhibition assays and molecular docking were used to verify the activity and affinity mechanisms of the potential bioactive compounds.

RESULTS

In vivo, DSS, YXHX, and JPLS prevented sodium retention in nephrotic rats. DSS and YXHX treatment decreased urinary plasmin activity but did not alter urinary plasmin(ogen) concentration, and their extracts showed strong uPA and plasmin inhibitory activity in vitro. These results suggested that uPA and plasmin are direct targets of DSS and YXHX in intervening NS sodium retention. Using BAU-UPLC-Q/TOF-MS, gallic acids, methyl gallate, albiflorin, and 1,2,3,4,6-O-pentagalloylglucose (PGG) were screened as uPA or plasmin affinity compounds. Among them, PGG was found to be a uPA and plasmin dual inhibitor, with an IC₅₀ of 6.861 μM against uPA and an IC₅₀ of 149.0 μM against plasmin. The molecular docking results of PGG with uPA and plasmin were consistent with the verification results.

CONCLUSION

Intervening in sodium retention by inhibiting uPA-mediated plasmin generation and plasmin activity in the kidneys could be possible mechanisms for DSS, as indicated by the results in PAN-induced nephrotic rats. We conclude that PGG is a potential bioactive compound responsible for the effect of DSS on natriuresis.

Efficacy and safety assessment of urokinase plus tirofiban in acute cerebral infarction patients without clear criminal vessels

To determine the efficacy and safety assessment of urokinase plus tirofiban in acute cerebral infarction patients without clear criminal vessels. Totally 96 cases of acute cerebral infarction (ACI) patients without clear criminal vessels enrolled in our hospital from July 2017 to July 2020 were randomized to the control group (n=48) with urokinase (n=48) and the observation group (n=48) with urokinase and tirofiban. Clinical efficacy, National Institute of Health Stroke Scale (NIHSS) score, Barthel Index (BI), Clusterin (CLU), tumor necrosis factor-α (TNF-α), serum hypersensitive C-reactive protein (hs - CRP), interleukin-6 (IL-6) and safety were compared. The observation group outperformed the control group in terms of clinical efficacy. Before treatment, the NIHSS scores, BI scores and serum levels of CLU, TNF-α, hs - CRP, and IL-6 in the control group were similar to those in the observation group. After treatment, the above indicators were all decreased, and lower in the observation group. The observation group had a lower incidence of adverse reactions. Arterial thrombolysis of urokinase plus tirofiban in ACI patients without clear responsible vessels effectively reduces postoperative NIHSS score, improves self-care ability, relieves the level of inflammatory factors, with fewer adverse reactions and higher safety profile.

Predictors of hemorrhagic complications after intravenous thrombolysis in acute cerebral infarction patients: A single-center study of 391 cases

For patients with ischemic stroke, intravenous (IV) thrombolysis with Urokinase within 6 hours has been accepted as beneficial, but its application is limited by high risk of hemorrhagic complications after thrombolysis. This study aimed to analyze the risk factors of hemorrhagic complications after intravenous thrombolysis using Urokinase in acute cerebral infarction (ACI) patients.Total 391 consecutive ACI patients were enrolled and divided into 2 groups: the hemorrhagic complications group and the non-hemorrhagic complications group. The related data were collected and analyzed.Univariate analysis showed significant differences in prothrombin time, atrial fibrillation (AF), Mean platelet volume, large platelet ratio (L-PLR), triglyceride (TG), Lactate dehydrogenase, alanine aminotransferase (ALT), high-density lipoprotein, and baseline National Institute of Health Stroke Scale score between the hemorrhagic complications and the non-hemorrhagic complications group (P < .1). Multivariate logistic regression analysis indicated that AF (odds ratio [OR] = 2.91, 95% confidence interval [CI] = 1.06-7.99 P = .039) was the risk factor of hemorrhagic complications, while ALT (OR = 0.27, 95% CI = 0.10-0.72 P = .009) and TG (OR = 0.16, 95% CI = 0.06-0.45 P = .000) were protective factors of hemorrhagic complications.For patients with AF and lower levels of ALT or TG, the risk of hemorrhagic complications might increase after ACI.

Low-dose urokinase thrombolytic therapy for patients with acute intermediate-high-risk pulmonary embolism: A retrospective cohort study

Introduction

Patients at intermediate-high risk of developing a pulmonary embolism (PE) are very likely to experience adverse outcomes, such as cardiovascular instability and death. The role of thrombolytic therapy in intermediate-high-risk PE remains controversial.

Objectives

This study aimed to determine the efficacy and safety of low-dose urokinase (UK) thrombolytic therapy for intermediate-high-risk PE.

Patients and methods

This retrospective study included 81 consecutive patients with intermediate-high-risk PE from two centers. Patients received low-dose UK or low-molecular-weight heparin (anticoagulant therapy group). The efficacy outcomes were mortality, computed tomography pulmonary angiography (CTPA)-confirmed absorption, and dyspnea. Safety was assessed as the incidence of bleedings.

Results

The in-hospital mortality, 9-month mortality, and long-term mortality at the last follow-up were comparable for the low-dose UK group and the anticoagulant therapy group (6.45% vs. 0%, p = 0.144, 9.68% vs. 8.16%, p = 0.815, and 12.90% vs. 12.24%, p = 0.931, respectively). CTPA-confirmed absorption at one month after admission was higher in the low-dose UK group than in the anticoagulant therapy group (p = 0.016). The incidences of short-term dyspnea at discharge and long-term dyspnea at the last follow-up were lower in the low-dose UK group than in the anticoagulant therapy group (27.59% vs. 52%, p = 0.035, 33.33% vs. 58.14%, p = 0.043, respectively). No major bleeding occurred. The incidence of minor bleeding was not significantly different between the two groups (3.23% vs. 6%, p = 0.974).

Conclusion

In intermediate-high-risk PE, a low-dose UK might increase CTPA-confirmed absorption and improve short-term and long-term dyspnea without affecting mortality or increasing the bleeding risk.

Safety and efficacy study of prourokinase injection during primary percutaneous coronary intervention in acute ST-segment elevation myocardial infarction

OBJECTIVES

To evaluate the efficacy and safety of intracoronary administration of prourokinase via balloon catheter during primary percutaneous coronary interventions in patients with acute ST-segment elevation myocardial infarction.

METHODS

Acute ST-segment elevation myocardial infarction patients underwent primary percutaneous coronary interventions were randomly divided into two groups: intracoronary prourokinase group (n = 125) and control group (n = 135). During primary percutaneous coronary interventions, prourokinase or saline was injected to the distal end of the culprit lesion via balloon catheter after balloon catheter dilatation. Demographic and clinical characteristics, infarct size, myocardial reperfusion, and cardiac functions were evaluated and compared between two groups. Hemorrhagic complications and major averse cardiovascular events (MACE) occurred in the 6-months follow-up were recorded.

RESULTS

No significant differences were observed between two groups with respect to baseline demographic, clinical, and thrombolysis in myocardial infarction grade (P > 0.05). In the intracoronary prourokinase group, more patients had ST-segment resolution (>50%) compared with control group (P < 0.05). Patients in the intracoronary prourokinase group showed lower levels of serum CK, creatine kinase-MB fraction, and troponin I than those in control group (P < 0.05). No significant differences in bleeding complications were observed between the two groups (P > 0.05). At 6-months follow-up, there was no statistically different of MACE between the two groups (P > 0.05).

CONCLUSIONS

Intracoronary administration of prourokinase via balloon catheter during primary percutaneous coronary interventions effectively improved myocardial perfusion and no increased bleeding in ST-segment elevation myocardial infarction patients.

Catheter-Directed Thrombolysis With a Continuous Infusion of Low-Dose Alteplase for Subacute Proximal Venous Thrombosis: Efficacy and Safety Compared to Urokinase

The purpose of this study was to compare the efficacy and safety associated with catheter-directed thrombolysis (CDT) using either recombinant tissue plasminogen activator (rt-PA) or urokinase (UK) for subacute deep venous thrombosis (DVT). From January 2014 to December 2016, we conducted a retrospective analysis on a total of 49 patients who underwent consistent CDT with either rt-PA (rt-PA-CDT group) or UK (UK-CDT group) treatment. The thrombolytic rate of the rt-PA-CDT group was significantly higher than that of the UK-CDT group (87.5% vs 60%, respectively; χ2 = 4.751; P = .029). The rt-PA-CDT group exhibited an improved grade III thrombolytic rate (9 patients vs 3 patients; χ2 = 5.144; P = .023). The time for the rt-PA-CDT group to achieve a grade III thrombolytic rate was shorter than that of the UK-CDT group (5.01 ± 1.09 days vs 6.43 ± 1.69 days, respectively; t = -2.187; P = .044). No severe complications were seen in either group and mild complications rates were 16.7% and 20.0% (χ2 = .091; P = .763). The clinical efficacy rates at discharge were 91.7% and 76.0%, respectively (χ2 = 2.200; P = .138). In conclusion, CDT with a continuous infusion of low-dose rt-PA resulted in safe and effective thrombolysis in the great majority of patients with proximal DVT in the subacute phase. Furthermore, rt-PA was significantly better than UK in terms of the thrombolytic rate. In our study, rt-PA-CDT improved the thrombolytic rate of grade III thrombus and achieved a grade III thrombolytic rate in a shorter time than UK-CDT.

Catheter-directed thrombolysis combined with manual aspiration thrombectomy for acute inferior vena cava filter thrombosis

BACKGROUND

The occurrence of inferior vena cava (IVC) filter thrombosis has been reported, however, the optimal treatment of IVC thrombosis has not been established yet. The aim of this study was to assess the results of catheter-directed thrombolysis (CDT) combined with aspiration thrombectomy (AT) in the treatment for IVC filter thrombosis.

