Viral infections in paediatric patients receiving conventional cancer chemotherapy

In severely immunocompromised patients, the diagnosis of viral infections relies on PCR/RT-PCR based methods. The availability of these modern diagnostic tools facilitates timely diagnosis and contributes to our increasing knowledge of the epidemiology and clinical spectrum of common and emerging viral pathogens in this highly susceptible population. Viral infections may result in life threatening disease in paediatric cancer patients after stem cell transplantation and also during conventional chemotherapy. Often, clinical symptoms are a consequence of endogenous reactivation of latent viral infection. Many of these viruses are easily transmitted between patients, relatives and health care workers. As prolonged symptomatic and asymptomatic viral shedding is a common feature in paediatric cancer patients, it is necessary to implement strategies for the prevention and control of these communicable pathogens in the hospital setting and in the outpatient clinic. Although no randomised controlled studies on paediatric cancer patients are available, physicians should be aware of potential treatment options since early treatment may prevent a complicated or fatal outcome and shorten the period of contagiosity.

[Value of transurethral resection of the prostate (TURP) for treatment of symptomatic benign prostatic obstruction (BPO): an analysis of efficiency and complications in 1015 cases]

1015 patients with benign prostatic hyperplasia who underwent transurethral resection (TURP) within the last seven years were analysed concerning indication, complications and results by evaluation of quality. The actual value of TURP should also be compared with that of alternative procedures of treatment. The transfusion rate (0.69 %), TUR syndrome (0.78 %) and the urinary infection rate (1.1 %) are all very low. In 4.7 % a re-operation was necessary, mostly due to significant haematuria. The mortality rate perioperatively was 0.1 %. With regard to the voiding outcome, the uroflow relatively improved in 131 % and post-void residual urine diminished in 81 %. The low rate of complications, high efficiency and satisfaction of the patients are of importance also for the evaluation of alternative procedures. At the present time these modes of treatment do not have the potential to substitute for TURP.

[Hyper- or normobaric oxygen therapy to treat migraine and cluster headache pain. Cochrane review]

BACKGROUND

The aim of this systematic review was to assess the benefits and harms of supplemental oxygen (HBOT/NBOT) for treating and preventing migraine and cluster headaches.

MATERIAL AND METHODS

All randomized trials comparing the effect of supplemental oxygen on migraine or cluster headache with those that exclude supplemental oxygen were included in this review. The systematic search included all relevant sources according to the paradigms of the Cochrane Collaboration. Data were analyzed with RevMan 4.2.

RESULTS

Nine trials involving 201 participants satisfied the inclusion criteria. HBOT was effective in relieving an acute migraine and seemed to be sufficient in the treatment of an acute cluster attack. NBOT was effective in terminating acute cluster headache compared to sham treatment, but not in comparison to sublingual ergotamine. There was no evidence for any prophylactic effects. Serious adverse effects were not noted in the trials investigated.

CONCLUSIONS

There is some evidence that HBOT is effective for termination of acute migraine. NBOT was similarly effective in cluster headache, however with sparse data. Because of costs and poor availability HBOT cannot be regarded as a routine therapy. Further indications in the case of treatment failure using standard therapy need to be defined based on data of future clinical trials.

A minimally invasive metabolic test with intramuscular injection of halothane 5 and 6 vol% to detect probands at risk for malignant hyperthermia

We hypothesised that intramuscular halothane injection increases local Pco(2) concentrations in malignant hyperthermia susceptible (MHS) but not in non-susceptible (MHN) individuals. Pco(2) probes with attached microtubing catheters for halothane injection were placed into the lateral vastus muscle of eight MHS and eight MHN probands. Following equilibration, a single bolus of 200 microl halothane 5 and 6 vol% was injected. Pco(2) was measured spectrophotometrically. Baseline Pco(2) concentrations were similar between groups. Maximum Pco(2) and maximum rate of Pco(2) increase was significantly enhanced by halothane 5 and 6 vol% in MHS compared to MHN probands. Systemic haemodynamic and metabolic parameters did not differ between both groups. Local halothane application induces a hypermetabolic reaction with a significant Pco(2) increase in MHS compared to MHN probands, indicating a susceptibility to malignant hyperthermia. Intramuscular halothane injection with Pco(2) measurement seems to be a suitable method for the development of a minimally invasive metabolic test to diagnose malignant hyperthermia susceptibility.

