Non-immediate drug hypersensitivity reactions secondary to intravitreal anti-vascular endothelial growth factors

Purpose

To describe a series of non-immediate drug hypersensitivity reactions after intravitreal anti-vascular endothelial growth factors (anti-VEGFs).

Patients and methods

Retrospective report of 6 patients with cutaneous non-immediate drug hypersensitivity reactions following intravitreal anti-VEGF injections, 4 after ranibizumab, 1 after bevacizumab and 1 after aflibercept.

Results

Clinical manifestations ranged from mild maculopapular rash, purpura to severe generalized erythroderma, with or without systemic involvement such as microscopic hematuria and proteinuria or fever. In two out of the six patients, reintroduction of either the same or an alternative anti-VEGF drug did induce a recurrence of the drug hypersensitivity reaction, while 4 patients showed no recurrence.

Conclusion

Cutaneous non-immediate drug hypersensitivity reactions secondary to intravitreal anti-VEGF may occur. Continuation of the same drug or switch to another anti-VEGF may either induce recurrence or be well supported by the patient. The decision of drug discontinuation should be guided by the severity of the disease.

Albumin—Beyond Fluid Replacement in Cardiopulmonary Bypass Surgery

Maintaining vascular barrier competence, preventing interstitial edema, and keeping microcirculation intact is crucial to achieve an optimal outcome in cardiopulmonary bypass surgery (CPB). Blood contact with roller pumps and foreign surfaces during CPB induces shear stress and a pressure drop across the pump boot that leads to transient systemic activation of the inflammatory and hemostatic systems. Moreover, patients after CPB often need volume resuscitation using the smallest possible amount of colloid solution because of fluid overload. For this purpose, human-derived albumin may be preferred over synthetic colloids because CPB priming with albumin preserves oncotic pressure, prevents platelet adhesion, and likely induces less consumption of coagulation factors. In patients with increased bleeding or renal failure, albumin is a safe alternative because of its minimal side effects. Large, randomized clinical trials comparing the benefit of albumin versus other fluids are warranted in the future to define albumin’s distinct role in select high-risk surgical populations.

[Spanish Society of Anaesthesia (SEDAR) guidelines for pre-anaesthesia checking procedures]

We present this document as a guide to preparing a specific institutional pre-anaesthesia checklist, as recommended in the Helsinki declaration on patient safety in anaesthesiology. Also, the recently recommended WHO "safe surgery check-list" includes a check-list for anaesthesia. A working group was established in accordance with the charter of the Spanish Society of Anaesthesiology and Resuscitation (Sociedad Española de Anestesiología y Reanimación [SEDAR]). The new patient safety culture introduced into medicine, and the recommendations of European anaesthesia societies has led us to design and update protocols in order to improve results in this important part of our speciality. We have prepared these recommendations or guidelines using, as examples, updates of pre-anaesthesia check-lists by other American (ASA), British, or Canadian societies of anaesthesia. With that aim, we enlisted the help of anaesthesia ventilator experts and the participation and advice of experienced anaesthesiologists from all parts of Spain. After various corrections and modifications, the document was available at www.sedar.es, so that any anaesthesiologist could propose any correction, or give their opinion. Finally, these guidelines have been approved by the SEDAR Board of Directors, before it was sent for publication in this journal. The aims of this document are to provide: a guideline applicable to all anaesthesia machines, a descriptive pre-anaesthesia check-list that include everything necessary for the anaesthesia procedure, and a resumed check-list to be available in all the anaesthesia machines or other equivalent, but prepared for each institution, which should include anaesthetic equipment and drugs. So, in order to ensure the aims and requirements of the European Board of Anaesthesiology, the European Society of Anaesthesiology, and the WHO are met, each institution should have a protocol for checking equipment and drugs. These guidelines are applicable to any anaesthesia equipment, enabling every institution to develop their own checking protocols, adapted to their anaesthesia machines and their procedures. With the consent of the SEDAR, this group will collaborate with anaesthesia machines providers in order to develop specific checklists for each of their models that will be available at www.sedar.es.

