[Sickle cell disease in adults: which emergency care by the internists?]

INTRODUCTION

Sickle cell disease is an inherited disease characterized by the presence of an abnormal haemoglobin. It is the most prevalent genetic disease at birth in the Ile-de-France area. Internists are involved in the management of acute complications, particularly acute vaso-occlusive crisis.

CURRENT KNOWLEDGE AND KEY POINTS

Sickle cell disease can be complicated by acute vaso-occlusive crisis, chronic visceral involvement related to the ischaemic process, and infectious complications. In adults, acute vaso-occlusive crisis is the major clinical problem prompting admission to the hospital and the main cause of death. It mainly manifests by osteoarticular pain but other clinical complications can be observed such as acute chest syndrome, priapism, ischaemic or haemorrhagic stroke, abdominal pain and acute multivisceral failure. The treatment of acute vaso-occlusive crisis is symptomatic. Simple transfusion or partial exchange transfusion is required in the more severe form of vaso-occlusive crisis.

FUTURE PROSPECTS AND PROJECTS

The management of adult patients with sickle cell disease must be based on a multidisciplinary approach. At the present time, more than 50% of patients survive beyond the fifth decade. This better and longer life in developed countries has resulted from basic investigations and symptomatic treatments.

Urinary tract infection in adults: research priorities and strategies

Waning interest in urinary tract infection (UTI) research has limited clinical advances during the past two decades. Although care has improved for some specific UTI syndromes, there is limited evidence for most of the decisions made each day in the management of these infections. Additional clinical research is necessary to improve UTI prevention and care strategies.

[Hemolytic anemia disclosing Wilson's disease. Report of 2 cases]

INTRODUCTION

The liver and central nervous system are the usual targets of Wilson's disease, an inherited disorder of copper metabolism. Severe hemolytic anemia is an unusual complication of Wilson's disease.

EXEGESIS

We report two cases of Wilson's disease revealed by acute intravascular hemolytic anemia associated with liver failure. Blood smear analysis showed stippled red cells in one case; hemolytic anemia improved within a few weeks in both patients but progressive liver failure required transplantation in the other. Hemolysis probably results from the toxic effect of free serum copper on erythrocyte membrane.

CONCLUSION

Diagnosis of Wilson's disease must be considered in case of acute hemolytic anemia associated with liver failure in young adults.

The ratio of campesterol to sitosterol that modulates growth in Arabidopsis is controlled by STEROL METHYLTRANSFERASE 2;1

The Arabidopsis genome contains three distinct genes encoding sterol-C24-methyltransferases (SMTs) involved in sterol biosynthesis. The expression of one of them, STEROL METHYLTRANSFERASE 2;1, was modulated in 35S:SMT2;1 Arabidopsis in order to study its physiological function. Plants overexpressing the transgene accumulate sitosterol, a 24-ethylsterol which is thought to be the typical plant membrane reinforcer, at the expense of campesterol. These plants displayed a reduced stature and growth that could be restored by brassinosteroid treatment. Plants showing co-suppression of SMT2;1 were characterized by a predominant 24-methylsterol biosynthetic pathway leading to a high campesterol content and a depletion in sitosterol. Pleiotropic effects on development such as reduced growth, increased branching, and low fertility of high-campesterol plants were not modified by exogenous brassinosteroids, indicating specific sterol requirements to promote normal development. Thus SMT2;1 has a crucial role in balancing the ratio of campesterol to sitosterol in order to fit both growth requirements and membrane integrity.

Glycosides and phenylpropanoid glycerol in vitis vinifera cv. Gewurztraminer wine

Eight glycosides and a phenylpropanoid glycerol were isolated from Vitis vinifera cv. Gewurztraminer wine, and their structures were elucidated by MS and NMR spectroscopies. cis-1-(5-Ethenyl-5-methyltetrahydrofuran-2-yl)-1-methylethyl O-beta-D-apiofuranosyl-(1-->6)-O-beta-D-glucopyranoside, (E)-3,6, 9-trihydroxymegastigm-7-ene 9-O-beta-D-glucopyranoside, 2-phenylethyl O-beta-D-apiofuranosyl-(1-->6)-O-beta-D-glucopyranoside, and 2-[4-(3-hydroxypropyl)-2-methoxyphenoxy]propane-1,3-diol are reported for the first time as wine components.

