Coagulation Studies after Administration of a Fat Emulsion, Intralipid®

A single infusion of a fat emulsion, Intralipid®, used for parenteral nutrition was given to 11 healthy normals, 3 patients with von Willebrand’s disease and 3 with mild or moderately severe thrombasthenia. The infusion had no effect on coagulation or the fibrinolytic system. Platelet adhesiveness, as determined with Hellem’s whole blood method, was markedly increased but not with his plasma-ADP method or with Salzman’s method. No shortening of the bleeding time was observed in the normals or in the patients with prolonged bleeding time. The change observed in platelet adhesiveness is therefore believed to be an in vitro artefact with no clinical relevance.

Demonstration of a Plasmatic Cofactor Different from Fibrinogen Necessary for Platelet Release by ADP and Adrenaline

Secondary wave production and release of platelet factor 4 were studied in washed platelet suspensions and citrate plasma. Induction of a secondary wave requires the presence of large aggregates and a plasmatic cofactor different from fibrinogen. Acetyl-salicylic acid inhibited the production of a second wave both in plasma and platelet suspensions. Plasma taken after the intake of acetyl-salicylic acid induced a second wave in platelets harvested before the intake. The possible production of thrombin or allied enzyme inside the platelet aggregates due to changed internal milieu is suggested as a possible cause of the release reaction induced by ADP and adrenaline. Fundamental differences existed between the release induced by ADP and adrenaline and that induced by collagen, kaolin and other particles.

γ M Globulin and Thrombasthenie Platelets

In the contrary to previous findings (3), it was not found any evident differences in the content of γ-M globulins between thrombastheniec and normal platelets.

Mg++ - and Ca++-Induced Platelet Aggregation and ADP

Reports on platelet aggregation after addition of calcium or magnesium to EDTA- PRP or platelet suspensions were confirmed. An aggregating principle was found in the EDTA-plasma and the supernatant of the platelet suspensions. Aggregation by magnesium in a platelet suspension was inhibited by adenosine and phosphoenol- pyruvic acid and pyruvate kinase, which suggested that the active principle was identical with ADP. Degradation of ADP in EDTA plasma was blocked.

It thus appears that aggregation induced by calcium or magnesium in EDTA-PRP and platelet suspension was due to accumulation of spontaneously liberated ADP, which was not degraded.

Effect of Fibrinolysis on Adhesion and Aggregation of Human Platelets

Streptokinase was infused in 7 patients with venous thrombosis. The bleeding time remained unchanged or slightly prolonged and the number of platelets did not decrease. As studied by photometric technique, platelet aggregation after addition of ADP or connective tissue suspension was not consistently changed. Platelet adhesiveness, as tested with Hellem’s whole blood method, was decreased. The platelets showed decreased adhesion and spreading on a glass slide.

Addition of streptokinase in vitro to citrated platelet rich plasma in doses of 1,600–7,000 u/ml caused a release reaction after 2–3 min, and the platelets aggregated. Incubation with urokinase impaired adhesion to glass and spreading and slightly diminished aggregation by ADP or connective tissue suspension.

Purified split products of D, E or high molecular type in final concentrations of 0.1–2.0 mg/ml did not aggregate platelets or influence aggregation by ADP or connective tissue suspension. A slightly decreased adhesion to glass and spreading occurred only when the doses used were large.

The implications of the multifacetted findings are discussed.

Suppressive Effect of Dextran on Platelet Adhesiveness

43 normal volunteers, 3 patients with thrombophlebitis, and 1 patient with a high platelet adhesiveness and a history of thrombophlebitis have received dextran and its action on the mechanism of haemostasis has been studied. Platelet adhesiveness has been investigated by a slight modification of Hellem’s methods for whole blood and plasma. Dextran with a mean molecular weight of 70,000 produced a markedly lowered platelet adhesiveness together with a moderate prolongation of the Ivy bleeding time. Factor VIII was decreased by about 50% and factor V, factor IX and fibrinogen were decreased slightly more than could be expected from haemodilution alone. No fibrinolysis occurred. Dextran of lower molecular size was less potent. The possible use of dextrans as a thrombosis prophylactic agent is discussed.

