Quantitative and semiquantitative evaluation of erythropoietin-induced bone marrow signal changes in lumbar spine MRI in patients with tumor anemia

BACKGROUND

The topic of this article is the quantitative and semiquantitative assessment of bone marrow signal alteration in magnetic resonance imaging (MRI) of the lumbar spine in patients with tumor anemia during therapy with epoietin beta or placebo.

PATIENTS AND METHODS

We examined 32 patients with head or neck cancer (16 epoietin beta, 16 placebo) during radiotherapy in a double-blind multicenter trial. During radiotherapy, the patients underwent epoietin beta therapy for 7-9 weeks. Lumbar spine measurements using T1-w SE, OPP and Turbo- STIR were taken prior to the first epoietin beta or placebo therapy, after the acquired hemoglobin level had been reached, and after the final radiotherapy. The semiquantitative assessment was made blinded by 2 independent radiologists.

RESULTS

We found significant differences between both groups. The first MRI showed normal marrow signals. The second MRI revealed a quantified decrease in bone marrow signal in T1-w SE (p < 0.018) and an increase in OPP (p < 0.01) and Turbo-TIR (p < 0.048) sequences. At the third MR imaging, quantified relative marrow signals returned to baseline level in all sequences. Semiquantitative assessment confirmed these results.

CONCLUSION

In both analyses, lumbar spine MRI demonstrates significant bone marrow changes in T1-w SE, OPP and Turbo-STIR sequences during epoietin beta therapy.

Dixyrazine for the prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy

BACKGROUND

The study assessed the efficacy and safety of dixyrazine, an alternative neuroleptic drug to droperidol, in the prophylaxis of postoperative nausea and vomiting (PONV).

METHODS

A total of 197 patients scheduled for laparoscopic cholecystectomy under general anesthesia were randomized to receive either dixyrazine 10 mg or placebo double-blinded at the end of surgery. Scores pertaining to PONV episodes, analgetic supply, rescue medication, adverse events and patient satisfaction were collected over the first 2 h in the PACU and the next 22 h in the ward.

RESULTS

The incidence of PONV over the entire 24-h period was reduced from 32% in the placebo group to 13% in the dixyrazine group (P< or =0.004). The incidence of nausea in the first 2 h was reduced from 15% in the placebo group to 4% in the dixyrazine group (P< or =0.02) and from 12% to 5% in the next 22 h. The incidence of emetic episodes was not different between the two groups. Postoperative shivering was significantly less prevalent in the dixyrazine than in the placebo group (2% vs. 13%; P< or =0008), and opioid analgesics were required significantly less often (61% vs. 75%; P< or =0.01). No significant adverse effects were observed. Patient satisfaction was similar in both groups.

CONCLUSION

Prophylactic dixyrazine is an effective, safe, and cheap antiemetic drug for laparoscopic cholecystectomy without involving any significant adverse events.

The efficacy and safety of a clonidine/bupivacaine combination in caudal blockade for pediatric hernia repair

We evaluated the analgesic efficacy and hemodynamic and respiratory safety of clonidine when added to bupivacaine for caudal blocks in 58 children aged 38 +/- 2 mo (mean +/- SEM). Patients scheduled for ambulatory hernia repair were randomly given a caudal injection (0.75 mL/kg) of either saline placebo (P group), bupivacaine, 0.25% (B group), bupivacaine plus epinephrine 1:200,000 (BE group), bupivacaine plus clonidine 1 microgram/kg (BC1 group), or bupivacaine plus clonidine 2 micrograms/kg (BC2 group). Postoperative measurements included duration of analgesia, hemodynamics, and respiratory monitoring for 6 h. Thereafter, parents assessed their child's analgesic requirements at home every 3 h for 18 h. The duration of analgesia (median [range]) was significantly longer (P < 0.05) in the BC1 and BC2 groups (360 [270-360] min and 360 [355-360] min, respectively) compared with the P (77[45-190]), B (346[105-360]), or BE group (300[75-360]). Similarly, the BC1 and BC2 groups required less additional analgesic within the first 24 h. All groups showed a significant decrease in mean arterial pressure compared with baseline values, but the differences among the groups were not significant. Bradycardia and respiratory depression were not observed. Clonidine 1 and 2 micrograms/kg can be safely added to bupivacaine caudal blockade in small children for ambulatory hernia repair to achieve an increased duration of analgesia compared with bupivacaine alone or bupivacaine plus epinephrine.

IMPLICATIONS

The addition of clonidine, an antihypertensive drug with analgesic properties, to local anesthetics in caudal blocks prolongs postoperative pain relief and reduces the need for additional pain treatment in children after hernia operation.

