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PubMed2003

Protein A immunoadsorption: a novel and effective adjuvant treatment of severe pemphigus.

BACKGROUND: Pemphigus foliaceus (PF) and pemphigus vulgaris (PV) are autoimmune blistering skin diseases usually treated with high-dose systemic corticosteroids and other immunosuppressants that may cause severe side-effects. Plasmapheresis also has been demonstrated to be of benefit in the treatment of pemphigus. In contrast to plasmapheresis, staphylococcal protein A immunoadsorption (PA-IA) specifically removes immunoglobulin from the circulation, allows treatment of larger plasma volumes, and does not require the substitution of plasma components. OBJECTIVES: To determine the effectiveness and side-effects of PA-IA in patients with severe pemphigus. METHODS: Five patients with severe pemphigus (PV, n = 4; PF, n = 1) were treated by PA-IA. Three of these patients had been refractory to various treatment regimens. In addition to PA-IA, methylprednisolone, 0.5 mg x kg-1 body weight day-1 was given initially and subsequently tapered. RESULTS: In all patients, a dramatic clinical improvement was seen within 2 weeks after initiation of therapy. Patients were free of lesions after 3, 4, 4, 10 and 21 weeks of treatment, respectively. Concurrently, autoantibody levels decreased rapidly. CONCLUSIONS: PA-IA is a rational, effective, and safe adjuvant therapy for severe pemphigus and warrants wider use for this indication. A controlled study should compare side-effects and effectiveness of PA-IA with other treatment options for pemphigus.

Adjuvants, Immunologic↗
PubMed1989

Salivary progesterone excellently reflects free and total progesterone in plasma during pregnancy.

To see if saliva is a valid substitute for plasma in assay of progesterone even when concentrations of hormone and binding proteins are fluctuating, we determined the concentrations of total and free progesterone in plasma and salivary progesterone in specimens from 36 women volunteers during the course of pregnancy and six weeks postpartum, using a highly specific RIA for total progesterone after extraction and chromatographic purification of the steroid. The free fraction in plasma was determined via equilibrium dialysis, followed by the same RIA analysis for progesterone in the dialysate. Despite the dramatic increases in concentrations of total progesterone and binding proteins in plasma during pregnancy, we found highly significant correlations between total and free progesterone in plasma and salivary progesterone in the group as a whole as well as individuals (P less than 0.001 in almost all cases). The proportion of free progesterone in plasma and of salivary progesterone relative to total progesterone in plasma remained constant at approximately 1% and 0.5%, respectively, whereas during the postpartum period there was much more variance. Evidently salivary progesterone is a very good alternative to plasma as a sample for use in follow-up during pregnancy.

Female↗
PubMed1995

Activation of endothelial cells by endotoxin: direct versus indirect pathways and the role of CD14.

Optimal activation of endothelial cells by nanomolar quantities of endotoxin (lipopolysaccharide, LPS) requires the presence of plasma or serum. We and others have demonstrated that soluble CD14 (sCD14) and LPS binding protein (LBP) were the key plasma proteins mediating endothelial cell responses to LPS. The role of LBP is to transfer LPS to sCD14 and newly formed LPS-sCD14 will in turn activate endothelial cells via an as yet unknown surface receptor. This plasma-dependent pathway of endothelial cells activation is referred as to the direct pathway. However, endothelial cells are in constant contact with whole blood and not only with plasma. In experiments where whole blood was substituted for plasma, we showed that endothelial cells became sensitive to picomolar, rather than nanomolar quantities of LPS. The fact that endothelial cell responses were amplified by the presence of whole blood prompted us to search for the responsible blood cell(s) and mediator(s) for this effect. Blood cell fractionation experiments, experiments with blood from PNH patients and the use of anti-CD14 antibodies pointed to the monocyte as the blood cell responsible for the amplification effect. Moreover, the blood effect could be entirely reproduced by cells from a CD14-expressing cell line, such as calcitriol-differentiated HL-60 cells. Inhibitors to TNF and to IL-1 blocked LPS-induced activation of endothelial cells partially when added separately to whole blood, but abrogated endothelial cell responses when added together. Thus, the whole blood effect begins with LPS activation of monocytes via cell membrane CD14 and results in endothelial cell activation by the effects of TNF and IL-1. The monokine-mediated endothelial cell activation is referred as to the indirect pathway.

Cells, Cultured↗
PubMed1995

[Treatment of acute loss of blood in major elective orthopedic surgery procedures].

Hypovolemia develops when volume of circulating fluid in the body during the surgical procedure and perioperative time is so depleted that effective tissue perfusion can not be maintained and generalized impairment of cellular function is possible. The study was designed to analyze, first, the perioperative acute blood loss in the course of implantation of hip endoprosthesis, and second, the prevention of hemorrhagic shock with regard to morbidity and mortality. In 35 patients, a total hip endoprosthesis was implanted in spinal anesthesia. Prior to surgery and three days following operation, hemoglobin, hematocrit, thrombocyte and APTV analysis was done. Further evaluation included assessment of blood loss during the operation and within 48 h after the surgical procedure until the drainage was removed. The results showed that during the first day postoperatively, the average hemoglobin level was -18 g/L and that of hematocrit -8 vol/% (20%) with fluid substitution by means of blood transfusion and plasma volume expanders (Soludex 1 and 70) maintaining normovolemia. 73% of the patients were given 1270 ml of red blood cells on the first day after the operation, and, on the third day postoperatively, blood transfusion of about 450 ml was administered to 36% of the patients. No functional organ failure was observed. We conclude that the most effective way of treating hypovolemic shock is by the rapid infusion of volume-expanding fluids. There is no optimal level of hematocrit in critically ill patients, so transfusion should be given on individual basis combined with adequate monitoring.