METHODS

A total of 35 consecutive patients received endovascular treatment with CDT alone or CDT with AT for IVC filter thrombosis at Second Affiliated Hospital of Suzhou University from May 2009 to May 2014 were included in this study. The procedure, complications and clinical outcome between these two groups were retrospectively reviewed.

RESULTS

The mean age of patients was 44.7±15.8 years (range: 17-74 years). The patients were consisted of 21 males and 14 females. CDT alone and CDT with AT were performed in 16 and 19 patients, respectively. The mean procedural time in the group receiving CDT alone group was longer than in the group receiving CDT with AT (99.5±51.4 vs. 64.9±35.9 hours, P<0.05) and the dose of urokinase used during the procedure was significantly lower in the CDT + AT group (2.1±1.1 vs. 1.5±0.6 million IU, P<0.05). Besides, total number of complications in the CDT + AT group was smaller than in the group treated with CDT alone (9 vs. 4 cases, P<0.05).

CONCLUSIONS

Our results confirmed that CDT with AT was a safe and effective method in the treatment of acute IVC filter thrombosis. Compared with CDT alone, it was better performing thanks to a shorter thrombolysis time and a lower urokinase dose required. In addition, it may decrease the occurrence of complications.

Tissue Plasminogen Activator as an Adjuvant Therapy for Pleural Empyema in Pediatric Patients

The authors retrospectively review the clinical course and outcome of 6 pediatric patients, ranging in age from 2 to 13 years, who were treated with TPA for complex empyema. Efficacy was assessed by evaluating pleural fluid drainage for 6 hours prior to and subsequent to each dose of TPA, as well as by resolution of fever and length of hospital stay. The average volume drained for 6 hours before infusion of TPA was 22.5 mL ± 18.4 mL, and the average volume 6 hours after TPA therapy was 141.7 mL ± 28.3 mL, P < .0001. After initiation of TPA therapy, 5 out of 6 patients became afebrile within 48 hours. The median length of stay after initiation of TPA therapy was 6 days, with a range from 4 days to 12 days. A discussion of other current therapies for empyema, along with a comparison of these therapies to TPA regarding the costs of therapies and risk-benefit ratios, is also included.

[Regional intraosseous thrombolytic therapy in comprehensive treatment of patients with diabetic foot syndrome]

The authors assessed efficacy of regional intraosseous administration of urokinase medac in comprehensive treatment of patients with complicated forms of diabetic foot syndrome by means of analysing therapeutic results in a total of 65 patients presenting with pyonecrotic complications of diabetic foot. The patients were subdivided into 2 groups. The control group was composed of 35 patients receiving basic therapy. The study group comprised 30 patients subjected to comprehensive treatment including regional intraosseous (into the heel bone of the affected limb) administration of urokinase medac at a dose of 100 thousand IU for 5 days. Efficacy of treatment was evaluated by the course of the wound process, indices of haemostasis, free radical oxidation, results of surgical treatment. In patients of the Study Group the terms of wound purification from pyonecrotic masses amounted to 9.8±0.3 days, which was by 4.7 days less than in the Control Group patients (p<0.01), marginal epithelialization of wounds also occurred averagely by 6.4 days faster. On day 22 of using the basic therapy alone, the haemostasis system preserved the condition of coagulation activity. The Study Group patients as early as on day 5 of treatment demonstrated shifts towards normocoagulation. In the Control Group by day 22 of treatment, the level of malonic dialdehyde decreased by 18.5%, the index of catalase activity increased by 24.6% (p<0.05); in the Study Group the level of malonic dialdehyde decreased by 42.6% and catalase activity increased by 69.4% (p<0.01). On the background of using urokinase the number of high amputations decreased by 18% and the number of operations with the supporting function preserved decreased by 12% as compared with basic therapy alone. A conclusion was made that additional use of regional intraosseous administration of urokinase medac as compared with basic therapy alone promoted a more significant decrease in the coagulation activity of blood and the level of free-radical lipid oxidation, stimulation of regenerative processes, as well as improvement of outcomes of surgical treatment.

Catheter-directed thrombolysis for acute upper extremity ischemia

AIM

Acute nontraumatic upper extremity ischemia has significant chronic disability when not treated adequately and timely. As surgical treatment can be challenging, this study evaluates catheter-directed thrombolysis as first-line treatment for acute upper extremity ischemia.

METHODS

Between January 2006 and December 2010, 28 patients (22 women; mean age, 63±16 years) underwent catheter-directed thrombolysis for acute upper extremity ischemia, Rutherford class I or IIa. Proximal extent of the occlusion was in the subclavian (32%), axillary (7%), brachial (25%) and forearm arteries (36%). Median occlusion length was 18 cm (range, 12-43). Causes were embolus (14%), thrombus (39%), thoracic outlet syndrome (14%), paraneoplastic (4%), or unknown (29%).

RESULTS

Technical success was 96%, radiologic success (>95% clot lysis) 61%, and clinical success 68%. Median duration of thrombolysis was 24 hours (range, 18-96). Of the 11 radiologically unsuccessful patients (39%), five were treated conservatively and six underwent surgical intervention. In-hospital amputation-rate was 7%. Four complications occurred: embolization to the lower extremity, a transient ischemic attack, a subcapsular splenic hematoma and a pseudoaneurysm. Cumulative amputation-free survival at six months was 93%, standard error (SE) 4.87 and at one year 88%, SE 6.50.

CONCLUSION

These results show that catheter-directed thrombolysis is effective in over 60% of patients as first-line treatment of extensive acute upper extremity ischemia and can prevent surgical intervention in these patients.

Fibrinolytic agents for peripheral arterial occlusion

BACKGROUND

Peripheral arterial thrombolysis is used in the management of peripheral arterial ischaemia. Streptokinase was originally used but safety concerns led to a search for other agents. Urokinase and recombinant tissue plasminogen activator (rt-PA) have increasingly become established as first line agents for peripheral arterial thrombolysis. Potential advantages of these agents include improved safety, greater efficacy and a more rapid response. Recently drugs such as pro-urokinase, recombinant staphylokinase and alfimperase have been introduced. This is an update of a review first published in 2010.

OBJECTIVES

To determine which fibrinolytic agents are most effective in peripheral arterial ischaemia.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched March 2013) and CENTRAL (2013, Issue 3) for randomised controlled trials (RCTs) comparing fibrinolytic agents to treat peripheral arterial ischaemia.

SELECTION CRITERIA

RCTs comparing fibrinolytic agents to treat peripheral arterial occlusion.

DATA COLLECTION AND ANALYSIS

Data were analysed for the outcomes vessel patency, time to lysis, limb salvage, amputation, death, complications including major haemorrhage, stroke, and distal embolization.

MAIN RESULTS

Five RCTs involving a total of 687 participants with a range of clinical indications were included. No new studies were included in this update. In one three-pronged study, vessel patency was greater with intra-arterial recombinant tissue plasminogen activator (rt-PA) than with intra-arterial streptokinase (P < 0.04) or intravenous rt-PA (P < 0.01). In participants with peripheral arterial occlusion there was no statistically significant difference in limb salvage at 30 days with either urokinase or rt-PA, though this may reflect the small numbers in the studies. Incidences of haemorrhagic complications varied with fibrinolytic regime but there was no statistically significant difference between intra-arterial urokinase and intra-arterial rt-PA. In the three-pronged study intravenous rt-PA and intra-arterial streptokinase were associated with a significantly higher risk of haemorrhagic complications than with intra-arterial rt-PA (P < 0.05).

AUTHORS' CONCLUSIONS

There is some evidence to suggest that intra-arterial rt-PA is more effective than intra-arterial streptokinase or intravenous rt-PA in improving vessel patency in people with peripheral arterial occlusion. There was no evidence that rt-PA was more effective than urokinase for patients with peripheral arterial occlusion and some evidence that initial lysis may be more rapid with rt-PA, depending on the regime. Incidences of haemorrhagic complications were not statistically significantly greater with rt-PA than with other regimes. However, all of the findings come from small studies and a general paucity of results means that it is not possible to draw clear conclusions.

Thrombolysis (different doses, routes of administration and agents) for acute ischaemic stroke

BACKGROUND

Stroke is a leading cause of death and disability world wide. Thrombolysis with recombinant tissue plasminogen activator (rt-PA) is licensed for treatment of acute ischaemic stroke in the early hours after symptom onset. It has been shown in randomised controlled trials (RCTs) and the 2009 Cochrane review of thrombolysis for acute ischaemic stroke to reduce dependency but at the increased risk of intracranial haemorrhage. Methods to reduce the risk of haemorrhage while retaining or enhancing the benefit could increase the use of thrombolytic treatment. While most available information comes from RCTs of intravenous rt-PA at 0.9 mg/kg, it is possible that other doses, drugs and other routes of administration might increase benefit and reduce the hazard.

OBJECTIVES

To assess the risks and benefits of different thrombolytic agents, doses and routes of administration for the treatment of acute ischaemic stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (May 2012), MEDLINE (1966 to May 2012) and EMBASE (1980 to May 2012). We handsearched journals and conference proceedings, searched ongoing trials registers and contacted pharmaceutical companies and researchers.

SELECTION CRITERIA

Unconfounded randomised and quasi-randomised trials of different doses of a thrombolytic agent, or different agents, or the same agent given by different routes, in people with confirmed acute ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and quality, and extracted the data using a structured proforma. We cross-checked and resolved discrepancies by discussion to reach consensus. We obtained translations and additional information from study authors where required.