The efficacy and safety of a clonidine/bupivacaine combination in caudal blockade for pediatric hernia repair

We evaluated the analgesic efficacy and hemodynamic and respiratory safety of clonidine when added to bupivacaine for caudal blocks in 58 children aged 38 +/- 2 mo (mean +/- SEM). Patients scheduled for ambulatory hernia repair were randomly given a caudal injection (0.75 mL/kg) of either saline placebo (P group), bupivacaine, 0.25% (B group), bupivacaine plus epinephrine 1:200,000 (BE group), bupivacaine plus clonidine 1 microgram/kg (BC1 group), or bupivacaine plus clonidine 2 micrograms/kg (BC2 group). Postoperative measurements included duration of analgesia, hemodynamics, and respiratory monitoring for 6 h. Thereafter, parents assessed their child's analgesic requirements at home every 3 h for 18 h. The duration of analgesia (median [range]) was significantly longer (P < 0.05) in the BC1 and BC2 groups (360 [270-360] min and 360 [355-360] min, respectively) compared with the P (77[45-190]), B (346[105-360]), or BE group (300[75-360]). Similarly, the BC1 and BC2 groups required less additional analgesic within the first 24 h. All groups showed a significant decrease in mean arterial pressure compared with baseline values, but the differences among the groups were not significant. Bradycardia and respiratory depression were not observed. Clonidine 1 and 2 micrograms/kg can be safely added to bupivacaine caudal blockade in small children for ambulatory hernia repair to achieve an increased duration of analgesia compared with bupivacaine alone or bupivacaine plus epinephrine.

IMPLICATIONS

The addition of clonidine, an antihypertensive drug with analgesic properties, to local anesthetics in caudal blocks prolongs postoperative pain relief and reduces the need for additional pain treatment in children after hernia operation.

Staphylococcus aureus meningitis: a review of 28 consecutive community-acquired cases

From 1966 to 1989 a total of 1,830 cases of bacterial meningitis were recorded at the Department of Infectious Diseases, Rigshospitalet, Denmark. Staphylococcus aureus meningitis accounted for 44 (2.4%) of these cases. Among these, 28 cases were classified as community-acquired S. aureus meningitis. The mortality rate for these cases was 43%. A retrospective study of clinical features and parameters in these community-acquired cases showed the following conditions to be associated with a high mortality risk: advanced age, an underlying condition requiring artificial ventilation, cardiovascular disease and immune deficiencies. At admission, more than 75% of the patients had fever, nuchal rigidity and decreased consciousness. In 57% of cases the focus for the S. aureus infection was endocarditis, pneumonia or skin infections. All the patients had complications due to the meningitis, the major one being insufficient respiration. Autopsy performed in 9 of the 12 fatalities showed endocarditis in 5, pneumonia in 4, and pyelonephritis in 2. All of the brains examined at autopsy showed cerebral and subarachnoid hemorrhage.

Serovars of Mycobacterium avium complex isolated from patients in Denmark

Danish isolates of Mycobacterium avium complex were serotyped by the use of seroagglutination. The most prevalent serovars among patients with AIDS (n = 89) were 4 and 6, while among non-AIDS patients the most prevalent serovars were 1, 6, and 4, with no major differences between those in patients with pulmonary disease (n = 65) and those in patients with lymph node infection (n = 58). The results suggest a Scandinavian distribution of serovars with a predominance of serovar 6 and fail to demonstrate any selective protection against different serovars by Mycobacterium bovis BCG vaccination.

Pseudo-outbreak of pseudomonas aeruginosa in HIV-infected patients undergoing fiberoptic bronchoscopy

Pseudomonas aeruginosa was isolated from bronchoalveolar lavage fluid from 8 consecutive patients undergoing bronchoscopy at an infectious diseases unit. None of the patients developed signs of respiratory tract infection that could be ascribed to the organism. The source of contamination was the suction channels of 2 fiberoptic bronchoscopes which, due to a lapse in routine procedures, were not cleansed manually prior to disinfection with glutaraldehyde. Although rarely of pathogenetic importance, the possible presence of P. aeruginosa in lavage fluids should never be discounted, as it may indicate faulty disinfection of bronchoscopy equipment and thereby point to a risk of transmission of true respiratory pathogens such as mycobacteria.

Follow-up study of patients with clinically suspected deep venous thrombosis and a normal venogram

OBJECTIVES

To evaluate the clinical course in patients with clinically suspected deep venous thrombosis (DVT) of the leg and a normal venogram.