Clinical aspects on 64 cases of juvenile and adult listeriosis in Sweden

In 1958-74 altogether 64 cases of bacteriologically verified infections of Listeria monocytogenes were diagnosed in Sweden in children, aged more than 27 days, and in adults. Immunosuppression predisposed to the disease. Thus, many patients had co-existing disorders, such as leukemia and alcoholism. Sixteen patients had been treated with corticosteroids, which were combined with cytostatic drugs in nine. Meningoencephalitis was diagnosed in 52 patients and was fatal in 16. The clinical symptoms did not differ from those in purulent meningitis caused by other bacteria. In the cerebrospinal fluid the cellular response was dominated by polymorphonuclear cells in 29 patients and by mononuclear cells in 20. Ten patients had septicemia, which was fatal in four. Clinical symptoms were dominated by chills, high fever and general prostration. One patient had pleurisy and one an abscess of the neck; both recovered. Serotypes 1 and 4b prevailed and were equally common. Many patients developed raised antibody titers in both the O-agglutination test and the complement fixation test. The titers were often not positive until after a month. Moderate granulocytosis was the rule and monocytosis was rarely seen. Ampicillin alone or combined with an aminoglycoside seemed to be the drug of choice in the treatment of listeriosis. An alternative drug was tetracycline. Most deaths occurred within six days of onset of the illness. Early diagnosis and treatment were imperative. Most patients recovered and serious sequelae were rare.

ADP-induced platelet aggregation in young female survivors of acute myocardial infarction and their female controls

Adenosine diphosphate (ADP)-induced platelet aggregation was studied in 35 young female survivors of acute myocardial infarction (AMI) 14-46 (median 30) months after the infarction. The results were compared to those obtained for 35 control females of comparable age. Five different final ADP concentrations (0.2-1.0 microM) were employed, and the object was to assess the slope for the primary wave of aggregation as well as the threshold ADP concentration for secondary aggregation. The results showed that AMI patients and control subjects did not differ with respect to the primary wave of aggregation. However, secondary platelet aggregation was recorded to a significantly higher extent (p less than 0.02) in AMI patients than in their controls. The results therefore support the concept that enhanced platelet reactivity is present in patients with documented ischemic heart disease.

Low specificity of the 125I-fibrinogen uptake test for the diagnosis of deep vein thrombosis in patients with erysipelas of the leg

The 125I-fibrinogen test was evaluated as a diagnostic tool for deep vein thrombosis in patients with erysipelas. In the investigated group of 43 patients, several showed an increased uptake that could not be verified by subsequent phlebography. The false positive test may have been caused by the local inflammatory process. The 125I-fibrinogen test seems to be too unspecific to be used for diagnosing deep vein thrombosis in this patient group.

Failure of excessive doses of ampicillin to prevent bacterial relapse in the treatment of acute pyelonephritis

In order to evaluate whether very high doses of ampicillin might be more effective than conventional therapy in eradicating bacteria in patients with acute pyelonephritis, 34 affected patients were randomly assigned into two treatment groups. One group was given ampicillin in a daily dose of 30 g for three days and 20 g for four days without further treatment. The other group was given ampicillin in moderate doses for one month. Out of 13 patients treated with excessive doses for one week, only three were completely cured whereas conventional therapy cured 9 out of 21. Thus, excessive doses of ampicillin given for one week were not more effective but more expensive and possibly less beneficial than conventional therapy.

Fewer bacterial relapses after oral treatment with norfloxacin than with ceftibuten in acute pyelonephritis initially treated with intravenous cefuroxime