MAIN RESULTS

We included 20 trials involving 2527 patients. Concealment of allocation was poorly described. Different doses (of tissue plasminogen activator, urokinase, desmoteplase or tenecteplase) were compared in 13 trials (N = 1433 patients). Different agents (tissue plasminogen activator versus urokinase, tissue-cultured urokinase versus conventional urokinase, tenecteplase versus tissue plasminogen activator) were compared in five trials (N = 875 patients). Five trials (N = 485) compared different routes of administration. As some trials compared different agents and different doses, some patients contributed to two analyses. There was an approximately three-fold increase in fatal intracranial haemorrhages in patients allocated to higher than to lower doses of the same thrombolytic drug (odds ratio (OR) 2.71, 95% confidence interval (CI) 1.22 to 6.04). There was no difference in the number of patients who were dead or dependent at the end of follow-up between those allocated higher or lower doses of thrombolytic drug (OR 0.86, 95% CI 0.62 to 1.19). Higher versus lower doses of desmoteplase were associated with more deaths at the end of follow-up (OR 3.21, 95% CI 1.23 to 8.39). There was no evidence of any benefit for intra-arterial over intravenous treatment.

AUTHORS' CONCLUSIONS

These limited data suggest that higher doses of thrombolytic agents may lead to higher rates of bleeding. However, the evidence is inadequate to conclude whether lower doses of thrombolytic agents are more effective than higher doses, or whether one agent is better than another, or which route of administration is the best, for acute ischaemic stroke. At present, intravenous rt-PA at 0.9mg/kg as licensed in many countries appears to represent best practice and other drugs, doses or routes of administration should only be used in randomised controlled trials.

The efficacy and safety of pharmacoinvasive therapy with prourokinase for acute ST-segment elevation myocardial infarction patients with expected long percutaneous coronary intervention-related delay

OBJECTIVES

To elucidate the efficacy and safety of pharmacoinvasive therapy by using prourokinase (prouk) in patients with ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Patients with STEMI often have long percutaneous coronary intervention (PCI)-related delays due to various reasons, which are associated with poor outcomes.

METHODS

A randomized study which enrolled patients from four centers in China was conducted. Patients were randomly assigned to accept routine primary PCI or prouk-PCI. The primary end points were the angiographic parameters, including thrombolysis in myocardial infarction (TIMI) flow grade, TIMI frame count, and myocardial blush grade. Secondary endpoints were incidence of major adverse cardiac events (MACE, defined as death from all causes, reinfarction, revascularization, or rehospitalization due to new or worsening congestive heart failure) at 30 days and 1 year.

RESULTS

One hundred and ninety-seven eligible patients were enrolled, of whom 100 were randomized to the prouk-PCI group. Significantly more patients in the prouk-PCI group than in the PCI group had an opened infarct-related artery on arrival in the catheterization laboratory (48% vs. 21%, P = 0.0002) and better TIMI frame count after PCI (33 ± 6 vs. 40 ± 10, P < 0.001). At 1-year follow-up, there was a trend that patients in the prouk-PCI group had less chances to have MACE (7.0% vs. 12.6%, P = 0.235) or be readmitted to hospital due to new or worsening congestive heart failure (1.0% vs. 4.1%, P = 0.209).

CONCLUSION

A strategy of emergent PCI preceded by fibrinolysis with prouk results in a better myocardial perfusion in infarct-related artery compared with primary PCI alone in patients with STEMI and long PCI-related delay.

A phase II study of a urokinase-derived peptide (A6) in the treatment of persistent or recurrent epithelial ovarian, fallopian tube, or primary peritoneal carcinoma: a Gynecologic Oncology Group study

PURPOSE

This multi-institutional phase II trial assessed the activity and tolerability of the anti-metastatic A6 peptide that binds CD44 in patients with persistent or recurrent epithelial ovarian, fallopian tube, or primary peritoneal carcinoma (EOC/FTC/PPC).

PATIENTS AND METHODS

Women with persistent or recurrent EOC/FTC/PPC were eligible for participation if they had measurable disease defined by RECIST criteria, good performance status, and good overall organ function. Patients must have received one prior platinum-based chemotherapeutic regimen and were allowed to have received one additional cytotoxic regimen for the management of recurrent or persistent disease. Women received a 150 mg twice daily subcutaneous dose of A6 and continued on treatment until disease progression or unacceptable toxicity. Primary measures of clinical efficacy were objective tumor response and progression-free survival (PFS) at 6 months. The association of CD44 in archival tissue specimens with clinical outcome was investigated.

RESULTS

Thirty-one eligible patients were evaluated. No responses were observed. Two patients (6.5%) were progression free for at least 6 months. The median PFS was 2.0 months, and median overall survival has not yet been reached. One patient died of hemorrhage which was possibly study related. There were no grade 4 toxicities. The most common grade 3 toxicities were constitutional (2/31; 6.5%). Archival specimens were available for 27 patients, and 5 (18.5%) were CD44 positive by immunohistochemistry. CD44 expression was not associated with the 6-month PFS (p=0.342).

CONCLUSION

A6 was well tolerated but had minimal activity in patients with persistent or recurrent EOC/FTC/PPC.

Mutant prourokinase with adjunctive C1-inhibitor is an effective and safer alternative to tPA in rat stroke

A single-site mutant (M5) of native urokinase plasminogen activator (prouPA) induces effective thrombolysis in dogs with venous or arterial thrombosis with a reduction in bleeding complications compared to tPA. This effect, related to inhibition of two-chain M5 (tcM5) by plasma C1-inhibitor (C1I), thereby preventing non-specific plasmin generation, was augmented by the addition of exogenous C1I to plasma in vitro. In the present study, tPA, M5 or placebo +/- C1I were administered in two rat stroke models. In Part-I, permanent MCA occlusion was used to evaluate intracranial hemorrhage (ICH) by the thrombolytic regimens. In Part II, thromboembolic occlusion was used with thrombolysis administered 2 h later. Infarct and edema volumes, and ICH were determined at 24 h, and neuroscore pre (2 h) and post (24 h) treatment. In Part I, fatal ICH occurred in 57% of tPA and 75% of M5 rats. Adjunctive C1I reduced this to 25% and 17% respectively. Similarly, semiquantitation of ICH by neuropathological examination showed significantly less ICH in rats given adjunctive C1I compared with tPA or M5 alone. In Part-II, tPA, M5, and M5+C1I induced comparable ischemic volume reductions (>55%) compared with the saline or C1I controls, indicating the three treatments had a similar fibrinolytic effect. ICH was seen in 40% of tPA and 50% of M5 rats, with 1 death in the latter. Only 17% of the M5+C1I rats showed ICH, and the bleeding score in this group was significantly less than that in either the tPA or M5 group. The M5+C1I group had the best Benefit Index, calculated by dividing percent brain salvaged by the ICH visual score in each group. In conclusion, adjunctive C1I inhibited bleeding by M5, induced significant neuroscore improvement and had the best Benefit Index. The C1I did not compromise fibrinolysis by M5 in contrast with tPA, consistent with previous in vitro findings.

Fibrinolytic agents for peripheral arterial occlusion

BACKGROUND

Peripheral arterial thrombolysis is used in the management of peripheral arterial ischaemia. Streptokinase was originally used but safety concerns led to a search for other agents. Urokinase and recombinant tissue plasminogen activator (rt-PA) have increasingly become established as first line agents for peripheral arterial thrombolysis. Potential advantages of these agents include improved safety, greater efficacy and a more rapid response. Recently drugs such as pro-urokinase, recombinant staphylokinase and alfimperase have been introduced.

OBJECTIVES

To determine which fibrinolytic agents are most effective in peripheral arterial ischaemia.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched October 2009) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (last searched 2009, Issue 4) for randomised controlled trials (RCTs) comparing fibrinolytic agents to treat peripheral arterial ischaemia.

SELECTION CRITERIA

RCTs comparing fibrinolytic agents to treat peripheral arterial occlusion.

DATA COLLECTION AND ANALYSIS

Data were analysed for the outcomes vessel patency, time to lysis, limb salvage, amputation, death, complications including major haemorrhage, stroke, and distal embolization.

MAIN RESULTS

Five RCTs involving a total of 687 patients with a range of clinical indications were included. In one three-pronged study, vessel patency was greater with intra-arterial recombinant tissue plasminogen activator (rt-PA) than with intra-arterial streptokinase (P < 0.04) or intravenous rt-PA (P < 0.01). In patients with peripheral arterial occlusion there was no statistically significant difference in limb salvage at 30 days with either urokinase or rt-PA, though this may reflect the small numbers in the studies. Incidences of haemorrhagic complications varied with fibrinolytic regime but there was no statistically significant difference between intra-arterial urokinase and intra-arterial rt-PA. In the three-pronged study intravenous rt-PA and intra-arterial streptokinase were associated with a significantly higher risk of haemorrhagic complications than with intra-arterial rt-PA (P < 0.05).

AUTHORS' CONCLUSIONS

There is some evidence to suggest that intra-arterial rt-PA is more effective than intra-arterial streptokinase or intravenous rt-PA in improving vessel patency in people with peripheral arterial occlusion. There was no evidence that rt-PA was more effective than urokinase for patients with peripheral arterial occlusion and some evidence that initial lysis may be more rapid with rt-PA, depending on the regime. Incidences of haemorrhagic complications were not statistically significantly greater with rt-PA than with other regimes. However, all of the findings come from small studies and a general paucity of results means that it is not possible to draw clear conclusions.

[Local fibrinolysis of hypertensive intracerebral hematomas]

Authors presented the results of experimental and clinical studies of effects of recombinant prourokinase on brain tissue, its toxicity and safety in intracerebral administration for lysis of hypertensive intracerebral hematomas. Experiments were performed in 64 rabbits. Histological specimens were examined in different periods after injection of prourokinase into white matter and into experimental hematoma. It is revealed that dose of 615 mg/kg causes minimal changes in cerebral tissue. Clinical study was based on analysis of puncture aspiration of intracerebral hematomas with local fibrinolysis performed in 275 patients with hemorrhagic stroke. Dynamics of MRI, clinical and laboratory parameters, coagulation, analysis of aspirated products of lysis were assessed. Authors showed that recombinant prourokinase and the drug "Puroplazan" are effective for local fibrinolysis. The drugs are non-toxic and non-allergenic and do not cause cerebral edema.