[Multidisciplinary approach to treating life-threatening massive hemoptysis]

Massive hemoptysis is an alarming event in which asphyxiation due to aspiration of blood is the main threat. The differential diagnosis taking into consideration a wide range of potential causes is required, and in 5% to 20% of cases, the reason for bleeding is never established. Hypoxemia and rebleeding are the main life-threatening complications. We describe the case of a 68-year-old man with no relevant medical history whose massive hemoptysis and complications were treated successfully by a multidisciplinary team.

[Problem-based learning in an undergraduate medical school course on anesthesiology, recovery care, and pain management]

INTRODUCTION

We describe our experience with problem-based learning (PBL) in an undergraduate course in anesthesiology and recovery care.

MATERIAL AND METHODS

The study was carried out over 5 consecutive academic years from 2000 through 2005. In total, 168 students took part. PBL was started in seminars in the first 3 years the course was given. In the last 2 years, PBL was used throughout the entire course, which consisted of 12 seminars. At the end, each student evaluated the activities overall, the tutor's intervention, the student's own participation, and the time invested in searching for information and preparing for discussions.

RESULTS

In the first 3 years, most students considered they had better assimilated the knowledge presented and that they had participated more. In the last 2 years, assessment of the course overall reached a score of 8.47 (SD, 1.24); of the instructor, 8.84 (0.98); and of student participation, 7.38 (1.29). The students used 2.11 (1.43) hours to search for information and 1.74 (1.14) hours to prepare for discussion.

CONCLUSIONS

The medical students' level of satisfaction with and acceptance of PBL in this anesthesiology course were high. The instructor's intervention and student participation were assessed highly. A large amount of time was used for study.

[Anesthesia in 2 cases of resection of a renal tumor involving the vena cava]

Renal tumors can be associated with a thrombus that affects the renal vein and even the inferior vena cava. Radical surgery may require a 2-phase approach involving different anesthetic techniques: an abdominal approach for removal of the kidney and a thoracic approach for extraction of the thrombus, with extracorporeal circulation and in some cases cessation of blood circulation. We present 2 cases in which nephrectomy and thrombectomy were carried out with the support of extracorporeal circulation. The thrombus was in the renal vein and the inferior vena cava, extending to the outlet to the right atrium in both cases. In 1 case a portion reached the bifurcation of the pulmonary artery. The operation was performed under hypothermia to reduce circulation and did not require aortic clamping, cardioplegia, or cessation of blood flow.

[Transvaginal contrast sonography of the uterus in the diagnosis of abnormal uterine blood loss: less hysteroscopies needed]

OBJECTIVE

To determine the value of transvaginal saline-infusion sonography of the uterus in patients with abnormal uterine blood loss in terms of avoiding hysteroscopy.

DESIGN

Prospective.

METHOD

According to the protocol, transvaginal saline-infusion sonography was carried out on all consecutive patients with abnormal uterine blood loss (post-menopausal patients with an endometrial thickness of > or = 5 mm and all pre-menopausal patients with menorrhagia or metrorrhagia) in the St. Joseph hospital in Veldhoven, the Netherlands, during the period 1999-2001. If sonography did not provide an image suitable for assessment, or if intracavitary (pedunculated) lesions such as polyps or myomas were suspected, a planned therapeutic hysteroscopy was carried out. Patients indicated their perception of pain on a visual analogue scale.

RESULTS

Saline-infusion sonography of the uterus was performed in 457 patients (age: 40-69 years). In 32 patients (7%) it did not result in a representative image. In 138 (32%) of the remaining 425 patients, a pedunculated lesion was suspected. In 262 (59%) of the 457 patients, diagnostic efforts were restricted to ultrasonic examination. This was combined with endometrial aspiration in 161 (61%) of these patients. In total, hysteroscopy was carried out in 195 of the 457 patients (43%). There were no complications. Pain was scored as 'none-little' by 292 patients (64%), 'moderate' by 76 (17%) and 'a great deal' by 48 (10%) patients.

CONCLUSION

Saline-infusion sonography of the uterus is a safe diagnostic method in patients with abnormal uterine blood loss, which, in more than half the cases, can replace less well-tolerated diagnostic procedures.