This double-blind, multicentre study was performed at nine centres on a total of 171 patients who presented with fever (> 38.5 degrees C) and signs of acute pyelonephritis. All were initially treated with intravenous cefuroxime. After 2-3 d, when the fever had subsided and urinary culture had revealed growth of Gram-negative bacteria ( > 10(7) colony-forming units per litre), treatment was changed to oral administration of ceftibuten 200 mg b.i.d. or norfloxacin 400 mg b.i.d. for 10 d. The patients were followed for signs of bacterial or clinical relapse 7-14 d after the end of treatment. The initial clinical and bacteriological cure was excellent in both groups, but there were significantly fewer bacterial relapses after oral treatment with norfloxacin than with ceftibuten in acute febrile pyelonephritis initially treated with intravenous cefuroxime. The causal strain was eradicated in 75% of patients (73% of males, 76% of females) in the ceftibuten group and in 89% of patients (94% of males, 85% of females) in the norfloxacin group. The relative frequency of eradication was 0.84 (p < 0.05; 95%, confidence interval 0.74-0.97). Adverse events were reported by 47% of the patients in the ceftibuten group and by 38% in the norfloxacin group. This difference was not significant, but diarrhoea or loose stools occurred more frequently in the ceftibuten group.

[Vicar's daughter died of cholera after drinking salt sea water]

In 1850 a vicar's daughter wanted to cure her lymphadenitis by health sea baths and drinking strengthening salt sea water. In the morning of the eleventh of August she took a bath and emptied three glass of salt sea water. At about 3 hours P.M. she fell ill with intensive watery diarrhoea and died on the following morning at 8 o'clock. Within one month 9 per cent of the population in the port of Malmo fell ill with cholera which killed every third of those affected. Necropsies were performed on some cases but did not reveal any remarkable changes. At the same time cholera attacked Lubeck and other ports of the Baltic sea. The sudden onset and the failure of quarantine precautions suggested intoxication of miasmic orgin. Thus the Swedish Medical Health authorities concluded that the disease was caused by atmospheric and telluric disturbances. Representatives of the Church opposed and considered that the disease was contagious. In 1883 Robert Koch discovered the cholera vibrion. Since then cholera has been considered as an intestinal infection. Cholera was supposed to affect only man, because it was not possible to transfer it to animals. Max von Pettenkofer disapproved the idea of contagiosity. He ingested cholera vibrions without falling ill. Recent findings have confirmed that there is need for at least one hundred billion of vibrions to cause clinical symptoms, whereas only 25 microgram of the toxin is required to produce intensive diarrhoea. Unlike true enteric bacteria, the cholera vibrions prefer aerobic conditions. They do not invade the tissues, and unlike dysentery, cholera disease does not induce inflammatory reactions. In 1855 John Snow proved that cholera was spread by water. All cholera outbreaks in Sweden have been associated with sea ports or inland seaways. Recent investigations have revealed that cholera vibrions are free-living planktonic organisms in sea water in many parts of the world. Human activities may help to spread the vibrions. Man is attacked by their toxin, but the infection takes place in the sea water rather than in the human gut. This is well illustrated by the present sad case report which was described without comments in the contemporary official medical report.

[Refugees at Malmö Epidemic Hospital in 1945]

In 1945, 423 refugees were admitted because of contagious disease at Malmö Epidemic Hospital. Of these refugees 159 men and 167 women arrived from the German concentration camps in Ravensbrück, Buchenwald, Bergen-Belsen, Neuengamme and others. Others arrived in a boat destined to be sunk when peace came and the crew changed mind, letting the boat board at Malmö harbour. Thus life was saved to more than 95% of its passengers. Of the refugees 31% came from Poland, 24% from Scandinavian countries, 12% from Benelux and 10% from France. Louse-borne typhus was the most frequent diagnosis that occurred in 35%. Other common disorders were diphtheria, scarlet fever, enteric fever and tuberculosis. Almost all prisoners from concentration camps were malnourished and had sustained severe cruelty. Most of them recovered rapidly when given food and vitamins.

Influence of teniposide on platelet functions in vitro

Teniposide added to citrated platelet-rich plasma reduced platelet aggregation induced by collagen, but did not interfere with ADP-induced aggregation. The availability of platelet factor 3 was decreased irrespective of inducer. Reptilase clot retraction induced by ADP or collagen was reduced. Teniposide did not interfere with platelet adhesion to glass. It did not release lactic dehydrogenase from the cytoplasm of platelets. Coagulation factors were not affected.