[Intravesical adjuvant chemotherapy for superficial bladder cancer -- results of a survey in Saxony]

For patients with superficial bladder cancer, adjuvant intravesical chemotherapy or immunotherapy with Bacillus Calmette-Guerin (BCG) is recommended in national and international guidelines. We analyzed whether the recommended therapeutic regimens are used in daily urological practice. Questionnaires concerning the adjuvant intravesical therapy were sent to 152 urologists in the German Federal State of Saxony. Of the surveyed physicians, 134 practiced in an outpatient medical facility and 18 in a hospital. Of the questionnaires, 73 (48.02 %) were returned and evaluated. An adjuvant intravesical therapy after transurethral bladder tumor resection was performed in every second patient (median value 50.07 %). The majority of the urologists (79.4 %) treated the bladder tumors with intravesical chemotherapy or BCG depending on tumor stage and grade of malignancy. Chemotherapeutic agents or BCG was exclusively used in 13.6 % and 4.1 % of treated patients, respectively. Chemotherapeutic agents were predominantly applied up to the primary tumor stage T1 and malignancy grade G2. In cases with recurrent T1 bladder tumors of G2 or higher grade of malignancy, BCG was the main agent for intravesical treatment. In patients with recurrent T1G3 tumors, the majority of urologist (57.1 %) preferred another therapeutic regimen than intravesical instillation. Only 23.2 % of the urologists believed that intravesical BCG is superior to chemotherapeutic agents. These data demonstrate that adjuvant intravesical instillation with chemotherapeutic agents and BCG is well established in urological practice. In contrast to the recommendations of national and international guidelines, chemotherapeutic agents are more frequently used in cases with a high risk of progression.

[Scrotal diverticulum of the urinary bladder -- rare cause of an inguinal hernia]

INTRODUCTION

Massive herniation of the bladder through the inguinal canal is a rare entity. We report on a patient with a large inguinoscrotal herniation of the urinary bladder commonly referred as "scrotal cystocele". Diagnostic means and therapeutic strategies are discussed.

CASE REPORT

After laparoscopic repair of a bilateral inguinal hernia, a 60-year-old man described a persistent right groin mass that varied in size with the degree of bladder distension. Diagnostic evaluation revealed a large bladder diverticulum extending into the right scrotum. Treatment consisted of inguinal resection of the bladder diverticulum, the peritoneal sack and closure of the hernia.

CONCLUSION

Inguinal herniation of a large bladder diverticulum has to be considered in the differential diagnosis of inguinal hernias, especially in patients with obstructive symptoms of the bladder outlet.

T-cell-depleted peripheral blood stem cell transplantation for alpha-mannosidosis

Alpha-mannosidosis (alpha-mannosidosis) is a lysosomal storage disease characterized by accumulation of oligosaccharides in various tissues leading to symptoms such as coarse facial features, dysostosis multiplex, hearing disabilities, mental developmental delay and skeletal involvement (dysostosis multiplex). Without treatment, the severe infantile onset form of this autosomal recessive disease leads to progressive neurodegeneration and sometimes to early death. Stem cell transplantation has been shown to be an effective treatment. In the five patients published so far, correction of skeletal abnormalities and improvement of neuropsychological capabilities have been observed. We report the first patient who received a T-cell-depleted peripheral blood stem cell transplantation (PBSCT) for alpha-mannosidosis. The diagnosis of alpha-mannosidosis was made at the age of 14 months. At the age of 24 months, he underwent PBSCT with T-cell depletion by CD34-positive selection from his HLA phenotypically identical mother. Conditioning was carried out with busulfan (20 mg/kg), cyclophosphamide (200 mg/kg), OKT3 and methylprednisolone. The patient is alive and well 27 months after PBSCT and has made significant developmental progress. The pattern of urinary oligosaccharides has returned to almost normal. CD34-positive-selected PBSCT is a feasible option to reduce risk for GVHD for these patients.