Randomized Trial of Intraarterial Infusion of Urokinase Within 6 Hours of Middle Cerebral Artery Stroke

Background and Purpose— The Middle Cerebral Artery Embolism Local Fibrinolytic Intervention Trial (MELT) Japan was organized to determine the safety and clinical efficacy of intraarterial infusion of urokinase (UK) in patients with stroke within 6 hours of onset.

Methods— Patients with ischemic stroke presenting within 6 hours of onset and displaying occlusions of the M1 or M2 portion of the middle cerebral artery on carotid angiography were randomized to the UK or control groups. Clinical outcome was assessed by the modified Rankin Scale, National Institutes of Health Stroke Scale, and Barthel Index.

Results— The Independent Monitoring Committee recommended stopping the trial after approval of intravenous infusion of recombinant tissue plasminogen activator in Japan. A total of 114 patients underwent randomization, 57 patients in each group. Background characteristics were comparable between the 2 groups. The primary end point of favorable outcome (modified Rankin Scale 0 to 2) at 90 days was somewhat more frequent in the UK group than in the control group (49.1% and 38.6%, OR: 1.54, 95% CI: 0.73 to 3.23) but did not reach a significant level ( P =0.345). However, excellent functional outcome (modified Rankin Scale 0 to 1) at 90 days, a preplanned secondary end point, was more frequent in the UK group than in the control group (42.1% and 22.8%, P =0.045, OR: 2.46, 95% CI: 1.09 to 5.54). There were significantly more patients with National Institutes of Health Stroke Scale 0 or 1 at 90 days in the UK group than the control group ( P =0.017). The 90-day cumulative mortality was 5.3% in the UK group and 3.5% in the control group ( P =1.000), and intracerebral hemorrhage within 24 hours of treatment occurred in 9% and 2%, respectively ( P =0.206).

Conclusions— The trial was aborted prematurely and the primary end point did not reach statistical significance. Nevertheless, the secondary analyses suggested that intraarterial fibrinolysis has the potential to increase the likelihood of excellent functional outcome.

Beyond intravenous thrombolysis

The National Institute of Neurological Disorders and Stroke trial of recombinant tissue plasminogen activator has been considered a landmark study in the acute treatment of ischemic stroke. Unfortunately, only a small percentage of all ischemic stroke patients presents to the hospital in time to receive the drug. Moreover, the recannalization rate of a major artery occlusion, such as the proximal middle cerebral artery or top of the internal carotid artery occlusion, after intravenous (IV) thrombolytic therapy has been disappointingly low. Since the Food and Drug Administration's approval of IV plasminogen activator, there have been numerous randomized clinical trials investigating the safety and efficacy of different thrombolytics administered in various time frames. In addition to the IV administration, efforts have been made in order to study the radiographic as well as clinical effects of intra-arterial (IA) thrombolysis. The combination of IV and IA thrombolysis has been studied. For patients who do not qualify for receiving chemical thrombolysis, new devices have been developed for mechanical thrombectomy. Angioplasty and stenting procedures are being performed more frequently than in the past as one of the treatment modalities for acute ischemic stroke patients. Relentless research effort is being made internationally in order to fight the devastating disease which now goes beyond the conventional IV thrombolysis.

[Multiple emboli from a cardiac metastasis of a renal-cell carcinoma]

A 68-year-old man was hospitalised with a vascular occlusion in the left leg. After treatment with urokinase he developed multiple intracerebral haemorrhages. The occlusion and the intracerebral haemorrhages evoked by urokinase were caused by embolisation originating from a cardiac metastasis of a renal-cell carcinoma. Cardiac surgery was performed, but complete removal of the tumour was not possible. The process of embolisation continued and the patient died a few weeks after diagnosis. Cardiac metastasis is seen in 10% of all cancer patients. Most of these metastases remain without symptoms. Left ventricular metastasis of renal-cell carcinoma without involvement of the inferior V. cava is very rare. If embolic occlusion of one or more vascular areas is present, transthoracic echography of the heart should be performed. Early detection and surgical treatment prevent further embolisation which may result in a better prognosis.

Symptomatic intracranial haemorrhage after intra-arterial thrombolysis in acute ischaemic stroke: assessment of 294 patients treated with urokinase

BACKGROUND

The PROACT II trial showed that intra-arterial thrombolysis (IAT) is effective for treatment of acute ischaemic stroke attributable to M1 and M2 segment occlusions. Incidence of symptomatic intracranial haemorrhage (sICH) was 10%.

OBJECTIVE

To evaluate the risk and predictors of sICH after IAT by using urokinase in a large number of patients presenting with the whole spectrum of cerebral vessel occlusions.

METHODS

294 patients with stroke treated with intra-arterial urokinase were retrospectively analysed. The risk of sICH as well as bleeding characteristics were assessed. Demographic and radiological data, time to treatment, urokinase dose, recanalisation rates, stroke aetiology and severity were analysed for predictors.

RESULTS

sICH occurred in 14 of 294 (4.8%) patients. The median National Institute of Health Stroke Scale score of all patients was 15. All but one sICH were located in the infarcted brain tissue, and no sICH occurred in patients with peripheral vessel occlusions (M3 or M4 segments of the middle cerebral artery). Poor collaterals (p = 0.001), early signs of ischaemia on computed tomography (p = 0.003), higher urokinase dose (p = 0.019), lower recanalisation rate (p = 0.02) and higher diastolic blood pressure on admission (p = 0.04) were found to be correlated with sICH on univariate analysis. On multivariate analysis, poor collaterals (p = 0.004), urokinase dose (p = 0.021) and early signs on computed tomography (p = 0.026) remained predictors of sICH.

CONCLUSIONS

With regard to the whole spectrum of cerebral vessel occlusions, an incidence of <5% sICH after IAT is distinctly low. This result underlines the important role of IAT in the treatment of acute stroke.

Comparison of Retavase and Urokinase for Management of Spontaneous Subclavian Vein Thrombosis

Thrombolysis is an essential first step in the surgical management of acute spontaneous axillo-subclavian vein thrombosis (Paget-Schroetter syndrome). During the past decade, Urokinase became the standard thrombolytic agent until temporarily withdrawn from the market. In its absence, recombinant tissue plasminogen activator (r-TPA) was introduced and attained widespread use. A direct comparison of the efficacy of these two agents in this setting has not been published. The goal of this study is to compare thrombolytic agents in the management of acute Paget-Schroetter syndrome. This study is based on a retrospective review of 30 consecutive patients (15 Urokinase, 15 r-TPA) who underwent thrombolysis and surgery for Paget-Schroetter syndrome. Our hypothesis is that thromblysis with Urokinase and r-TPA is equally safe and effective in management of acute axillo-subclavian vein thrombosis. Primary outcome measures include success of lysis, hemorrhagic complications, subclavian vein patency at completion of treatment, resolution of presenting symptoms, and restitution of normal arm function. There were no significant differences in the primary outcome measures: success of lysis, hemorrhagic complication, perioperative bleeding, and subclavian vein patency. Time to completion of lysis was slightly shorter with r-TPA (but this did not achieve statistical significance). One patient in each group suffered incomplete lysis of thrombus. One patient in the r-TPA group required transfusion due to surgical bleeding. No patient received transfusion due to thrombolysis-related bleeding. All patients experienced resolution of symptoms and return of arm function. Our findings support the hypothesis that Urokinase and r-TPA are similarly safe and successful for management of spontaneous axillo-subclavian vein thrombosis. Given these results, secondary factors such as cost, availability, and familiarity with the different agents will likely determine the agent of choice.

Ischemic and hemorrhagic complications after intra-arterial fibrinolysis in vertebrobasilar occlusion

BACKGROUND AND PURPOSE

To evaluate the incidence and location of hemorrhagic and ischemic lesions after local intra-arterial (IA) fibrinolysis in patients with acute vertebrobasilar occlusion (VBO).

METHODS

One hundred forty-three patients with VBO treated with local IA fibrinolysis were retrospectively evaluated. Two different thrombolytic substances, namely urokinase (UK, n = 57 patients) and recombinant tissue plasminogen activator (rtPA, n = 86 patients), were used. Incidence and location of intracranial hemorrhage and ischemic infarction were assessed by means of 403 peri-interventional CT and MR imaging scans. Recanalization success and bleeding rate were correlated with the type and dosage of fibrinolytic agent. Multiple logistic regression was used for statistical analysis.

RESULTS

Intracranial hemorrhage was detected in 46 (32%) patients. Bleeding rate was significantly higher for high-dose rtPA than for UK (36% versus 21%, P < .01). Neurologic outcome was worse in patients with postinterventional bleeding (P < .001). Ischemic infarctions were present in 136 (95%) patients. Ischemic lesions of the occipital lobe and thalamus were more frequently seen in the case of successful recanalization than after absent recanalization (P < .005). Occlusion of the postcommunicating segment of the posterior cerebral artery after successful recanalization was seen in 39% of patients.

CONCLUSIONS

In acute VBO, bleeding rate after IA rtPA seems to be higher than that using IA UK, especially after high-dose rtPA. Ischemic lesion patterns after successful local IA fibrinolysis are common and correspond to the frequent distal migration of the thrombus. Novel recanalization techniques allowing for endovascular thrombectomy are needed to reduce ischemic and hemorrhagic complications in the treatment of acute VBO.

Intra-arterial thrombolysis for acute stroke in patients 80 and older: a comparison of results in patients younger than 80 years

BACKGROUND AND PURPOSE

Intra-arterial fibrinolytic therapy is a promising treatment for acute ischemic stroke. Few data are available on its use in elderly patients. The purpose of this study was to compare the baseline characteristics, complications, and outcomes between intra-arterially treated ischemic stroke patients aged > or = 80 years and their younger counterparts.

METHODS

Patients aged > or = 80 years (n = 33) were compared retrospectively with contemporaneous patients aged < 80 years (n = 81) from a registry of consecutive patients treated with intra-arterial thrombolysis over a 9-year period.