Breast tumor contamination of peripheral blood stem cell harvests: increased sensitivity of detection using immunomagnetic enrichment

Contaminating tumor cells in peripheral blood stem cell (PBSC) grafts infused for hematopoietic rescue after high-dose chemotherapy could potentially contribute to relapse in BrCa patients. To date the prevalence of PBSC contamination in BrCa patients, as determined by standard immuno-cytochemistry (ICC) assays, has generally been found to be relatively low. However, assay sensitivity may have an important impact on the ability to detect contamination. In this investigation a novel and highly sensitive BrCa cell assay using immunomagnetic enrichment with a panel of antiBrCa monoclonal antibodies (MAbs) and detection by ICC has been characterized. The immunomagnetic enrichment with ICC detection (IE-ICC) assay was directly compared with standard ICC in ability to detect BrCa contamination of PBSC specimens from patients with high-risk stage II/III and metastatic disease. The sensitivity of the IE-ICC assay was approximately 50-fold greater than that of standard ICC. As determined by standard ICC assay, BrCa cells were present in 1/14 patients (7%) and 2/26 (8%) specimens. In contrast, with IE-ICC assay the proportions of positive findings in patients (12/14, 86%) and specimens (19/26, 73%) were significantly higher (p = 0.001 and p < 0.0005, respectively). These preliminary findings suggest that the prevalence of PBSC contamination may be substantially higher than previously appreciated. Consequently, measures to reduce tumor contamination in the graft may have the potential to improve patient outcomes. Higher sensitivity assays such as the IE-ICC assay may play an important role in assessing the risks associated with tumor contamination and the effectiveness of tumor-purging approaches such as positive selection of CD34+ cells and in monitoring patient response to therapy.

Unusual case of diagnosis of pigeon breeder's hypersensitivity pneumonitis with ventilation-perfusion lung scan

The authors describe a patient thought to have pulmonary embolism. Results of a perfusion scan were normal, but Tc-99m DTPA aerosol ventilation lung scan showed, in successive views, decreased activity of the deposited aerosol. The lung Tc-99m DTPA clearance was measured and was markedly increased. This suggested possible hypersensitivity pneumonitis, which was later confirmed as pigeon breeder's disease. The decreased activity observed on the DTPA ventilation scan must be directed toward increased lung clearance and its measurement.

Plant sterol-C24-methyl transferases: different profiles of tobacco transformed with SMT1 or SMT2

Higher plant cells contain a mixture of 24-desmethyl, 24-methyl(ene), and 24-ethyl(idene) sterols in given proportions according to species but also to cell type. As a first step to investigate the function of such sterol compositions in the physiology of a plant, we have illustrated in the present work the coexistence of two distinct (S)-adenosyl-L-methionine sterol-C24-methyltransferases (SMT) in transgenic Nicotiana tabacum L. Indeed, modulation of the expression of the tobacco gene SMT1-1, which encodes a cycloartenol-C24-methyltransferase, results in variations of the proportion of cycloartenol and a concomitant effect on the proportion of 24-ethyl sterols. Overexpression in tobacco of the Arabidopsis thaliana (L.) Heynh. gene SMT2-1 which encodes a 24-methylene lophenol-C24(1)-methyltransferase, results in a dramatic modification of the ratio of 24-methyl cholesterol to sitosterol associated with a reduced growth, a topic discussed in the present work.

