Controlled trial of high- versus low-dose aspirin treatment after percutaneous transluminal angioplasty in patients with peripheral vascular disease.

Percutaneous transluminal angioplasty of aortoiliac and femoropopliteal atherosclerotic lesions can provide long-lasting hemodynamic improvement. High-dose aspirin is commonly prescribed as reocclusion prophylaxis, but low doses would be preferable because of fewer adverse effects. We performed a double-blind, randomized, controlled clinical trial in patients with peripheral vascular disease with lesions appropriate for angioplasty. We compared the efficacy and side effects of two doses of aspirin (50 mg vs. 900 mg daily) during a period of 12 months after angioplasty. A total of 359 patients were evaluated: 175 were randomly assigned to treatment with 900 mg aspirin daily and 184 to 50 mg aspirin daily. Thirty-nine patients developed restenosis at the angioplasty site; the cumulative percentage of event-free survival after 1 year (patency rate) was 85% in 900 mg group and 84% in 50 mg group. An equivalence test showed the two groups equivalent with respect to restenosis rates (P = 0.0003 for an equivalence region of < 10% difference. Nine patients (5%) in the 900 mg group had serious gastrointestinal side effects (peptic ulcer, 8; erosive gastritis requiring transfusion, 1) compared to two ( peptic ulcer) in the 50 mg group (P = 0.03). The results of our study show that a dose of 50 mg aspirin a day is as effective as 900 mg for the prevention of restenoses after lower limb angioplasty, and that severe gastrointestinal side effects are less frequent.

[Assisted communication]. / Vermittelte Kommunikation.

The basic rules of communication are discussed in order to find out whether communication is also possible via technical media, such as audiovisual conferences, and via the dissimination of data in printed media. With some restrictions audiovisual media may be helpful as a means of communication as they allow a detailed discussion over the individual patient and his particular problem. Printed media are helpful as a means of communication if the information given there is discussed with those colleagues who are familiar with the patient in order to establish whether it can be applied in this particular case. If this information cannot be applied because of a problem between the doctor and his patient, a discussion in a Balint-group may be helpful.

[Language use in medicine]. / Sprachgebrauch in der Medizin.

Language is a main constituent of communication. To understand its signs it is necessary for doctors to use different codes depending on whether they communicate with each other, with their patients, or outsiders. Such codes are every day language, technical language, scientific language and language to the knowledge of different groups of non-specialists.

[Dose-dependent side effects of acetylsalicylic acid therapy. Results of a prospective randomized clinical study in patients with peripheral arterial occlusive disease]. / Dosisabhängige Nebenwirkungen der Acetylsalicylsäuretherapie. Ergebnisse einer prospektiven, randomisierten klinischen Studie bei Patienten mit peripherer arterieller Verschlusskrankheit.

BACKGROUND AND METHODS: In 359 patients with peripheral arterial occlusive disease who had undergone percutaneous transluminal angioplasty (PTA), a randomized double-blind, controlled clinical study was done to investigate the tolerability of acetyl salicylic acid (ASA) given for reocclusion prophylaxis. A comparison was made between a conventional daily dose of 900 mg ASA and a dose of 50 mg ASA. RESULTS: Within an observation period of one year following PTA, 35 patients (20%) in the 900 mg group, and 32 patients (17%) in the 50 mg group left the trial because of side effects (p = NS). Under the higher dose, however, severe gastrointestinal side effects (ulcer, haemorrhagic gastritis requiring transfusion) were significantly more common (nine patients delta 5.1% vs two patients delta 1.1%, respectively; p = 0.03). Overall, 107 patients (30%) reported subjective side effects such as upper abdominal pain, a sensation of fullness or nausea during the course of the trial. 62 of these patients were from the 900 mg group (35%) as compared with 45 patients (24%) in the 50 mg group (p = 0.02). Self-scoring of epigastric pain on the basis of a visual analogue scale revealed a score of 1.3 (95% confidence interval 0.9 to 1.6) in the 900 mg group and 0.8 (95% confidence interval 0.6 to 1.0) in the 50 mg group. The subjective pain intensity showed a uniform time course for all three types of symptom, with a maximum after three months. CONCLUSION: Our results confirm the superior tolerability of the lower dose, in particular in elderly patients. For long-term treatment, the smallest possible effective dose should be chosen.