RESULTS

The very elderly and younger cohorts were very similar in baseline characteristics, including pretreatment stroke severity (National Institutes of Health Stroke Scale [NIHSS] 17 versus 16), differing only in history of stroke/transient ischemic attack (42% versus 22%, P = .01) and weight (66.8 versus 75.8 kg; P = .02). Significant differences in recanalization (TIMI 2-3) rates could not be detected between the very elderly and younger patients (79% versus 68%, P = .10). Rates of major symptomatic hemorrhage (7% versus 8%) and any intracerebral hemorrhage (39% versus 37%) did not differ. Outcomes at 90 days showed lower rates of excellent functional outcome (mRS < or = 1, 26% versus 40%, P = .02) and survival (57% versus 80%, P = .01) among the very elderly.

CONCLUSIONS

Intra-arterial fibrinolysis in the elderly can be accomplished with recanalization rates and hemorrhage rates equal to that in younger patients. Although mortality rates are higher and good functional outcomes are lower than in younger persons, nondisabling outcomes may be achieved in a quarter of patients. These findings suggest that the investigation and use of intra-arterial thrombolytic treatment in very elderly patients should not be avoided but pursued judiciously.

Thrombolytic therapy with urokinase for pulmonary embolism in patients with stable hemodynamics

BACKGROUND

Thrombolytic agents such as urokinase have been used in the treatment of patients with massive pulmonary embolism and hypotension, but their effect in patients with submassive pulmonary embolism and normal blood pressure has been controversial.

MATERIAL/METHODS

Urokinase (20,000 IU /kg) was intravenously administered to 36 patients who had pulmonary embolism and a normal blood pressure. This was followed by subcutaneous injection of a low-molecular-weight heparin for a week.

RESULTS

Improvement in clinical symptoms and reduction in pulmonary pressure was observed in 28 (77.8%) patients within the first week of the thrombolytic therapy. The improvement rate in patients with embolic symptoms of less than 14 days, and in those who had symptoms between 14 and 30 days before the thrombolytic therapy was 86% and 50%, respectively (p<0.01). Non-life threatening bleeding complications were observed in 10 (22.2%) patients.

CONCLUSIONS

Thrombolytic therapy with urokinase followed by low-molecular-weight heparin is an effective therapeutic strategy for patients with pulmonary embolism and stable haemodynamics. However, the long-term benefits of this strategy remain to be seen and further studies are warranted.

Is intra-arterial thrombolysis safe after full-dose intravenous recombinant tissue plasminogen activator for acute ischemic stroke?

BACKGROUND AND PURPOSE

The optimal approach for acute ischemic stroke patients who do not respond to intravenous recombinant tissue plasminogen activator (IV rt-PA) is uncertain. This study evaluated the safety and response to intra-arterial thrombolytics (IATs) in patients unresponsive to full-dose IV rt-PA.

METHODS

A case series from a prospectively collected database on consecutive acute ischemic stroke patients treated with IATs after 0.9 mg/kg IV rt-PA during a 7-year interval was collected. Primary outcome measures included symptomatic intracranial hemorrhage and mortality. As indicators of response, secondary outcome measures were recanalization and discharge disposition.

RESULTS

Sixty-nine patients (mean+/-SD age, 60+/-13 years; range, 26 to 85 years; 55% male) with a median pretreatment National Institutes of Health Stroke Scale score of 18 (range, 6 to 39) were included. IV rt-PA was started at 124+/-32 minutes (median, 120 minutes) and IAT, at 288+/-57 minutes (median, 285 minutes). IATs consisted of reteplase (n=56), alteplase (n=7), and urokinase (n=6), with an average total dosage of 2.8 U, 8.6 mg, and 700 000 U, respectively. Symptomatic intracranial hemorrhage occurred in 4 of 69 (5.8%) patients; 3 cases were fatal. Recanalization was achieved in 50 (72.5%) and a favorable outcome (home or inpatient rehabilitation) in 38 (55%).

CONCLUSIONS

IAT therapy after full-dose IV rt-PA in patients with persisting occlusion and/or lack of clinical improvement appears safe compared with IV rt-PA alone or low-dose IV rt-PA followed by IAT. A high rate of recanalization and favorable outcome can be achieved.

Peripheral Arteries: Treatment with Antibodies of Platelet Receptors and Reteplase for Thrombolysis—APART Trial

PURPOSE

To prospectively compare the safety and efficacy of combination therapy with the glycoprotein IIb/IIIa antagonist abciximab plus the third-generation thrombolytic agent reteplase versus those of therapy with the standard thrombolytic agent urokinase plus abciximab.

MATERIALS AND METHODS

The study was approved by the local ethics committee, and patient informed consent was obtained. Patients with peripheral arterial occlusions less than 60 days old (n=120) were enrolled in the study: 50 patients (32 men, 18 women; mean age, 67 years; range, 23-88 years) received reteplase plus abciximab and 70 patients (36 men, 34 women; mean age, 68 years; range, 28-88 years) received urokinase plus abciximab. Study end points were the rate of major complications at 30 days, therapeutic success, and survival without open surgery or major amputation at follow-up. Fisher exact test was used to compare treatment groups with respect to dichotomous variables, and the event-free-survival probabilities were calculated with the Kaplan-Meier method. For the comparison of the lengths of occlusions among the groups, a two-sample t test was used.

RESULTS

Therapeutic success (P=.7) did not differ between the groups, whereas the time required for thrombolysis was lower in the urokinase-plus-abciximab group (P=.001). Patients who received reteplase plus abciximab tended to develop more minor complications (mainly bleeding events) (P<.001). During long-term follow-up (2-4 years), no group differences were observed. The reocclusion rate was 48% (22 of 46) in the reteplase-plus-abciximab group and 45% (29 of 64) in the urokinase-plus-abciximab group. Only two of 120 major amputations were counted in the follow-up period.

CONCLUSION

The proposed regimen resulted in only a limited number of major complications, and the low amputation rate in both groups may be attributed to abciximab.

Intrapleural urokinase for the treatment of loculated malignant pleural effusions and trapped lungs in medically inoperable cancer patients

BACKGROUND

Pleural fluid loculations or trapped lungs frequently render patients with symptomatic malignant pleural effusions (MPEs) unsuitable for pleurodesis. Thoracoscopic surgery or thoracotomy with decortication is generally not feasible for patients with a poor performance status. MPEs have augmented procoagulant and depressed fibrinolytic activity that contributes to fibrin deposition within the pleural space. The authors conducted an observational prospective cohort study to investigate the use of intrapleural urokinase (IPUK) for such patients and made a comparison with a historical control group.

METHODS

Between March of 2000 and August of 2005, 48 consecutive patients with symptomatic MPEs with an average Karnofsky performance scale score of 46.7% were recruited. Dyspnea persisted with the presence of substantial residual loculated MPEs in 36 patients and trapped lungs in 12 patients, when the effectiveness of 8-French intrapleural catheter drainage had decreased despite regular saline flushes. Urokinase was instilled daily through the catheter at a dose of 100,000 IU diluted in 100 ml of normal saline for 3 days. Additional IPUK instillation was required upon partial improvement. The records and chest radiographs of another 52 patients with symptomatic MPEs had met these eligibility criteria between January of 1995 and February of 2000 and received saline flushes only were also reviewed.

RESULTS

Immediate lung reexpansion and resolution of dyspnea was achieved in 29 of the 48 patients who underwent IPUK therapy (60.4%). The mean dose of urokinase instillations per patient was 360,000 IU. There were no major complications. A significant association of earlier intervention with the success of IPUK therapy was noted. Responders also had a significantly increased drainage within the 24 hours after the first dose of IPUK. Minocycline pleurodesis was subsequently performed for the 29 IPUK responders. Eighteen patients were followed up until death, with a median survival of 6.5 months. The other remained alive at the time of analysis with a median follow-up of 5 months. Two patients had an immediate failure of pleurodesis at 1 month. Three relapses occurred at 3, 4, and 7 months from pleurodesis, respectively. Twenty-three patients (79.3%) had lifelong pleural symphysis, including 21 having loculated MPEs and two having trapped lungs, respectively. Compared with the historical control group, the IPUK study group had significantly greater improvement on chest radiography and a shorter duration of pleural drainage.

CONCLUSION

These results suggest that IPUK is a safe and useful nonsurgical adjunct therapy for loculated MPEs or trapped lungs in medically inoperable cancer patients.

Managing peripherally inserted central catheter-related venous thrombosis: How I do it

Imaging-guided insertion of central venous catheters, either in the form of a peripherally inserted central catheter (PICC) or through a subclavian or a jugular approach, is becoming the preferred method of acquiring long-term venous access for a variety of therapeutic purposes. The most significant complication from central venous catheters is thrombosis of the catheterized vein. Venous thrombosis related to the insertion of PICC lines is conventionally treated with line removal followed by anticoagulation. Direct thrombolysis with urokinase, using the lumen of the PICC line to facilitate the insertion of the infusion catheter is a simple, safe and effective treatment option. In this article, we describe our experience with this procedure and the technique used.

Percutaneous hydrodynamic thrombectomy for congenital deep vein thrombosis in a neonate

A 1-day-old boy with a complete occlusive inferior vena cava and bilateral renal vein thrombus removed successfully using a hydrodynamic thrombectomy catheter is reported. Although blood flow to the inferior vena cava and bilateral renal veins was restored with no distal embolism or vascular injury, he died of bleeding complications due to fibrinolytic therapy after hydrodynamic thrombectomy. To the best of our knowledge, this is the first report of hydrodynamic thrombectomy of a neonate.

Fibrinogengesteuerte Urokinaselyse einer Portal- und Mesenterialvenenthrombose bei akutem Schub einer Colitis ulcerosa

HISTORY AND ADMISSION FINDINGS

A 23-year-old woman with a 5-year history of ulcerative colitis was admitted to our hospital because of bloody diarrhea. Two years previously she had undergone a hemicolectomy for a right colonic stricture. A recurrence of inflammatory bowel disease was suspected and treatment with prednisolone begun. The symptoms improved gradually, but 7 days later she complained of lower abdominal pain. Physical examination revealed a soft abdomen, but bowel sounds were reduced.