[Spontaneous rupture of a lumbar artery. A rare etiology of retroperitoneal hematoma]

A ruptured lumbar artery is an uncommon lesion for a retroperitoneal hematoma. This report describes a 77-year-old man with bladder carcinoma who developed a spontaneous retroperitoneal hemorrhage during anticoagulation therapy for an artificial cardiac valve. The diagnosis was suggested by computed tomography scan and confirmed with angiography. Successful treatment consisted of occluding bleeding arteries by transcatheter embolization.

Colonic mucosal vasoactive intestinal peptide receptors in malformations of the enteric nervous system are reduced compared with morphologically normal innervated colon

Vasoactive intestinal peptide (VIP) is the most important peptidergic transmitter in intestinal relaxation. VIPergic nerves are reduced in aganglionosis (AG). Corresponding findings in intestinal neuronal dysplasia (IND) are sparse. It is unknown whether superficial mucosal VIP receptors are reduced in AG, IND, or hypoganglionosis (HYP) compared to concentrations in morphologically normal innervated colon (MNIC). Cryostat sections from 38 colonic biopsies (23 patients with AG, IND, or HYP, 15 with MNIC) were incubated with radioactive iodinated (125)I-VIP. Receptors were analyzed by autoradiography. Radioactive-marked receptors trigger the precipitation of metallic silver as silver grains within a photographic emulsion. Grains were quantified by image analysis, calculating the percent covered cell surface. Statistical analysis was done by Mann-Whitney and Kruskal-Wallis tests (significance #E5/E5#<0.05). VIP receptors covered 4.31% of the cell surface in MNIC. The values were significantly reduced in AG (2.72%; #E5/E5#=0.012) and IND (2.93%; #E5/E5#=0.008). The two HYP biopsies showed the lowest values (1.83%). Aganglionic colon could be distinguished from healthy proximal segments and IND from habitual constipation. In AG and IND, even the superficial mucosal VIPergic innervation seems to be impaired. The reduction of mucosal VIP receptors in developmental faults of the enteric nervous system may thus be an indicator of a sensomotor disturbance.

Megestrol acetate to correct the nutritional status in an adolescent with growth hormone deficiency: Increase of appetite and body weight but only by increase of body water and fat mass followed by profound cortisol and testosterone depletion

Megestrol acetate (MA) is a synthetic, orally active derivative of the naturally occurring hormone progesterone. MA is increasingly used to correct loss of appetite and improve the nutritional status. We used MA in an adolescent with growth hormone (GH) deficiency due to former irradiation therapy in order to evaluate if MA can improve the nutritional status. In fact, MA increased appetite and weight dose-dependent. The energy expenditure measured by indirect calorimetry changed from hypo- to normometabolism. However, weight gain was first primarily due to an increase in body water and then in fat mass. The gain of fat mass was much more prominent than the gain of fat free mass. As important side-effect, MA lead to rapid and profound cortisol and testosterone depletion after only 10 days with a long-lasting effect on testosterone depletion. Therefore, MA as a single therapy cannot be recommended to improve the nutritional status. If MA is given, cortisol and testosterone levels have to be monitored and supplemented as needed.

Allogeneic bone marrow transplantation for active Epstein-Barr virus-related lymphoproliferative disease and hemophagocytic lymphohistiocytosis in an infant with severe combined immunodeficiency syndrome

A 5-month-old male presented with fever, hepatosplenomegaly, leukocytosis with atypical lymphoblasts, anemia and thrombocytopenia. Severe combined imunodeficiency syndrome (T-, B+, NK+), B lymphoproliferative disease and hemophagocytic lymphohistiocytosis triggered by Epstein-Barr virus (EBV) were diagnosed. As his clinical situation deteriorated rapidly, BMT was performed with unmanipulated marrow stem cells from his EBV-positive HLA-identical sister after conditioning with dexamethasone (1.75 mg/kg/day), cyclophosphamide (114 mg/kg) and etoposide (10 mg/kg), with no immunosuppression given post transplant. Engraftment occurred on day 6 with explosive proliferation of donor CD8(+) T cells. The patient died 3 days later from acute respiratory distress syndrome. Autopsy revealed full donor engraftment and no signs of hemophagocytic lymphohistiocytosis or B lymphoproliferative disease. Thus, transplanted T cells can expand very rapidly within days after BMT and clear EBV lymphoproliferative disease and hemophagocytic lymphohistiocytosis.