Granulocyte colony-stimulating factor enhances the expression of CD62 on platelets in vivo.

The expression of CD41, CD42 and CD62 on platelets was determined in ten patients with and without G-CSF treatment. CD41 and CD42 is expressed in nearly 100% of the platelets without change after G-CSF treatment. The expression of CD62 on the platelets' surface is significantly enhanced by G-CSF indicating a depletion of the alpha-granules. No platelet aggregation was observed. The enhanced secretion of thrombocyte-specific proteins does not induce aggregation but may promote ADP-induced aggregation. Furthermore, the surface-bound and soluble CD62 binds specifically to macrophages and endothelial cells and is involved in the regulation of inflammatory processes. Thus indirect mechanisms may supplement direct effects of G-CSF after chemotherapy.

Effect of recombinant human granulocyte colony-stimulating factor (rhG-CSF) on circulating platelets.

The effect on platelets of rhG-CSF was studied in 20 healthy volunteers with the thrombometer, a specially developed device which is described in detail. Additionally, conventional aggregation tests were performed. Low doses of rhG-CSF enhance functional platelet activity, as shown by significant acceleration of the occlusion of the thrombometer channel. Similar results were found in conventional aggregation tests utilizing collagen for induction. At G-CSF concentrations of 0.1 and 1.0 ng/ml the time to response was significantly accelerated and the maximum response was observed in a higher proportion of platelets. However, the second phase of aggregation induced by epinephrine was significantly inhibited by 1.0 ng/ml G-CSF. The activation of platelets may be beneficial in thrombocytopenia, but it may also increase platelet turnover and platelet loss. Further investigation is needed to clarify the mechanism by which G-CSF exerts its effects on platelets.

[Thrombocyte function and thrombocyte-associated immunoglobulins in patients with systemic lupus erythematosus and chronic polyarthritis]. / Thrombozytenfunktion und Thrombozyten-assoziierte Immunglobuline bei Patienten mit systemischem Lupus erythematodes und chronischer Polyarthritis.

The investigation of in vitro platelet functions from patients with SLE and rheumatoid arthritis (RA) revealed a distinctly reduced aggregation mass after both collagen und ADP induction. The platelet serotonin contents were significantly decreased in both groups. An "aspirin-like" platelet defect could be excluded by finding a normal malonyldialdehyde release of patients' platelets upon thrombin stimulation. Significantly increased platelet associated IgG was also detected, whereas platelet associated IgM remained within normal limits. These results are interpreted as indicating an ongoing platelet release reaction induced by IgG platelet antibodies, which induce the observed impairment of platelet functions and may also lead to the release of proinflammatory platelet mediators.

[The induction of an acquired storage pool deficiency of the thrombocytes by IgG antibodies in systemic lupus erythematosus and chronic polyarthritis]. / Induktion einer 'acquired storage pool deficiency' der Thrombozyten durch IgG-Autoantikörper bei systemischem Lupus erythematodes und chronischer Polyarthritis.

Sera of patients with RA and SLE contain platelet-reactive IgG antibodies, which bring about the release of serotonin from platelets. They can also induce the aggregation of normal human platelets. In addition, such antibodies cause a decreased in vitro disaggregation of platelets after ADP exposure, as well as a significantly reduced collagen-induced aggregation. Thus, IgG platelet antibodies in RA and SLE can cause a functional impairment of patients' platelets, and may also be instrumental in systemic inflammatory rheumatoid disease by releasing proinflammatory mediators.

[Significance of thrombocyte-collagen interaction in arterial laceration]. / Bedeutung der Thrombozyten-Kollagen-Interaktion bei Arterienzerreissung.