INVESTIGATIONS

The abdominal X-ray was unremarkable, but ultrasonography revealed moderate ascites and no blood flow in the portal vein on Doppler examination. The spleen was slightly enlarged. Contrast-enhanced abdominal magnetic resonance imaging (MRI) was performed immediately, revealing thrombosis of the portal and mesenteric veins.

TREATMENT AND COURSE

As there was no suggestion of intestinal necrosis, laparatomy was not considered necessary. Intravenous thrombolytic treatment with urokinase was given continuously (bolus of 250,000 units, followed by 200,000 units per hour), in order to lower the fibrinogen level to 100 - 150 mg/dl, together with unfractionated heparin, maintaining the activated partial thromboplastin time between 60 and 85 seconds. The thrombolytic treatment had to be stopped several times because of bloody diarrhea, but no transfusion was necessary. Two days after the start of thrombolytic treatment the abdominal pain and ascites ceased. Doppler sonography now demonstrated hepatopetal flow in the previously occluded portal vein. 4 days later, MRI revealed that the thrombus in the portal vein had dissolved and the portal vein was fully patent. The mesenteric vein was partially perfused, a residual thrombus extending into the portal vein. Tests for thrombophilia were negative. The thrombolytic therapy was stopped after 112 hours and the patient was treated with oral anticoagulation for 6 months. The patient recovered completely, with no evidence of portal hypertension during the following 6 months.

CONCLUSIONS

Thrombolysis with urokinase, guided by the level of fibrinogen, may be an alternative, semi-invasive treatment option in acute thrombosis of the portal and mesenteric veins.

Comparative Safety and Efficacy of Urokinase and Recombinant Tissue Plasminogen Activator for Peripheral Arterial Occlusion: A Meta-Analysis

STUDY OBJECTIVE

To evaluate differences in the efficacy and safety of recombinant tissue plasminogen activator (rt-PA) and urokinase in the treatment of peripheral arterial occlusion.

DESIGN

Systematic review and meta-analysis of prospective comparative trials.

DATA SOURCE

PubMed/MEDLINE database from 1966-October 2004.

MEASUREMENTS AND MAIN RESULTS

The literature was systematically searched to identify prospective comparative trials of urokinase and rt-PA for the treatment of peripheral arterial occlusion. The primary outcome measure was successful complete lysis of the occlusion. Other outcome measures were hemorrhage (major, minor, or combined), intracranial hemorrhage, limb loss, and mortality. Six trials were identified, five of which were randomized. On meta-analysis, the rate of clot lysis was higher with rt-PA than with urokinase (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.12-2.10, p=0.007). However, urokinase was associated with lower rates of minor (OR 0.52, 95% CI 0.28-0.97, p=0.04) and total (OR 0.51, 95% CI 0.29-0.91, p=0.02) bleeding. Rates of major hemorrhage, intracranial hemorrhage, limb loss, and mortality were similar between agents.

CONCLUSION

Urokinase was less effective than rt-PA in successfully lysing acute peripheral arterial occlusion, but it was associated with lower rates of total and minor bleeding. Overall, rt-PA was a reasonable substitute for urokinase, now that urokinase has been removed from the market in the United States. However, judicious monitoring for minor bleeding is necessary.

A6, a urokinase plasminogen activator (uPA)-derived peptide in patients with advanced gynecologic cancer: a phase I trial

OBJECTIVES

The aim of this study was to define the toxicity, maximum feasible dose (MFD), and pharmacokinetics (PK) of A6, a peptide derived from human urokinase plasminogen activator (uPA), in patients with advanced gynecologic cancers, and to explore anti-tumor activity and the effects of A6 on biomarkers of the urokinase system.

METHODS

A6 was administered subcutaneously daily, and doses were escalated in cohorts of three to six subjects. Serial blood specimens were obtained for pharmacokinetics and levels of urokinase plasminogen activator (uPA), uPA receptor (uPAR), and plasminogen activator inhibitor-1 (PAI-1).

RESULTS

Sixteen patients were enrolled and eligible for evaluation. No serious drug-related adverse events or dose-limiting toxicity occurred. A6-related toxicities were limited to grades 1 and 2 adverse effects including local injection site reactions. Five patients had stable tumor measurements for at least 4 cycles, one of whom stayed on study for 12 months. One patient had a confirmed cancer antigen (CA)-125 response (decrease in CA-125 of >50%) with stable disease on CT scan after 14 cycles and continues on study. Time to peak plasma level of A6 was 1-2 h. C(max) is proportional to dose. The half-life of A6 was approximately 2 h. Baseline biomarker levels did not predict response and trends over time did not correlate with outcome.

CONCLUSIONS

A6 given daily continuously is well tolerated at all dose levels, without any dose-limiting toxicity. Based on the preliminary activity of A6, a phase II trial is underway in ovarian cancer.

Systemische fibrinolytische Therapie mit Urokinase bei Zentralarterienverschluss der Netzhaut

BACKGROUND AND OBJECTIVE

Systemic fibrinolysis has become an important therapeutical option in patients with thrombotic occlusion of coronary or pulmonary arteries. In view of the hemorrhagic risk systemic fibrinolytic therapy for retinal vessel occlusion has been discussed controversial. In the present case study results and complications of systemic fibrinolysis should be investigated in patients with central retinal artery occlusion.

PATIENTS AND METHODS

From 1995 to 2002 a case series of 19 consecutive patients (8 female, 11 male, age: 63.2+/-14,3 years) with central retinal artery occlusion were treated by systemic application of urokinase using a standardized scheme. The latency from initial symptoms until the initiation of therapy and the medical history of the patients were documented. Visual acuity was determined on admission and before discharge and possible complications were documented. Additionally, screening investigations for genetic thrombophilia were performed.

RESULTS

15 patients showed an improvement of the visual acuity (79 %, 95 %-KI: 54 %-94 %). For 3 patients no improvement and for one patient a decrease of the visual acuity was determined. Hemorrhagic complications were observed in two patients (11 %, 95 %-KI: 1 %-33 %). As these minor bleedings were self-limiting the fibrinolytic therapy was discontinued only in one patient. As risk factors most commonly arterial hypertension (68 %) and smoking (26 %) were identified. In 4 patients a genetic thrombophilia was diagnosed.

CONCLUSIONS

Considering the poor prognosis of central retinal artery occlusion and the disappointing results of conservative treatment, an improvement of the visual acuity in the absence of critical complications was observed with systemic fibrinolytic therapy in the presented case study. However, only controlled trials can provide proof for the effect of fibrinolysis versus spontaneous improvement.

Recombinant urokinase for restoration of patency in occluded central venous access devices. A double-blind, placebo-controlled trial

The interval occlusion of central venous access devices (CVADs) remains a significant clinical problem, often requiring re-intervention for catheter exchange or replacement. The purpose of this Phase 3, multi-center, double-blinded study was to test the hypothesis that instillation of recombinant urokinase (r-UK) 5000 IU/ml is superior to placebo in restoring total catheter patency to an unselected cohort of occluded CVADs. After obtaining informed consent, adult and pediatric patients with occluded, non-hemodialysis CVADs of any duration or type were randomized (2 : 1) to receive either r-UK 5000 IU/ml or placebo instilled into all occluded lumens of their catheter. Catheter function was assessed at 5, 15 and 30 min after the first instillation. If the catheter remained occluded after 30 min, a second dose was instilled with repeat assessments at 5, 15 and 30 min. The primary efficacy variable was the restoration of catheter function to all treated lumens (i.e., total catheter patency) after one or two instillations. Catheters that were not successfully recanalized after two instillations were allowed to receive up to two instillations of open-label r-UK administered in the same manner. The primary safety variable was the occurrence of hemorrhagic and non-hemorrhagic events within 72 hr after instillation. A total of 180 patients were enrolled at 43 sites in the United States and Canada. Most patients were adults, although 20% were </=18 years of age. CVAD types included totally implanted subcutaneous ports (45%), PICC lines (26%), non-tunneled percutaneous catheters (18%), and tunneled percutaneous catheters (10%). All CVADs were occluded by virtue of their inability to withdraw blood (withdrawal occlusion). Additionally, 32% of catheters were completely dysfunctional as blood could not be withdrawn and fluids could not be infused (total occlusion). Analysis of the results showed that r-UK was significantly better than placebo in restoring catheter function (54% versus 30%, p = 0.002). There were no major hemorrhagic events within 72 hr after up to four r-UK instillations, and the incidence of non-hemorrhagic events was similar among the r-UK and placebo groups. In conclusion, r-UK is superior to placebo in restoring total catheter patency to occluded CVADs. In patients with occluded CVADs, intra-catheter thrombolysis can restore patency and may obviate the need for catheter replacement.

Efficacy of methylprednisolone and urokinase pulse therapy combined with or without cyclophosphamide in severe Henoch-Schoenlein nephritis: a clinical and histopathological study

BACKGROUND

There have been few controlled studies of combined therapy with multiple drugs, including immunosuppressives, for severe Henoch-Schoenlein nephritis (HSPN). We evaluated the efficacy of methylprednisolone and urokinase pulse therapy combined with cyclophosphamide for patients with HSPN of at least grade IVb.

METHODS

We studied 37 patients who had been diagnosed with HSPN of at least grade IVb. Of them, 20 (Group A) were treated with methylprednisolone and urokinase pulse therapy, and 17 (Group B) were treated with methylprednisolone and urokinase pulse therapy combined with cyclophophamide. We analysed the clinical features, laboratory and pathological findings of the two groups retrospectively.