Comparison of transvaginal sonography, saline infusion sonography, and hysteroscopy in premenopausal women with abnormal uterine bleeding

PURPOSE

Saline infusion sonography (SIS) is a relatively new technique in the evaluation of abnormal uterine bleeding. We compared the diagnostic accuracy of SIS with that of transvaginal sonography (TVS) in the detection of intracavitary abnormalities in premenopausal women with abnormal uterine bleeding.

METHODS

In this prospective study, consecutive premenopausal women who underwent a hysteroscopy for abnormal uterine bleeding also underwent TVS and SIS. The findings at TVS and SIS were compared with the hysteroscopic and histologic findings. Sensitivity, specificity, and likelihood ratios were calculated. Receiver operating characteristic curves were constructed to assess the performance of endometrial thickness measured using TVS.

RESULTS

Sixty-two patients were included in the study. TVS demonstrated 60% sensitivity in directly visualizing intracavitary abnormalities and 93% specificity. The likelihood ratio of the presence of an intracavitary abnormality was 8, and the likelihood ratio of the absence of an intracavitary abnormality was 0.43. Defining an abnormality at TVS as direct visualization of an intracavitary abnormality or an endometrial thickness greater than 5 mm, TVS had an 85% sensitivity and a 21% specificity, with corresponding likelihood ratios of 1.1 and 0.71, respectively. For SIS, the sensitivity, specificity, and likelihood ratios of the presence and absence of intracavitary abnormalities were 88%, 95%, 10, and 0.13, respectively.

CONCLUSIONS

SIS is more accurate in the diagnosis of intracavitary abnormalities in premenopausal women than is TVS. An approach using endometrial thickness measurement by TVS and reserving SIS for patients who have an endometrial thickness greater than 5 mm or an intracavitary abnormality visualized by TVS would be the most effective method to reduce the number of hysteroscopies.

Comparison of transvaginal ultrasonography and saline infusion sonography for the detection of intracavitary abnormalities in premenopausal women

OBJECTIVE

To compare the diagnostic accuracy of transvaginal sonography (TVS) and saline infusion sonography (SIS) for detecting intracavitary abnormalities in premenopausal women with abnormal uterine bleeding.

METHOD

Consecutive premenopausal women who underwent hysterectomy for abnormal uterine bleeding were included. All women underwent TVS and SIS before their hysterectomy. The findings at TVS and SIS were compared with the findings of the hysterectomy specimen. Sensitivity, specificity, and likelihood ratios were calculated.

RESULTS

The results of 50 patients with abnormal uterine bleeding were evaluated. Histological examination revealed normal endometrial histology in 27 patients, submucous myomas in 13 patients and intracavitary polyps in 10 patients. The sensitivity of TVS in directly visualizing intracavitary abnormalities was 61% for a specificity of 96%. The likelihood ratio of presence of an intracavitary abnormality was 16 and the likelihood ratio of absence of such a finding was 0.41. When defining abnormality at TVS as direct visualization of an intracavitary abnormality or an increased endometrial thickness (cut-off level 5 mm), the sensitivity of TVS was 87% for a specificity of 56%, with corresponding likelihood ratios of 2 and 0.23, respectively. The sensitivity and specificity of SIS was 100% and 85% with likelihood ratios of 6 and 0.0, respectively. No intracavitary abnormality was missed by SIS.

CONCLUSION

The diagnostic accuracy of SIS is higher than the accuracy of TVS. A combined approach using endometrial thickness measurement by TVS and, reserving SIS for patients with increased (> 5 mm) endometrial thickness, or endometrium inadequately visualized on TVS, is the optimal method of reducing the hysteroscopy rate.

[Ultrasonographic diagnosis of endometrial disorders: correlation with the histological results in 112 patients]