Ampicillin plus mecillinam vs. cefotaxime/cefadroxil treatment of patients with severe pneumonia or pyelonephritis: a double-blind multicentre study evaluated by intention-to-treat analysis

In this double-blind multicentre study, using the intention-to-treat approach, a total of 293 patients with fever (> or = 38.5 degrees C), symptoms of sepsis and signs of pneumonia or pyelonephritis were randomly assigned to treatment with ampicillin and mecillinam (A+M) or cefotaxime followed by cefadroxil. In the febrile phase, treatment was given intravenously twice daily, either with 1,200 mg ampicillin together with 600 mg mecillinam or with 2 g cefotaxime alone. When the patients stayed afebrile, the intravenous administration was replaced by oral treatment twice daily for 14 days, either with 500 mg pivampicillin and 400 mg pivmecillinam or 1 g cefadroxil. In the A+M group, 33% (48/144) of the patients did not complete the full course of treatment as compared with 32% (47/149) in the cephalosporin group, the reasons being treatment failure in 27 and 29, respectively, or adverse effects (n = 16 in both groups). The median duration of fever was 47 h in the A + M group and 50 h in the cephalosporin group. Of 135 patients with pneumonia, 68% were completely cured in the A + M group, and 65% in the cephalosporin group, the main reasons for treatment failure being Mycoplasma pneumonia or ornithosis. Of 136 patients with pyelonephritis, 63% were cured in each group. The main reason for failure was bacteriological relapse. Side-effects were reported by 32 patients (22%) of the A+M group, as compared with 41 (28%) of the cephalosporin group. Epigastric complaints were equally frequent in both groups, but there was a tendency for a higher frequency of exanthema in the A+M group, and for antibiotic-associated diarrhoea and fungal superinfections in the cephalosporin group.

Simplified monitoring of aminoglycosides

For many years it has been standard practice to give aminoglycosides in divided daily doses monitored by serum aminoglycoside assays. Recent experience indicates that aminoglycosides can be given as a single daily dose with equal or better efficacy and equal or less toxicity. The single-daily dose regimen is both cheaper and more convenient. Recommended serum aminoglycoside concentrations immediately before the next dose, or 8 h later, vary according to whether a single daily dose or divided dose schedule is used. This is seldom realized in practice. Estimated creatinine clearance enables better prediction of the daily dose than was formerly recognized, and is to be preferred. Earlier fears of giving aminoglycosides as a bolus intravenous injection have not been substantiated. After more than 40 years of use, we are beginning to learn how to monitor these potentially toxic drugs.

The rise and fall of sexually transmitted diseases in Sweden

Syphilis appeared in Sweden in 1497. It was recognized as a sexually transmitted disease that rapidly spread in the upper classes and later to the poor. It ravaged the country in the eighteenth and nineteenth centuries. At that time the concept of venereal disease included all sexually transmitted diseases. Preventive measures were introduced. They were based on information, medical intervention and elimination of risk factors. Registration of hospitalised patients was introduced in the eighteenth century. The highest incidence of syphilis occurred during the First World War. In the last decade the incidence of sexually transmitted disorders has abruptly decreased. Thus the yearly incidence of gonorrhoea has decreased from 40,000 to 500 cases. The law demands contact tracing with obligatory testing. People who deliberately expose others to risk may be condemned to isolation for an unrestricted time. This legislation has probably contributed less to the successful containment than the fact that information on aids and sexually transmitted diseases has reached all the population, and made it aware of the risks and produced changed behaviour, especially among prostitutes, homosexual men and drug addicts.

Prediction of creatinine clearance by several methods in patients with severe infections

Since almost all urinary creatinine is derived from the muscle mass, the amount of creatinine in the urine will be proportional to muscle mass, and it will show an almost constant decrease with age. A simple equation for estimating creatinine clearance has been derived. For women the creatinine clearance (ml.min-1) was [150-(years)].body weight (kg)/serum creatinine (mumol.l-1). For men less than 70 years it was [170-age (years)].body weight (kg)/serum creatinine (mumol/l) and for men greater than or equal to 70 years it was [160-age (years)].body weight (kg)/serum creatinine (mumol/l). The prediction was quite simple when laboratory results were given in SI units. A simple nomogram was devised for easy estimation of the creatinine clearance in individual patients according to the age, sex and weight. Predicted values according to our equations were compared with those derived from other formulae in 54 patients with severe infections treated with aminoglycosides. No major differences were found, but the new method seemed more convenient.