RESULTS

After 6 months of treatment, mean urinary protein excretion in Group B had significantly decreased compared with Group A, and the activity index of both groups at the second biopsy was lower than that at the first. Furthermore, at the second biopsy, the chronicity index of Group B was lower than that of Group A. Four patients of Group A but none of Group B had persistent nephropathy (P<0.05).

CONCLUSIONS

Our study suggests that methylprednisolone and urokinase pulse therapy combined with cyclophosphamide is useful for patients with severe HSPN.

Sequential combination of intravenous recombinant tissue plasminogen activator and intra-arterial urokinase in acute ischemic stroke

BACKGROUND AND PURPOSE

Combined intravenous (IV) and intra-arterial (IA) thrombolytic therapy may be faster and easier to initiate than monotherapy, and its recanalization rate may be better as well. The sequential combination of recombinant tissue plasminogen activator (rTPA) and urokinase (UK) has synergistic and complementary effects on clot lysis. We prospectively evaluated the effectiveness and safety of sequential combination of IV rTPA and IA UK in acute ischemic stroke.

METHODS

IV rTPA was administered to patients with acute stroke within 3 hours of onset. Those whose condition had not improved at the end of rTPA infusion were further treated with selective IA UK. We evaluated baseline and 30-day National Institutes of Health Stroke Scale (NIHSS) scores and 90-day modified Rankin Scale scores.

RESULTS

Thirty patients were initially treated with IV rTPA; 24 were further treated with IA UK. Four patients who had rapid reocclusion following initial successful IA therapy received IV abciximab. Fourteen of 24 patients who underwent angiography had an effective perfusion state of Thrombolysis in Myocardial Infarction grade 3 flow. Median baseline and 30-day NIHSS scores were 18 and 2, respectively. Eighteen patients improved to a modified Rankin scale score of 0 or 1 after 90 days. Symptomatic hemorrhage developed in two patients.

CONCLUSION

The strategy of using conventional-dose IV rTPA and the sequential combination of IA UK in patients without an early clinical response to IV treatment was safe and feasible. This strategy achieved high complete arterial recanalization rates and good functional outcomes.

Safety of Thrombolytic Therapy with Urokinase or Recombinant Tissue Plasminogen Activator for Peripheral Arterial Occlusion:A Comprehensive Compilation of Published Work

PURPOSE

To report a comprehensive literature review focused on comparing the risk of complications with urokinase versus recombinant tissue plasminogen activator (rtPA) for thrombolytic treatment of peripheral arterial occlusions.

METHODS

The English-language literature between 1985 and 2002 was searched for studies that used tissue-derived urokinase or rtPA in the treatment of peripheral arterial occlusions. Forty-eight studies (22 urokinase, 22 rtPA, and 4 that included both treatments) were identified, encompassing 2226 urokinase-treated patients and 1927 rtPA-treated patients. The safety of each thrombolytic agent was assessed based on the incidence of major hemorrhage, intracerebral hemorrhage, major limb amputation, transfusions, and mortality.

RESULTS

The review revealed a wide range of study protocols, patient conditions, ages of occlusions, dosages/delivery methods of lytic agents, and criteria for reporting complications. The incidence of major hemorrhage varied widely, but the overall rate was lower among urokinase-treated patients (6.2%) than for patients treated with rtPA (8.4%, p=0.007). The overall incidence of intracerebral hemorrhage was also significantly lower for urokinase (0.4% versus 1.1% for rtPA, p=0.020). The major amputation rate was similar for both treatments (urokinase 7.9%, rtPA 7.2%), but the mortality rate was significantly lower for urokinase (3.0% versus 5.6% for rtPA, p<0.001). The need for transfusions was less frequent with urokinase (11.1% versus 16.1%, p=0.002).

CONCLUSIONS

These results from a large body of published literature suggest that urokinase may be associated with a lower incidence of complications than rtPA in the treatment of peripheral arterial occlusions.

[Effectiveness and safety of intraventricular fibrinolysis in secondary intraventricular hemorrhages (a prospective, randomized study)]

BACKGROUND AND PURPOSE

Intraventricular clot secondary to brain hemorrhage has still one of the worst prognosis among all stroke subtypes, regardless of conservative therapy or surgical interventions. The rapid clot resolution with thrombolytic agents could improve the outcome by restoring the impaired cerebrospinal fluid circulation, for this reason, the authors examined the safety and efficacy of Urokinase therapy in a randomized, controlled study.

METHODS

They enrolled 27 patients with severe intraventricular hemorrhage between 1998 and 2002. All patients had supratentorial intracerebral hemorrhage caused by hypertension, with IVH, moreover clinically worsening course due to the obstructive hydrocephalus confirmed by CT. Eleven persons were treated with ventriculostomy alone and 16 received adjunctive intraventricular urokinase. The authors examined the early, 30-day and 1-year mortality, furthermore the neurological (Scandinavian Stroke Scale) and functional outcome (Barthel Scale). The mean age was 60 +/- 9.5. The initial Scandinavian Stroke Scale was 7.51 +/- 8.64, Glasgow Coma Scale was 6.85 +/- 2.52, intracerebral hemorrhage volume was 22.44 +/- 18.14 ml.

RESULTS

The 1 year survival rate was significant higher in the urokinase treated group (p = 0.014), This tendency in the mortality (31.3% vs. 54.5%) and in the neurological/functional condition (SSS, p = 0.078/Barthel, p = 0.119) at 30th day have been also documented. No hemorrhagic complications due to urokinase were observed. Two meningitis (7.4%) and two intraparenchymal hemorrhages (7.4%) related to drain insertion were detected (p = 0.009). The probability of pulmonary infection was roughly two times higher in the group without clot lysis (RR = 1.870; 95% CI: 1.004-3.482).

CONCLUSIONS

In the authors experience, urokinase treatment reveals to be safe in the intraventricular clot lysis. This therapy allows earlier mobilization and rehabilitation, and decreases the number of infections, which are favorable to the long-term survival rate.

The role of recombinant lysine-plasminogen and recombinant urokinase and sulfur hexafluoride combination in inducing posterior vitreous detachment

PURPOSE

To determine the optimal method of generating plasmin in vitreous using recombinant lysine-plasminogen and recombinant urokinase and to determine its efficacy in inducing posterior vitreous detachment when combined with sulfur hexafluoride.

METHODS

Plasmin concentration of the rabbit vitreous after separate and combined intravitreal administrations of recombinant lysine-plasminogen and recombinant urokinase was tested in 78 rabbits to determine the optimal method of administration. The safety and efficacy of these agents and sulfur hexafluoride in inducing complete posterior vitreous detachment (total separation of the vitreous apart from vitreous base) were also evaluated.

RESULTS

The highest plasmin concentration in vitreous was measured 10 minutes after injection. Intravitreal administration of recombinant lysine-plasminogen and recombinant urokinase did not cause any toxicity findings up to concentrations of 100 microg and 200 IU, respectively, on funduscopy, electroretinography, and histopathologic studies. When combined with sulfur hexafluoride injection, separate intravitreal administrations of 75 microg/0.1 mL of recombinant lysine-plasminogen and 15 IU/0.1 mL of recombinant urokinase induced complete posterior vitreous detachment in 75% of the eyes compared with 13% in eyes that received sulfur hexafluoride injection combined with balanced salt solution, recombinant lysine-plasminogen, or recombinant urokinase.

CONCLUSIONS

Plasmin was effectively generated in the vitreous after separate intravitreal administrations of recombinant lysine-plasminogen and recombinant urokinase. When combined with intravitreal gas injection, this method of plasmin production induced complete posterior vitreous detachment in 75% of the eyes.

[Effectiveness of urokinase used in combination with batroxobin (DF-521) in rat model of focal cerebral ischemia-reperfusion]

OBJECTIVE

This study was designed to use urokinase (UK) in combination with batroxobin in thrombolytic therapy so as to see whether batroxobin(DF-521) would be effective for neuroprotection.

METHODS

The model of right middle cerebral artery occlusion (MCAO) in male SD rats was established. 120 rats were randomized into 9 groups, namely control group, sham control group, and groups that were treated with batroxobin and urokinase together or separately. Each group comprised 15 rats. Intracranial bleeding, infarct volume ratio and neurological function were observed.

RESULTS

Intracranial bleeding was found in 5 rats of the UK 5000 U/kg group, in 4 rats of the UK 5000 U/kg (2 h) + DF-521 5 BU/kg (2 h) group, and in only 1 rat of the UK 5000 U/kg (2 h) + DF-521 5 BU/kg (1 h) group. Cerebral infarct volume ratio was obviously reduced in 5 BU/kg batroxobin group. No difference was observed in neurological deficit scores.

CONCLUSION

5000 U/kg urokinase increased the risk of intracranial hemorrhage in rat MCAO model. Batroxobin either used separately or in combination with urokinase would not increase the risk of intracranial hemorrhage in rat MCAO model.

Safety, tolerability and pharmacokinetics of subcutaneous Å6, an 8-amino acid peptide with anti-angiogenic properties, in healthy men

AIMS

To assess the safety, tolerability and pharmacokinetics of subcutaneous A6, an 8-amino acid peptide with anti-angiogenic properties, in healthy men.

METHODS

Double-blind, placebo-controlled, parallel-group, dose-rising, phase I study of single and repeated doses. In the single dose phase, successive groups of 5 subjects received A6 15, 35, 75, 150, 300 mg, or placebo, as subcutaneous injections in the upper thigh. In the repeat dose phase, 2 groups of 6 subjects received repeat doses of A6 35 mg and 75 mg, or placebo, and 1 group of 5 subjects received 150 mg, or placebo, 12-hourly for 6 days (11 doses in total). In each group, 4 subjects received active treatment, the remainder placebo. Pharmacokinetics of A6 were assessed up to 24 h after single doses, for 12 h after the first of the repeated doses, and up to 24 h after the last of the repeated doses.

MATERIALS

A6 for subcutaneous injection in phosphate buffer, pH 5.6-6.0. Phosphate-buffered saline was used as placebo.