DESIGN

Prospective study over 15 months with a follow-up of 4-12 (median 8.6) months after a normal venogram. A questionnaire survey was performed at follow-up. Information from general practitioners and medical records was reviewed. An alternative diagnosis was established at presentation and at the time of follow-up.

SETTING

The Department of Internal Medicine in a Danish university hospital.

SUBJECTS

A total of 133 consecutive out-patients referred with clinical suspicion of DVT and a normal venogram.

MAIN OUTCOME MEASURES

The state of symptoms at follow-up. The frequency of referrals to hospitals and contacts with general practitioners or medical specialists in the follow-up period. Clinical diagnoses provided at presentation and at follow-up.

RESULTS

The follow-up response rate was 78% (n = 104). The symptoms were still present at follow-up in 53 (51%) patients. More than half of the patients had been referred to medical facilities for the same disorder. Diagnoses could be established in 93 (70%) of the 133 patients at presentation and in 119 (89%) at follow-up.

CONCLUSIONS

The majority of patients with clinical signs and symptoms of a DVT and a normal venogram may require a follow-up surveillance programme to ensure correct diagnosis and adequate treatment. Further studies are recommended to confirm our results and to assess the cost-effectiveness.

Lactoferrin, myeloperoxidase, lysozyme and eosinophil cationic protein in exudate in delayed type hypersensitivity

A skin window technique was used to study the morphology of leucocytes in upper dermis and exudate during nickel challenge in patients with contact allergy to nickel. Contact allergic patients and healthy volunteers tested with a skin widow without addition of nickel to the chamber medium served as controls. The morphology of the leucocytes in dermis was studied in biopsies taken 8, 24, or 48 h after skin window application, and in a parallel test the morphology of the exudate was examined by sequential collection of the chamber medium during a 48 h period. The infiltrate in dermis of contact allergic patients with nickel challenge in the chamber medium showed a time-dependent increase of mononuclear cells, eosinophils and basophils and a concomitant decrease of polymorphonuclear granulocytes, characteristic of a combined specific and unspecific inflammation. The morphology of the exudate in contact allergic patients exposed to nickel showed a dominance of polymorphonuclear granulocytes throughout the study period, while mononuclear cells, eosinophils and basophils were detected at a much lower quantity and with a considerable delay. Further, we studied the kinetics of the leucocyte granule proteins: lactoferrin, myeloperoxidase, lysozyme and eosinophil cationic protein in exudate fluid in a parallel test. A significant higher flux was found for all during the second day of allergen exposure compared to contact allergic patients without allergen challenge as well as normal volunteers. The increased protein fluxes were not accompanied by an increased flux of polymorphonuclear granulocytes in the exudate.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute cholangitis and pancreatitis associated with sulindac (clinoril)

A 68-year-old man without previous hepatobiliary or pancreatic disease was admitted after five attacks of nausea, vomiting, abdominal pain and high fever. Laboratory investigations indicated cholestatic liver disease and pancreatitis. For 1.5 years the patient had occasionally been taking a non-steroidal anti-inflammatory drug, sulindac (clinoril, MSD, New York), for osteoarthritis. On suspicion of a drug-associated disease, a rechallenge experiment was performed with sulindac. Five hours after drug administration symptoms recurred. There was a pronounced increase in serum alkaline phosphatase and amylase. A liver biopsy 3 d later showed portal tract inflammatory infiltration and abnormal interlobular bile ducts with degeneration and necrosis of the epithelium and neutrophilic infiltration of the ducts. Sulindac-induced cholangitis has not been described previously. The pathogenetic mechanism is considered to be an immunoallergic idiosyncratic reaction to the active metabolite of sulindac absorbed by the bile duct epithelium. The lesion is apparently reversible.

Acetaminophen metabolism by the perfused rat liver twelve hours after acetaminophen overdose

The effect of a toxic dose of acetaminophen on the hepatic conjugations of acetaminophen was studied in single pass perfused livers from rats given acetaminophen overdose 12 hr prior to perfusion and from control rats. Four different acetaminophen concentrations (0.1-6 mmol/1) were used in each perfusion. Glucuronidation of acetaminophen was increased and sulfation of acetaminophen occurred at an unchanged rate in acetaminophen damaged livers as compared to control livers. Hepatic glutathione concentrations declined to about 0.4 mumol/g liver during perfusion, possibly due to excretion of glutathione to perfusion medium, but in spite of this the formation of glutathione conjugates was increased with acetaminophen concentrations increasing up to about 5 mmol. We conclude that decreased sulfation, glucuronidation and glutathione conjugation in the liver is not present in the early development of acetaminophen-induced hepatic damage.