Intravenous immunoglobulin for adults with autoimmune thrombocytopenic purpura: results of a randomized trial comparing 0.5 and 1 g/kg b.w

Since the first reports demonstrating the ability of a total dose of 2 g/kg body weight (b.w.) of intravenous immunoglobulin (IVIg) to increase the platelet count in patients with autoimmune thrombocytopenic purpura (AITP), the optimal dose has remained controversial. We report the results of a randomized study which compared two low doses of IVIg (0.5 g/kg b.w., group A, n = 19, and 1 g/kg b.w., group B, n = 18) in 37 adults with AITP and platelet count <50 x 109/l, in preparation for surgery or in a situation with a risk of bleeding. On day 4 the proportion of responses, defined by a platelet count > 80 x 109/l and at least twice the initial platelet count, was significantly higher in the group receiving 1 g/kg b.w. (12/18 in group B versus 4/19 in group A, P = 0.005). All but one of the day 4 responders had already responded on day 3. The daily changes in the platelet count from the beginning of IVIg treatment were larger in group B, with a significant difference relative to group A on day 3 (92 x 109/l in group B versus 50 x 109/l in group A, P = 0.03) and on day 4 (106 x 109/l in group B versus 55 x 109/l in group A, P = 0.03). Patients who had not responded by day 4 subsequently received 1.5 g IVIg/kg b.w. (group A) or 1 g IVIg/kg b.w. (group B). A response was observed in 11/13 initial non-responders in group A, and in 2/6 initial non-responders in group B. Finally, on day 8, the proportion of responders was 78% (29/37) in the entire group and was similar in the two subgroups. In conclusion, (1) initial treatment with 1 g/kg b.w. of IVIg appeared to be more effective than 0.5 g/kg b.w. in adults with AITP; (2) infusion of a low dose of IVIg did not jeopardize the efficacy of IVIg reinfusion; (3) some adults who did not respond to 1 g IVIg/kg b.w. responded to a higher dose.

Costs and benefits of measures to prevent needlestick injuries in a university hospital

OBJECTIVE

To document the costs and the benefits (both in terms of costs averted and of injuries averted) of education sessions and replacement of phlebotomy devices to ensure that needle recapping did not take place.

DESIGN

The percentage of recapped needles and the rate of needlestick injuries were evaluated in 1990 and 1997, from a survey of transparent rigid containers in the wards and at the bedside and from a prospective register of all injuries in the workplace. Costs were computed from the viewpoint of the hospital. Positive costs were those of education and purchase of safer phlebotomy devices; negative costs were the prophylactic treatments and follow-up averted by the reduction in injuries.

SETTING

A 1,050-bed tertiary-care university hospital in the Paris region.

RESULTS

Between the two periods, the proportion of needles seen in the containers that had been recapped was reduced from 10% to 2%. In 1990, 127 needlestick (12.7/100,000 needles) and 52 recapping injuries were reported versus 62 (6.4/100,000 needles) and 22 in 1996 and 1997. When the rates were related to the actual number of patients, the reduction was 76 injuries per year. The total cost of information and preventive measures was $325,927 per year. The cost-effectiveness was $4,000 per injury prevented.

CONCLUSION

Although preventive measures taken to ensure reduction of needlestick injuries appear to have been effective (75% reduction in recapping and 50% reduction in injuries), the cost of the safety program was high.

The response to high-dose intravenous immunoglobulin or steroids is not predictive of outcome after splenectomy in adults with autoimmune thrombocytopenic purpura

The response to high-dose intravenous immunoglobulin (IVIg) was recently reported to be predictive of outcome after splenectomy in patients with autoimmune thrombocytopenic purpura (AITP). We analysed the records of 75 adults with chronic AITP who received IVIg and subsequently underwent splenectomy. There was no significant difference in the response rate to splenectomy according to whether or not patients had responded to IVIg (81% v 67%, P = 0.36). Age, the time from diagnosis to splenectomy, and the response to steroids were also not significantly associated with outcome after splenectomy. These results indicate that the response to IVIg or steroids is not predictive of the efficacy of splenectomy.

Prostatitis unplugged? Prostatic massage revisited

Repetitive prostatic massage is not a new tool in the urologists' armatarium. Once the most popular therapeutic maneuver used to treat prostatitis, it was abandoned as primary therapy almost 3 decades ago. Based on experience reported outside North America and anecdotal experiences of some patients and their physicians, it may be making a comeback. Unfortunately, there are almost no prospective data that would substantiate a claim as to its effectiveness. This article discusses the historic aspects of prostatic massage, suggests possible mechanisms of action, and describes the opinions of North American urologists who are associated with academic clinical research centers and are universally acknowledged as experts in the diagnosis and treatment of prostatitis. At this time, the science of prostatic massage must rely on anecdotal experiences, small, uncontrolled studies, and perhaps somewhat biased opinions of the major thought leaders in the field of chronic prostatitis/chronic pelvic pain syndrome.