RESULTS

All dose regimens of A6 were safe and well-tolerated, both systemically and locally. Time to peak plasma concentration was similar (0.5-2.1 h) in all dosage groups. Cmax and AUC(0-inf) were linearly proportional to dose. Mean Cmax ranged from 454-10,333 ng/ml and mean AUC(0-inf) from 1,690-43,371 ng x h/ml after the 15 and 300 mg single doses, respectively. Terminal t(1/2) was 1.4-1.8 h, and there was no evidence of unexpected drug accumulation. Urinary excretion of unchanged A6 was 94.6% (SD 20.7) after the 300 mg single dose (0-24 h collection), and 78.4% (SD 13.0) after the 150 mg repeated dose (0-12 h collection). A6 did not trigger production of anti-A6 IgG antibodies within 14 days of the first dose.

CONCLUSION

Single doses of A6 up to 300 mg, and repeated doses up to 150 mg, were well-tolerated and safe in healthy young men. A6 was rapidly absorbed; it was eliminated, mainly unchanged, in urine. Plasma concentrations were dose-proportional. A6 did not trigger an early immunogenic response.

Thrombolytic therapy for acute ischemic stroke

Available evidence of thrombolysis in acute ischemic stroke comes from a series of recent trials conducted in patients with acute stroke, and from a meta-analysis published in the Cochrane Library. The objective of this paper is to review the literature on tolerability and efficacy of thrombolytic therapy in patients with acute ischemic stroke, to find out what the level of evidence is for each thrombolytic drug, and what should consequently be done in the routine practice. This review is based on a bibliographic search of published meta-analyses of randomized trials, published randomized trials, and ongoing randomized trials, with the outcomes of disability, death, and symptomatic intracerebral hemorrhages (fatal or non-fatal). Our primary end-point is a combination of death and disability, in terms of "death or dependency", with dependency defined as a modified Rankin Score (mRS) of >/=3. The level of evidence for the efficacy of a thrombolytic treatment is considered sufficient if there is both a statistically significant effect in the meta-analysis of all randomized trials, without statistically significant heterogeneity, together with one adequately powered and designed conclusive trial. Streptokinase has a clearly harmful effect, without any demonstrated benefit and must not be used in patients with acute ischemic stroke. The level of evidence of an effect of intra-arterial pro-urokinase to reduce death or dependency is low, available data are sparse (only 220 patients), the estimation of its real efficacy and tolerability remains unclear, and its use in clinical practice is not presently justified. The efficacy of alteplase has been incompletely demonstrated because the results vary across trials and type of outcomes (death, death or dependency), and the cut-off of the disability scale. There is a significant heterogeneity in the effect on death or dependency. However, we can conclude that there is a beneficial effect, but its clinical application is limited because of the absence of adequate criteria to identify patients most likely to benefit from treatment. Overall the use of alteplase in patients with acute stroke was associated with some benefit, but it significantly increased total mortality in two trials. Given the observed confidence interval (CI), the results are compatible with, in the best situtation, 203 advoided death or dependency and 61 avoided death per 1000 treated patients, and at worst 77 avoided death or dependency and 38 extra deaths per 1000 treated patients. Further trials aimed at validating more discriminant selection criteria are mandatory.

Intraventricular Thrombolysis Speeds Blood Clot Resolution: Results of a Pilot, Prospective, Randomized, Double-blind, Controlled Trial

OBJECTIVE

Animal models and clinical studies suggest that intraventricular thrombolysis improves clot resolution and clinical outcomes among patients with intraventricular hemorrhage. However, this intervention may increase the rates of rebleeding and infection. To assess the safety and efficacy of intraventricular thrombolysis, we conducted a pilot, randomized, double-blind, controlled, multicenter study.

METHODS

Patients with intraventricular hemorrhage requiring ventriculostomy were randomized to receive intraventricular injections of normal saline solution or urokinase (25,000 international units) at 12-hour intervals. Injections continued until ventricular drainage was discontinued according to prespecified clinical criteria. Head computed tomographic scans were obtained daily, for quantitative determinations of intraventricular hemorrhage volumes. The rate of clot resolution was estimated for each group.

RESULTS

Twelve subjects were enrolled (urokinase, seven patients; placebo, five patients). Commercial withdrawal of urokinase precluded additional enrollment. The urokinase and placebo groups were similar with respect to age (49.6 versus 55.2 yr, P = 0.43) and presenting Glasgow Coma Scale scores (7.14 versus 8.00, P = 0.72). Randomization to the urokinase treatment arm (P = 0.02) and female sex (P = 0.008) favorably affected the clot resolution rate. The sex-adjusted clot half-life for the urokinase-treated group was reduced 44.6%, compared with the value for the placebo group (4.69 versus 8.48 d).

CONCLUSION

Intraventricular thrombolysis with urokinase speeds the resolution of intraventricular blood clots, compared with treatment with ventricular drainage alone.

[Case of cholesterol crystal embolism occurring after treatment of cerebral infarction with urokinase]

A 74-year-old man with hypertension and diabetes mellitus was admitted to our hospital because of acute exacerbation of chronic renal failure after treatment with urokinase for a cerebral infarction. A percutaneous renal biopsy was performed to examine the cause of renal damage, revealing glomerulosclerosis and cholesterol clefts in the small arteries. Subsequently eosinophil was increased to 21% and livedo reticularis was found in the patient's foot. A skin biopsy was performed, and cholesterol clefts were again found in the small arteries. For the reason, our diagnosis was cholesterol crystal embolism. Although 30 mg of prednisolone was administered, the patient's renal function did not improve and maintenance hemodialysis therapy was necessary. This is a rare case of cholesterol crystal embolism caused by urokinase without any invasive vascular procedures.

Effect on Cerebral Vasospasm of Coil Embolization Followed by Microcatheter Intrathecal Urokinase Infusion Into the Cisterna Magna

Background and Purpose— Vasospasm remains the leading cause of death and permanent neurological disability in patients with aneurysmal subarachnoid hemorrhage (SAH). The objective of our prospective randomized trial of coil embolization followed by intrathecal urokinase infusion into the cisterna magna (ITUKI therapy) was to test its effectiveness in preventing or alleviating the severity of ischemic neurological deficits caused by vasospasm.

Methods— We enrolled 110 patients with ruptured intracranial aneurysms eligible for coil embolization and randomly assigned them to embolization with (n=57) or without (n=53) ITUKI therapy performed within 24 hours of aneurysmal SAH. The incidence of symptomatic vasospasms and the clinical outcomes, based on the Glasgow Outcome Scale, 6 months after SAH onset were assessed.

Results— There were no side effects or adverse reactions attributable to ITUKI therapy. Symptomatic vasospasm occurred in 5 patients (8.8%) with and 16 (30.2%) without ITUKI therapy; the difference was significant ( P =0.012). Although the mortality rate did not differ between the groups, patients with ITUKI therapy had significantly better outcomes than those without ( P =0.036).

Conclusions— Our results demonstrate that ITUKI therapy significantly reduced the occurrence of symptomatic vasospasm. Although it did not completely prevent vasospasms, ITUKI therapy resulted in a lower rate of permanent neurological deficits.

[Risk factors for intracerebral hemorrhage after intravenous thrombolysis in acute cerebral infarction]

OBJECTIVE

To identify risk factors of intracerebral hemorrhage (ICH) after intravenous thrombolysis in acute cerebral infarction.

METHODS

Eighty-two patients with acute cerebral infarction were treated with intravenous urokinase within 12 hours from stroke onset. The data of clinic and laboratory were as readily available baseline factors and were analyzed to select potential contributors to ICH.

RESULTS

ICH occurred in 15 patients (18.3%), including 6 hemorrhagic infarction (HI, 7.3%) and 9 Parenchyma hemorrhage (PH, 11.0%). Seven patients had symptomatic ICH, and 4 patients died. Patients with ICH had significantly lower European stroke scale (ESS) scores. Patients with ESS<60 scores, early ischemic changes (EIC) on cranial CT scans or artrial fibrillation had significantly higher risk of ICH.

CONCLUSION

Risk factors associated with ICH are severity of neurological deficit, EIC and artrial fibrillation.

[Treatment of empyema and complicated pleural effusion with intrapleural fibrinolysis]

BACKGROUND AND OBJECTIVE

Intrapleural fibrinolysis (IPF) can avoid surgery in patients with loculated pleural effusions. Few clinical trials on IPF for the treatment of empyemas (PEM) and complicated pleural effusions (CPE) have been reported. We describe here our experience with IPF in the treatment of PEM/CPE patients.

PATIENTS AND METHOD

81 patients with PEM/CPE were included. Urokinase, 100000 U, was instilled into the pleural cavity, three times a day. A mean of 12.9 doses of urokinase were administered.

RESULTS

The mean of days having a chest tube was 7.7 days and the mean hospital stay was 22.2 days. No radiological sequelae were observed or these were mild in 66 cases (81.5%). There were four deaths and three patients needed surgery.

CONCLUSIONS

IPF is an efective and reliable method for the treatment of PEM/CPE.

Amediplase: CGP 42935, K2tu-PA, MEN 9036

Amediplase [CGP 42935, MEN 9036, K2tu-PA] is a recombinant chimeric plasminogen activator, consisting of the kringle 2 domain from the A-chain of tissue plasminogen activator (t-PA) and the carboxy terminal region of pro-urokinase. Amediplase was the outcome of a collaborative project with Ciba Geigy (now Novartis), but subsequent preclinical and clinical development has been completed by Menarini. Menarini is currently investigating amediplase in phase III clinical trials in Europe as a thrombolytic given as a single bolus to patients with myocardial infarction. In June 2002, Prometic Life Sciences announced that its collaboration with Menarini Biotech had resulted in the discovery of a scaleable manufacturing process for amideplase, based on Prometic's Mimetic Ligand- technology; amideplase manufactured by this process is expected to be used in the phase III studies.