The interaction of platelets with the extracellular matrix (i.e., collagen) has been the subject of intensive research in the past 25 years. With today's knowledge it is possible to explain why blood loss is minimal in cases of arterial rupture. As discussed earlier, a direct interaction of platelets with collagen was suspected for cellular thrombogenesis in arterial injuries. The first step in this interaction is a loose adhesion of platelets onto mature collagen with activation of the platelets. This is followed by aggregation and activation of the platelets through adhesins, which interact with special glycoproteins of the platelet's surface. At the same time, fibrinogenesis is started and facilitated by expression of platelet-factor 3 from the membrane surface of the platelet, so the production of thrombin is acclerated. The activation of platelets induces mobilization of calcium from the dense tubular system, which is needed for almost all reactions in arterial thrombogenesis. Exogene and platelet-endogene factors are responsible for the platelet activation. The further activation of platelets is maintained by thromboxane A2 and thrombin. The regulation of platelet aggregation is controlled by cAMP and prostacyclin. These well-documented findings are the reason for the very rapid arterial thrombogenesis in cases of arterial rupture combined with a special "fingertrap mechanism" of the scissorlike structure of the adventitia. Therefore, severe hemorrhage is prevented. Even in microvascular lesions the platelet-collagen interaction will be found, so this mechanism must also be considered in the pathophysiology of traumatic compartment syndrome and lung contusion.

[Comparison of thrombocyte concentrates of the cell separator AS 104 with preparations of the cell separator CS 3000 (Fenwal)]. / Vergleich der Thrombozytenkonzentrate des Zellseparators AS 104 (Fresenius) mit Präparaten des Zellseparators CS 3000 (Fenwal).

Platelet concentrates of the cell separator AS 104 (Fresenius) are compared with those of the cell separator CS 3000 (Fenwal). At each cell separator two platelet preparation protocols and at CS 3000 additionally a WBC preparation protocol was analysed. Platelet counts before and after cellapheresis as well as separation efficiencies show no significant differences between the separation protocols (A, B) and the two cell separators. Platelets of varying volumes show different separation efficiencies. While in WBC concentrates the separation efficiencies of platelets continuously increase from small (2fl) to large (20 fl) platelets, the efficiencies in platelet concentrates decrease in volume range 2 fl-8 fl, and increase in range 8 fl-20 fl. There are no differences between the cell separators. The efficiencies of platelets with 2 fl and 4 fl volumes differ significantly (p less than 0.001) between the protocols A and B of AS 104. After WBC-donation, platelet loss of donors corresponds with platelet yields of the concentrates for the platelet volume range 2 fl-20 fl. Compared with the calculated platelet loss of donors after platelet donation more small platelets with 2 fl-8 fl volumes are found in platelet concentrates. The yields of platelets with 10 fl-20 fl volumes are in accordance with donor's platelet loss.

Antiplatelet drugs or dicoumarol: what is the most effective prophylaxis in occlusive arterial disease?

Arterial thromboses lead to disturbances of vital function: myocardial infarction, ischemic cerebral infarction, disorders of peripheral blood flow, nephrosclerosis. Prophylaxis of thrombosis is still an unsolved problem, since diseases caused by thrombosis remain the first cause of death, at least in Western countries. After describing the pathomorphological and pathobiochemical findings, a survey of the literature on prophylaxis of occlusive arterial diseases is presented and the difference between anticoagulants and aggregation inhibitors is pointed out.

Psychotherapeutic interventions in alexithymic patients. With special regard to ulcerative colitis and Crohn patients.

Starting from the psychosomatic patients in clinico-medical wards and the inherent two primary alexithymic features "highly limited introspective capacity' and "very low motivation concerning dynamic psychotherapy', which we proved empirically, we describe the therapist's attitude and the three steps of supportive psychotherapy which initially represent the most indicated procedure in this patient group. In Hannover, this supportive psychotherapeutic procedure is applied by student auxiliary therapists. On the basis of our empirical findings, the effectivity of supportive psychotherapy, accomplished by students, in the alexithymic psychosomatic clinico-medical inpatients could be clearly demonstrated. Furthermore, we comment on some previous psychotherapeutic findings with regard to Crohn patients. Starting from our pretreatment and our follow-up measurements, we were able to prove that patients who were treated by both supportive psychotherapy and psychoanalytically orientated inpatient ward psychotherapy, showed remarkable improvements at all levels of the measurement techniques. Finally, we outline some clinico-psychosomatic aspects with regard to secondary alexithymia.