Leukotriene- and histamine-induced increases in vascular permeability and interstitial transport in the skin

The aim of the present study was to investigate the edema induced by leukotriene D4 (LTD4). Edema is the gross effect of increased blood flow and capillary permeability. Our objective was to elucidate the effect of LTD4 on edema generation without the influence of the concomitantly increased blood flow induced by this potent vasodilator. A new method was outlined measuring the exudation through skin windows of a macromolecular tracer [( 131I]albumin) and a micromolecular tracer [( 99Tc]pertechnetat). Exudation of [131I]albumin is a function of enhanced vascular permeability and interstitial transport and blood flow, whereas that of [99Tc] pertechnetat is mainly a function of blood flow. Thus a ratio of the 2 exudate measurements gives a specific estimate of the changes in vascular permeability and interstitial transport. Histamine was employed to establish the method. A dose-response relation was found for histamine in the dose range of 10(-4) to 10(-7) M. The effect of 10(-5) M LTD4 on vascular permeability and interstitial transport of macromolecules was indistinguishable from that of histamine in the same concentration. This property together with their well-known vasodilatory capabilities indicate that the leukotrienes of the slow-reacting substance of anaphylaxis may play a role in the vascular changes in the allergic-inflammatory reaction.

Potentiated hepatotoxicity from concurrent administration of acetaminophen and allyl alcohol to rats

Female Wistar rats were treated with acetaminophen 3.0 g/kg BW and allyl alcohol 75 microliter/kg BW by gastric tube. Hepatic function, measured as galactose elimination capacity and prothrombin index, was reduced to about 0.40 times control value. Plasma alanine transferase activity was elevated more and earlier after treatment with acetaminophen and allyl alcohol compared to administration of acetaminophen alone. Also prothrombin index was reduced more and earlier from the combination. Hepatic glutathione was depleted to a lower level 3 hr after administration of the combination of toxins, compared to administration of acetaminophen alone, after 6 hr there was no difference. Excretion of acetaminophen metabolites, especially the acetaminophen mercapturate, into urine was not changed from the combination. After administration of the toxic combination histological changes in the liver were minor. The results indicate that the two toxins potentiate each other's action. The potentiation is proposed to be due to prevention of compensatory hyperfunction of non-necrotic liver cells rather than to direct metabolic interaction of the toxins.

Phenobarbital induction does not potentiate hepatotoxicity but accelerates liver cell necrosis from acetaminophen overdose in the rat

Rats were pretreated with phenobarbital to induce hepatic cytochrome P-450. Compared to noninduced rats, a similar relation between the dose of acetaminophen and mortality, and between dose and changes in liver function (prothrombin index) and identical time courses, was found. The urinary excretion of acetaminophen mercapturate and acetaminophen cysteine was identical in induced and noninduced rats. The metabolism of acetaminophen in terms of blood levels and excreted metabolites was not influenced by phenobarbital induction. At the same dose level, hepatic necrosis was accelerated (maximum 24 h) compared to noninduced animals (maximum 72 h), but no difference in the maximum extent was found. These data cannot support the concept that induction of cytochrome P-450 leads to greater formation of the hypothetical toxic metabolite of acetaminophen, or that induction enhances its hepatotoxicity, in the rat. Several factors may contribute to accelerate the necrotic changes which make it possible to histologically identify cell damage and death. In that case, functional studies are more relevant than morphological evaluation in quantitative assessment of liver damage.

Human leukocyte cyclic AMP and cyclic GMP levels during chemotaxis in delayed type hypersensitivity

Ten nickel-allergic patients and six healthy control subjects participated in a study of the morphology, kinetics and evolution of the cAMP and cGMP concentrations of migrated leukocytes, using an improved skin chamber technique. Also studied was the effect of nickel exposure in the chamber medium during development of an eczematous reaction in the nickel-allergic patients. Nickel exposure had a specific effect on the morphology, from the 24th hour to the end of the 48 h observation period, with a significant increase in the percentages of basophils, eosinophils and lymphocytes and a decrease of neutrophils. A significantly increased leukocyte migration rate (LMR) was observed from the 27th to 39th hour in six of the allergic patients exposed to nickel. There were no specific permanent changes in cAMP and cGMP concentrations during nickel exposure. The control chambers of the allergic patients and healthy controls had identical leukocyte morphology, LMR and leukocyte concentrations of cAMP and cGMP. However, no correlations were found between LMR, cAMP and cGMP in the eczema patients throughout the observation period.