Zidovudine-induced mitochondrial disorder with massive liver steatosis, myopathy, lactic acidosis, and mitochondrial DNA depletion

Zidovudine is known to be responsible for a mitochondrial myopathy with ragged-red fibres and mitochondrial DNA depletion in muscle. Lactic acidosis alone or associated with hepatic abnormalities has also been reported. A single report mentioned the concomitant occurrence of muscular and hepatic disturbances and lactic acidosis in a patient receiving zidovudine, but muscle and liver tissues were not studied. A 57-year-old man with AIDS, who had been treated with zidovudine for 3 years, developed fatigue and weight loss. Serum creatine kinase and hepatic enzyme levels were high. Lactic acidosis was present. Liver biopsy showed diffuse macrovacuolar and microvacuolar steatosis. After withdrawal of zidovudine, creatine kinase, aspartate aminotransferase, and alanine aminotransferase levels normalised within 5 days, and lactacidaemia decreased. Acidosis persisted. The patient became confused and febrile and died 8 days after detection of high blood lactic acid. A muscle sample obtained at autopsy showed mitochondrial abnormalities with ragged-red fibres and lipid droplet accumulation. Southern blot analysis showed depletion of mitochondrial DNA, affecting skeletal muscle and liver tissue. No depletion was found in myocardium and kidney. This case emphasises that zidovudine treatment can induce mitochondrial multisystem disease, as revealed in our case by myopathy, liver steatosis and lactic acidosis.

[Hemolysis and schizocytosis, malabsorption and the "folate trap": unusual semiological peculiarities associated with vitamin B12 deficiency]

INTRODUCTION

Hemolysis and red cell fragmentation accompanying vitamin B12 deficiency may misdirect the diagnosis. Signs of malabsorption and abnormalities related to folic acid metabolism characterized by discrepancies between folic acid normal serum levels and erythrocytic folic acid levels may also exist.

EXEGESIS

We report the occurrence of hemolysis and red cell fragmentation mimicking microangiopathic hemolytic anemia, malabsorption and folic acid deficiency in the course of vitamin B12 deficiency. Appropriate replacement therapy corrected all abnormalities.

CONCLUSION

An association between hemolysis, malabsorption and folic acid deficiency should lead physicians to search for signs of vitamin B12 deficiency.

Pulmonary embolism; lung scanning interpretation: about words

OBJECTIVE

To assess clinicians' agreement on how they interpret lung scan reports with regard to the diagnosis of pulmonary embolism.

DESIGN

In this prospective study, nuclear medicine physicians provided two types of reports for each lung scan: a routine descriptive report and a short form with a standardized conclusion on the likelihood of pulmonary embolism: "high probability," "no conclusion," and "diagnosis excluded." Three independent blinded senior clinicians reviewed all routine reports and chose one of the following conclusions: "high probability," "no conclusion," or "diagnosis excluded."

SETTING

An acute care teaching hospital near Paris.

SUBJECTS

Eighty-two lung scans were studied.

MAIN OUTCOME MEASUREMENTS

Inter-clinician agreement and agreement between clinicians' conclusions and the nuclear medicine physicians' standardized reports were analyzed using the kappa index.

RESULTS

The distribution of the clinicians' conclusions from routine reports strongly differed (p < 0.001). Agreement among the three clinicians was observed in 40.2% of the routine reports, and the inter-clinician agreement was poor to moderate (kappa range, 0.28 to 0.52). A complete agreement among the three clinicians and the nuclear medicine physicians' standardized conclusions was observed for 32.9% of the reports. The agreement between each clinician and the standardized conclusions was also poor to moderate (kappa range, 0.32 to 0.55).

CONCLUSION

Reading the same routine reports, clinicians reached different conclusions. Furthermore these differed greatly from the nuclear medicine physicians' standardized conclusions. These results support the notion that physicians should be given standardized reports.