Does administration of an aminoglycoside in a single daily dose affect its efficacy and toxicity?

Treatment efficacy, oto- and nephrotoxicity, and aminoglycoside pharmacokinetics were evaluated in a prospective, comparative, randomized clinical study of aminoglycosides given once a day or three times a day for severe infections. Sixty patients were treated with netilmicin or gentamicin 4.5 mg/kg bodyweight/day, either once a day or divided into three doses a day. The patients were allocated randomly to the different groups. The clinical effect was difficult to compare in the different groups, because of the small numbers of patients. Therapeutic failures were seen in seven patients (three after one and four after three doses per day). Two patients, one with Staphylococcus aureus endocarditis and one with streptococcal endocarditis, on netilmicin once daily and conventional high-dose therapy with a penicillin had positive blood cultures after five and seven days of treatment, respectively. Vestibular function and hearing acuity were examined by serial audiograms and electronystagmograms. In spite of extensive diagnostic evaluation, only two cases of ototoxicity were detected. One patient treated with gentamicin three times a day developed vertigo and a severe abnormality of her electronystagmogram. One young patient treated with gentamicin once daily had a slight bilateral reduction of hearing. Nephrotoxicity was mild and did not differ in the four treatment groups. This was the first investigation of a once-daily dosing regimen conducted in seriously ill patients with systemic infections. We could not demonstrate any evidence that aminoglycoside treatment once daily has greater oto- or nephrotoxicity than the traditional three times daily regimen.

Frequency of thromboembolic complications in patients with acute pneumonia and pyelonephritis

Infectious complications increase the risk of postoperative thromboembolism. In order to assess the risk of deep vein thrombosis (DVT) in acute infections not associated with surgery, 36 patients with acute pneumonia or pyelonephritis were evaluated regarding development of DVT with the 125I-fibrinogen uptake test with confirmative phlebography. 1/15 patients with pyelonephritis and 1/21 patients with pneumonia developed DVT. No fatal pulmonary embolism was seen. The frequency of DVT was thus 6%. This low figure may be due to early mobilization of the patients and does not motivate routine anticoagulant prophylaxis against thromboembolic complications in patients with acute infections.

Prevention of recurrent acute cystitis by methenamine hippurate: double blind controlled crossover long term study

In a randomised, double blind, long term, crossover study 1 g twice daily of methenamine hippurate was compared with placebo for its preventive effect on recurrent attacks of acute cystitis. Methenamine hippurate and placebo were interchanged every six months for two years. During one of the years patients took 250 ml extra fluid every morning and evening. Out of 21 enrolled patients, 14 completed the first year and 13 both years of treatment, which permitted the evaluation of 27 patient years. There were 52 episodes of acute cystitis caused by reinfection: 41 occurred during placebo treatment and only 11 during the methenamine hippurate regimen (p less than 0.01). Extra fluid intake did not reduce the incidence of acute cystitis, nor did it reduce the effect of methenamine hippurate. Methenamine hippurate is an effective prophylactic agent against recurrent acute cystitis and has the advantage of not inducing cross resistance to conventional antibiotics.

NonHodgkin's lymphoma of the female urethra

A 63-year-old woman presented with a massive proliferative growth in the urethral region. Fine needle aspiration and biopsy revealed nonHodgkin's lymphoma. No other tumor localization was found and complete remission occurred after 3 courses of chemotherapy. Primary localization of a lymphoma to the urethra is rare.

Apolipoprotein B and platelet function in diabetes mellitus

Serum levels of apolipoprotein B were measured, and investigations of the platelet function were carried out in 32 patients with insulin-dependent diabetes and in 34 healthy controls similar in age. Mean serum levels of apolipoprotein B were 1.51 g/l in the diabetic patients and 1.18 g/l in the control group, and this difference was significant. In the diabetic patients a secondary wave of aggregation was more easily induced by low concentrations of adenosine diphosphate or adrenaline. It was also possible to induce 50% of maximal aggregation by lower concentrations of adenosine diphosphate or arachidonic acid in these patients, and their number of circulating platelet aggregates increased. Plasma levels of beta-thromboglobulin and platelet factor 4 were raised and, in the presence of N-ethyl maleimide, platelets from diabetic patients produced significantly more malondialdehyde than those from normal controls. The relationship between increased serum levels of apolipoprotein B and platelet hyperreactivity may be more than accidental and should be studied further to elucidate its possible implication with platelet function and atherogenesis.