Cerebrospinal fluid levels of cyclic nucleotides in meningitis and idiopathic polyneuritis

Cyclic adenosine 3',5'-monophosphate (cAMP) and cyclic guanosine 3',5'-monophosphate (cGMP) were measured in cerebrospinal fluid (CSF) and plasma from 7 patients with bacterial meningitis, 9 patients with serous meningitis, 5 patients with idiopathic polyneuritis and 15 reference patients. A significantly (P less than 0.01) higher mean concentration of CSF cAMP was found in serous meningitis (33.8 +/- 12.5 nmol/l) compared to the reference group (20.2 +/- 4.0 nmol/l). No significant difference could be observed between the patients with purulent meningitis compared to the reference group. The CSF cAMP concentration (11.0 +/- 2.8 nmol/l) for idiopathic polyneuritis was significantly (P less than 0.01) lower than in the reference group. No difference in CSF levels of cGMP or in the cAMP/cGMP ratios were detected between the groups. Our data suggest that the ratio between cAMP concentrations in CSF and plasma may aid in the differential diagnosis between serous and purulent meningitis.

Use of protein A-positive Staphylococci as adsorbent in a radioimmunoassay for cyclic AMP and cyclic GMP

A reproducible (SD less than 4%), sensitive (in the 5 to 50 fmoles range) and inexpensive radioimmunoassay has been set up for the quantitation of cyclic. AMP and cyclic GMP based on acetylation or succinylation of the test sample. Separation of antibody-bound from free ligand was achieved by adsorption to formalinized protein A-positive Staphylococci of the Cowan 1 strain. The quantity of adsorbent (5% suspension) needed per 300 microliters of antiserum (diluted 24 x 10(4)) was 10 microliters. The blank value was below 2% and separation could be run at room temperature or at 4 degrees C as convenient. The acetylation or succinylation procedure of the sample totally eliminated interference of test sample immunoglobulins with antiserum binding to the absorbent.

Treatment of rheumatoid arthritis with prostaglandin E1 precursors cis-linoleic acid and gamma-linolenic acid

20 patients with active rheumatoid arthritis were treated for 12 weeks with the prostaglandin E1 precursors cis-linoleic acid and gamma-linolenic acid in the form of primrose evening oil (Efamol) and the co-factors zinc, ascorbic acid, niacin, and pyridoxin (Efavit). There was a slight fall in skin reactivity to UV light during the treatment, but no effect on plasma or urine concentrations of PGE1, cAMP or cGMP. There was no effect of the treatment on ESR, P-fibrinogen, number of tender joints, number of swollen joints, the duration of morning stiffness, or on the patient's estimation of pain.

Human leukocyte mobilization and morphology in nickel contact allergy using a skin chamber technique

An improved skin chamber technique has been devised and used for quantitative evaluation of the leukocyte mobilization rate (LMR). The method was applied in 10 nickel-hypersensitive patients exposed to nickel sulphate. Each patient served as his own control and for additional control purpose, 5 healthy individuals without nickel hypersensitivity were studied. The kinetics of the mobilized leukocytes were followed over a 48-hour period. After an initial lag phase of 2-4 hours, maximum migration was observed from the 24th to the 48th hour, with a wide interindividual variability in the number of mobilized cells at the time of maximum LMR response. The median cumulative leukocyte count was 1.412 x 10(6) leukocytes/cm2/48 h. In the same period a statistically significant increase in the basophils for all the nickel allergic patients was observed. In 8 out of 10 patients a statistically significant effect upon the lymphocytes could be demonstrated. Six of these 8 patients had an increased lymphocyte mobilization. Throughout the period the neutrophil granulocytes were the dominant cell type, although the number decreased as the number of basophils and lymphocytes increased. The chamber technique is a valuable means for quantitative evaluation of leukocyte mobilization and morphology in skin exudates during exposure to an allergen in delayed hypersensitivity reactions.

In vitro crosslinking of DNA by 8-methoxypsoralen visualized by electron microscopy

By electron microscopic visualisation of totally denatured DNA, we have detected photochemically induced 8-methoxypsoralen crosslinks in vitro after irradiation at 360 nm. The amount of crosslinks was expressed as the percentage of DNA length which was kept in double-stranded appearance by closely situated crosslinks. This percentage correlated well with irradiation time, irradiation intensity, and the concentration of 8-methoxypsoralen. These parameters have also been correlated with the mean size and the size distribution of non-crosslinked regions of DNA, so called bubbles. For a comparison with another psoralen type, we have carried out a similar set of experiments using 4,5,8-trimethylpsoralen.