Adult↗
PubMed2001

Timing and volume of fluid administration for patients with bleeding following trauma.

BACKGROUND: Treatment of haemorrhagic shock involves maintaining blood pressure and tissue perfusion until bleeding is controlled. Different resuscitation strategies have been used to maintain the blood pressure in trauma patients until bleeding is controlled. However, while maintaining blood pressure may prevent shock, it may worsen bleeding. OBJECTIVES: To assess the effects of early versus delayed, and larger versus smaller volume of fluid administration in trauma patients with bleeding. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, the specialised register of the Injuries Group, MEDLINE, EMBASE, the National Research Register and the Science Citation Index. We checked reference lists of identified articles and contacted authors and experts in the field. SELECTION CRITERIA: Randomised trials of the timing and volume of intravenous fluid administration in trauma patients with bleeding. Trials in which different types of intravenous fluid were compared were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed trial quality. MAIN RESULTS: We did not combine the results quantitatively because the interventions and patient populations were so diverse. Early versus delayed fluid administration: Three trials reported mortality and two coagulation data. In the first trial (n=598) relative risk (RR) for death with early fluid administration was 1.26 (95% confidence interval of 1.00-1.58). The weighted mean differences (WMD) for prothrombin time and partial thromboplastin time were 2.7 (95% CI 0.9-4.5) and 4.3 (95% CI 1.74-6.9) seconds respectively. In the second trial (n=50) RR for death with early blood transfusion was 5.4 (95% CI 0.3-107.1). The WMD for partial thromboplastin time was 7.0 (95% CI 6.0-8.0) seconds. In the third trial (n=1309) RR for death with early fluid administration was 1.06 (95% CI 0.77-1.47). Larger versus smaller volume of fluid administration: Three trials reported mortality and one coagulation data. In the first trial (n=36) RR for death with a larger volume of fluid resuscitation was 0.80 (95% CI 0.28-22.29). Prothrombin time and Partial thromboplastin time were 14.8 and 47.3 seconds in those who received a larger volume of fluid as compared to 13.9 and 35.1 seconds in the comparison group. In the second trial (n=99) RR for death with a high (100 mm Hg) compared to low (70 mm Hg) systolic blood pressure resuscitation target was 1.02 (95% CI 0.27-3.85). In the third trial (n=25) there were no deaths. REVIEWER'S CONCLUSIONS: We found no evidence from randomised controlled trials to support early or larger volume of intravenous fluid administration in uncontrolled haemorrhage. There is continuing uncertainty about the best fluid administration strategy in bleeding trauma patients. Further randomised controlled trials are needed to establish the most effective fluid resuscitation strategy.

Hemorrhage↗
PubMed1995

Human albumin and colloid fluid replacement: their use in general surgery.

This review considers the pharmacology and indications for use of human albumin and synthetic colloids in general and transplantation surgery. The selection of a particular agent should be based on sound knowledge of their pharmacokinetic and pharmadynamic properties together with some consideration of cost. For correction of hypovolemia, human serum albumin solutions can adequately be replaced by present day colloids such as hydroxyethyl starch solutions. The duration of their effect in the intravascular space and their properties for plasma volume substitution or expansion are the main factors that will influence their selection. Albumin solutions, however, remain useful for treatment of all acute situations of hypovolemia accompanied by hypoalbuminemia during and after surgery.

Colloids↗
PubMed2000

Human albumin solution for resuscitation and volume expansion in critically ill patients. The Albumin Reviewers.

BACKGROUND: Human albumin solutions are used in a range of medical and surgical problems. Licensed indications are the emergency treatment of shock and other conditions where restoration of blood volume is urgent, burns, and hypoproteinaemia. Human albumin solutions are more expensive than other colloids and crystalloids. OBJECTIVES: To quantify the effect on mortality of human albumin and plasma protein fraction (PPF) administration in the management of critically ill patients. SEARCH STRATEGY: We searched the Cochrane Injuries Group trials register, Cochrane Controlled Trials Register, Medline, Embase and BIDS Index to Scientific and Technical Proceedings. Reference lists of trials and review articles were checked, and authors of identified trials were contacted. The search was last updated in November 1999. SELECTION CRITERIA: Randomised controlled trials comparing albumin/PPF with no albumin/PPF, or with a crystalloid solution, in critically ill patients with hypovolaemia, burns or hypoalbuminaemia. DATA COLLECTION AND ANALYSIS: We collected data on the participants, albumin solution used, mortality at the end of follow up, and quality of allocation concealment. Analysis was stratified according to patient type. We assessed publication bias using the regression test for funnel plot asymmetry. MAIN RESULTS: We found 30 trials meeting the inclusion criteria and reporting death as an outcome. There were 156 deaths among 1419 trial participants. For each patient category the risk of death in the albumin treated group was higher than in the comparison group. For hypovolaemia the relative risk of death following albumin administration was 1.46 (95% confidence interval 0.97 to 2.22), for burns the relative risk was 2.40 (1.11 to 5.19), and for hypoalbuminaemia the relative risk was 1.69 (1.07 to 2.67). The pooled relative risk of death with albumin administration was 1.68 (1.26 to 2.23). Overall, the risk of death in patients receiving albumin was 14% compared to 8% in the control groups, an increase in the risk of death of 6% (3% to 9%). These data suggest that for every 17 critically ill patients treated with albumin there is one additional death. REVIEWER'S CONCLUSIONS: There is no evidence that albumin administration reduces the risk of death in critically ill patients with hypovolaemia, burns or hypoalbuminaemia, and a strong suggestion that it may increase the risk of death. These data suggest that the use of human albumin in critically ill patients should be urgently reviewed and that it should not be used outside the context of a rigorously conducted randomised controlled trial.

Blood Proteins↗