The Hannover Consultation Liaison model: some empirical findings.

Starting from the definitions concerning the concepts 'Liaison medicine' and 'Consultative Psychiatry' we begin with remarks with regard to the Consultation Liaison-Situation in West Germany on the basis of the key-words 'Brief history', 'Independent university units with regard to Psychotherapy and Psychosomatics as well as the connected organization' and 'Teaching procedures'. Following it the Hannover Consultation Liaison model is presented particularly with regard to both the psychosomatic inpatient ward including the functional organization and psychotherapeutic processes as well as the so-called 'Innere Ambulanz' which includes the consultation liaison services in the clinico-medical departments outside Psychiatry and Psychosomatics. Within the 'Innere Ambulanz', which is closely connected to our psychosomatic inpatient ward, the consultation liaison activities and the resulting supportive psychotherapeutic strategies are performed by student auxiliary therapists who are interested in completing their 4-5 months internship-time in our department. We describe both the three supportive psychotherapeutic steps, which may last months to years including subsequent dynamically psychotherapeutic strategies as well as the reactions of the auxiliary therapist function on the students. Furthermore, we may state that there exists no one more optional education procedure of graduate students than the student's confrontation with his partial self-responsibility vis-à-vis a patient who is being supportive-psychotherapeutically treated by him. Specific empirical proofs concerning our patient oriented consultation liaison activities are demonstrated on the basis of previous psychotherapeutic findings in Crohn patients. Here we are able to demonstrate the effectivity of psychotherapy in the case of the supplementarily psychotherapeutically treated patients in comparison to the patients who received medical therapy only. Finally we are able to present quantitative clinico-medical inpatient needs with regard to consultation liaison activities starting from our 'Innere Ambulanz'. On the basis of our conservative estimate, 31-42% of patients showed severe psychosomatic or psychic symptoms who should be treated by psychological means in addition to the medical treatment.

[Methotrexate resistance in acute lymphatic leukemia treated intrathecally]. / Methotrexat-Resistenz bei intrathekal behandelter akuter lymphatischer Leukamie.

During intrathecal methotrexate therapy of meningeal manifestations of acute lymphatic leukemia, renewed occurrence of lymphoblasts in the cerebrospinal fluid cell picture developed in two women. Prompt clearance could be attained by application of cytosine arabinoside. Methotrexate-resistance as one reason is discussed. The value of differentiated cerebrospinal fluid cell investigations for diagnosis and treatment of meningeal leukemia is pointed out. Neuralgic pain syndrome due to neoplastic neuropathy by direct infiltration of peripheral nerves are discussed, therapeutic measures pointed out.

[Problems of haemostasis in patients with dialysis for terminal renal insufficiency (author's transl)]. / Hämostaseprobleme bei Dialysepatienten.

This review deals with the pathophysiology of thrombus formation on foreign surfaces. The partners of this reaction (thrombocytes, vessel wall, foreign surfaces respectively) are discussed in detail also the haemostasiological problems of dialysators. The administering of low-dose heparin is recommended.

Spontaneous cell-mediated cytotoxicity (SCMC) associated with lymphocytes negative for acid alpha-naphthyl acetate esterase (ANAE) activity.

A modified histochemical procedure for nonspecific acid alpha-naphthyl acetate esterase (ANAE) activity in human lymphocytes was used to identify a subpopulation of E-rosette forming cells. Performing a one hour reaction at pH 6.5 the distinct dot-like staining pattern was almost exclusively observed on high affinity E-rosettes which sedimented readily in a regular Ficoll-Metrizoate gradient. By combining latex phagocytosis with staining for ANAE activity, a clear-cut distinction between mononuclear phagocytes and lymphocytes could be made. An attempt was undertaken to relate the ANAE marker on human lymphocytes to their functional capacity in spontaneous cell-mediated cytotoxicity (SCMC) reactions. Using as targets two allogeneic (K562,IGR3) and a xenogeneic cell line (L1210) it could be clearly demonstrated that high SCMC activity is mediated by ANAE negative mononuclear cells, whereas enrichment for ANAE positive lymphocytes resulted in a loss of SCMC.