The diagnosis of endometrial lesions hitherto was mainly made on the basis of histological examination. The objective of this study was the assessment of the diagnostic accuracy of transvaginal ultrasound investigation by comparison with the usual histological investigation, which implies painful endometrial sampling. 112 perimenopausal women with irregular vaginal blood loss were examined by transvaginal ultrasound. Shortly afterwards endometrial sampling was performed by means of aspiration, conventional curettage or hysteroscopically guided biopsies. The group of 112 patients included 11 women who had previously received hormone substitution therapy (10%). The other patients (without previous hormone substitution therapy) were divided into a premenopausal group (n = 47) and a postmenopausal group (n = 54). In case of an endometrial thickness (single layer) of less than 3 mm in postmenopausal patients, no (pre)malignant lesions were found. In the pre- and postmenopausal group, using this cut-off-level two of the five endometrial hyperplasias were ultrasonographically missed. All fourteen endometrial carcinomas in 112 patients were ultrasonographically detected by an endometrial thickness > or = 4 mm. In the postmenopausal group specificity was 73% (16/22) using a cut-off-level of 3 mm, in the premenopausal patients it was only 36% (11/31). Regular echo-density or a clear alignment between endo- and myometrium hardly had any value in the diagnosis of (pre)malignant lesions of the endometrium. If our patients with an endometrial thickness of less than 3 mm would not have had an endometrial curettage, 38 of 112 (34%) endometrial samplings might have been avoided. According to our view, transvaginal endometrial examination can be of distinct value in the detection of (pre)malignant endometrium.

Monitoring of oestrogen replacement therapy by vaginosonography of the endometrium

To prevent hyperplasia and carcinoma of the endometrium during oestrogen replacement therapy (ORT), the addition of progestogens once a month is considered mandatory. However, there is no sound scientific basis for this assumption. As the addition of progestogens has several disadvantages, it is important to minimize the frequency of progestogen addition. Vaginosonography is a rather new technique which has not yet been used for monitoring ORT. In this study the increase in endometrial thickness, as measured by vaginosonography, was taken as an indicator of stimulation of the endometrium by oestrogens. Oestrogen treatment was started in post-menopausal women with little endometrium (thickness less than 3 mm). As long as there was virtually no increase during oestrogen treatment, no progestogen was added, but where considerable growth occurred (greater than 3 mm) progestogen was administered. By means of vaginosonography the growth of the endometrium can be monitored precisely on an individual basis. It is thus possible to distinguish women with a slow growing endometrium from those with an endometrium that grows fast. In this way it will perhaps become possible to minimize progestogen addition during ERT by tailoring dosage to individual requirements.

Investigation of the antihistaminic action of dimethindene maleate (Fenistil) and its optical isomers

Dimethindene maleate (DM) (= Fenistil) is a potent antihistamine with a prolonged duration of action. On the histamine-stimulated guinea-pig ileum DM has a pA2 of 9.3 but produces a very marked depression of the maximum response at 10(-8) M. DM has no effect on H2 receptors nor on H3 receptors, and is not a calcium channel blocker. Muscarinic receptors (carbachol-stimulated ileum) were only influenced (competitively) at 10(-7) M or above, suggesting that the non-competitive effects described above could be due to a specific reaction with the histamine H1 receptor. As non-specific effects, such as membrane-stabilisation, would normally be seen with both isomers equally, we studied the effects of the optical isomers of DM. The (-) isomer had a profile identical to that of DM, but was slightly more potent. The (+) isomer was some 30 times less potent (results confirmed by binding studies). However in contrast to DM and the (-) isomer, the (+) isomer showed a "classical" antagonism, pA2 = 7.7, with no evidence of non-competitive effects. Thus the more active (-) isomer of DM has a potent, non-competitive H1 histamine antagonist effect. The relevance of these findings to DM's clinical profile is discussed.

Does a 2----5 beta-turn structure exist in enkephalins? Study of a fully protected Leu-enkephalin in organic solution by 17O-NMR

The 17O chemical shifts of the Gly-2 and Gly-3 oxygens of a fully protected Leu-enkephalin were measured to be identical in acetone solution. This allows the conclusion that neither of these peptide oxygens is hydrogen bonded and that no specific 2----5 beta-turn structure exists to an appreciable extent.

A new culdocentesis system

A new culdocentesis system is presented, based on vacuum fixation of the posterior vaginal wall together with Douglas peritoneum in a small vacuum cup, enabling a controllable central perpendicular puncture with a special catheter-needle unit. The advantages of the new system are the creation of a relatively safe and painless access to the pouch of Douglas, less risk of contamination, the possibility of repetitive examinations, and satisfactory effectiveness in collecting peritoneal fluid. The results of 164 culdocenteses in ambulant infertility patients are reported. Application of the technique is proposed for the investigation of sperm migration in vivo, steroid analysis of peritoneal fluid, and intraperitoneal insemination.