Relationship between platelet aggregation and plasma beta-thromboglobulin levels in arterio-vascular and renal diseases

The incidence of second wave of platelet aggregation induced by a small dose of ADP (1 mumol/l) was compared with plasma levels of beta-thromboglobulin in 81 normal individuals, 34 patients with acute myocardial infarction, 11 patients with acute cerebrovascular disease and 26 patients with renal disease. Platelet hyperaggregability was observed in 7% of normal individuals. Plasma levels of beta-thromboglobulin were higher in normal individuals over 60 years of age (48 vs. 32 micrograms/l). In contrast, hyperaggregability was observed in 79% of patients with acute myocardial infarction and in 64% of those with acute cerebrovascular disease. Median plasma levels of beta-thromboglobulin were also significantly elevated in patients with acute myocardial infarction (82 micrograms/ml) or acute cerebrovascular disease (99 micrograms/l). Levels of beta-thromboglobulin in plasma were significantly higher in those patients who demonstrated hyperaggregability. In patients with renal disease only 12% had signs of hyperaggregability. Nevertheless their plasma levels of beta-thromboglobulin were elevated (76 micrograms/l) and correlated with the serum creatinine values. These investigations indicate that patients with acute myocardial infarction or stroke have hyperreactive platelets and evidence of increased platelet inactivation in the circulation. However, evaluation of increased levels of beta-thromboglobulin requires consideration of renal function.

Hepatitis D (delta agent) in primary hepatocellular carcinoma and liver disease in Senegal

A total of 308 individuals belonging to ten different ethnic groups in Senegal were investigated. They suffered from primary hepatocellular carcinoma (PHC), liver cirrhosis, chronic hepatitis and other liver diseases, or were healthy controls. Their sera were investigated for the presence of markers of infection with hepatitis B and D (delta agent) virus. Out of 130 clinically diagnosed patients with PHC, 88 had alpha-fetoprotein levels above 100 micrograms/l, supporting the diagnosis. After clinical examination, 133 subjects were considered to be healthy or to have a liver disease other than PHC. Among these, 83 (31 clinically healthy and 52 with liver disease) had alpha-foetoprotein less than 15 micrograms/l and were therefore considered not to have PHC. Out of the 88 patients with definite PHC, 74% were positive for HBsAg, whereas out of the 83 subjects without PHC, 50% of those with other liver disease and 26% of the healthy controls were positive. Anti-delta was present in 21% of the patients with or without PHC. It was found in nine different ethnic groups in the country. The present data confirm that HBV is related to the etiology of PHC. The present investigation showed a high prevalence of delta antibodies in patients with PHC, but against the role of hepatitis D infection in the evolution of malignancy is the fact that it was equally common in chronic liver disease without evidence of carcinoma.

Effect on platelet aggregation of oral administration of 10 non-steroidal analgesics to humans

Platelet aggregation was investigated in platelet-rich plasma from normal volunteers before and at various times after intake of 10 analgesic drugs. The drugs used were aspirin, piroxicam, naproxen, indomethacin, diclofenac, ibuprofen, diflunisal, paracetamol and oxyphenbutazone. Aggregation of the platelets was induced by adrenaline or ADP and the first and second waves of aggregation were evaluated. It was found that no drug exerted any effect on the first wave of aggregation. The second wave of aggregation was abolished by aspirin that produced a long-lasting effect for 5-8 d. Piroxicam also abolished the second wave of aggregation and this effect persisted on the 2 following d. Naproxen was normalized in half of the volunteers on the 2nd d. The inhibition caused by indomethacin and diclofenac was corrected on the 2nd d. Ibuprofen and diflunisal produced a definite but short-term effect. The effect of salicylic acid was weak. Paracematol and oxyphenbutazone did not affect platelet aggregation.