Successful treatment of gut-caused halitosis with a suspension of living non-pathogenic Escherichia coli bacteria--a case report

In up to 90% of cases, severe halitosis is a result of gastrointestinal or orolaryngeal problems. This case study reports on a girl with bad breath caused by increased formation of malodorous intestinal gases (halitosis), which could be successfully treated with a suspension of living non-pathogenic bacteria Escherichia coli.

CONCLUSION

in unclear cases of bad breath, an increased formation of intestinal gases should also be considered.

Griscelli syndrome: report of the first peripheral blood stem cell transplant and the role of mutations in the RAB27A gene as an indication for BMT

Griscelli syndrome is characterized by partial albinism with variable immunodeficiency. Two different gene loci are responsible for this rare, autosomal recessive disease: the myosin Va gene and the RAB27A gene. As recently reported, only patients with mutations of the RAB27A gene suffer from immunodeficiency and hemophagocytic lymphohistiocytosis. Thus, only patients who suffer from the Griscelli syndrome with mutations of the RAB27A gene should receive BMT/PBSCT, which is the only curative therapy. Due to the risk of early relapse or severe infections, BMT/PBSCT should be carried out as soon as possible; if patients do not have HLA-identical family members, valuable time may be lost by searching for an HLA-identical unrelated donor. We report the first peripheral blood stem cell transplant (PBSCT) with T cell depletion in a 6-month-old girl with Griscelli syndrome, and a deletion of the RAB27A gene. The donor was her phenotypically HLA-identical mother. Conditioning included busulfan, VP16 and cyclophosphamide. The patient was transfused with 15.4 x 10(6)CD34-positive cells/kg and 17.6 x 10(3) CD3-positive cells/kg recipient weight. Three months after the transplant, a curable lymphoproliferative syndrome occurred. 26 months after the transplant, the patient is doing well with stable mixed chimerism (52% donor cells).

Accelerated phase in partial albinism with immunodeficiency (Griscelli syndrome): genetics and stem cell transplantation in a 2-month-old girl

A 2-month-old girl presented with fever, hepatosplenomegaly, pancytopenia, hypertriglyceridaemia and silvery-greyish hair, suggesting the diagnosis of Griscelli syndrome (partial albinism with immunodeficiency). This diagnosis was confirmed by the characteristic agglomeration of melanin in the hair shaft and accumulation of melanosomes in melanocytes of the skin. The patient was homozygous for polymorphic markers around the myosin-Va gene on chromosome 15q21, which co-localize to the Griscelli disease locus. Natural-killer cells were in the lower range. The stimulation of lymphocytes with antigen and mitogen was normal. The patient's accelerated phase, characterized by haemophagocytosis was treated with prednisolone, rabbit anti-thymocyte globulins, and intrathecal methotrexate. Remission was maintained with cyclosporin A until HLA-compatible peripheral blood stem cell transplantation from her mother.

CONCLUSION

The silvery-greyish hair associated with fever, pancytopenia and hypertriglyceridaemia is the clue to early diagnosis of Griscelli syndrome and important to prevent death before stem cell transplantation.

Towards molecular farming in the future: using plant-cell-suspension cultures as bioreactors

Plant-suspension cells are an in vitro system that can be used for recombinant protein production under carefully controlled certified conditions. Plant-suspension cells can be grown in shake flasks or fermenters to produce secondary metabolites, like vincristine and vinblastine, and to produce recombinant proteins after transformation. This review article focuses on discussing the generation of transformed suspension-cell lines expressing recombinant proteins, like antibodies, and recombinant-protein downstream processing and purification.

Towards molecular farming in the future: using plant-cell-suspension cultures as bioreactors

Plant-suspension cells are an in vitro system that can be used for recombinant protein production under carefully controlled certified conditions. Plant-suspension cells can be grown in shake flasks or fermenters to produce secondary metabolites, like vincristine and vinblastine, and to produce recombinant proteins after transformation. This review article focuses on discussing the generation of transformed suspension-cell lines expressing recombinant proteins, like antibodies, and recombinant-protein downstream processing and purification.