Symptomatic corpus luteum hemorrhage in adolescent females with ITP

Patients with immune thrombocytopenia (ITP) usually present with minor mucocutaneous bleeding. Corpus luteum hemorrhage (CLH) is generally asymptomatic but may, rarely, lead to severe intraperitoneal bleeding, mostly in patients with coagulation disorders. CLH causing intraperitoneal bleeding has only been described in few individuals with ITP. The objective of this retrospective observational study was to assess the clinical course and incidence of symptomatic CLH in adolescent females with newly diagnosed or chronic ITP. Additionally, a comprehensive literature review was conducted to scrutinize cases of pediatric female patients with ITP, complicated by CLH. We identified three patients with ITP and hemoperitoneum secondary to CLH. They presented with acute abdominal pain, had severe thrombocytopenia (platelet counts below 20 × 109/L), and required blood transfusions as well as ITP-directed therapy. All the patients were hemodynamically stable and did not require emergency surgical intervention.  Conclusion: CLH could potentially pose a significant complication in the context of adolescent females with ITP, requiring a strong index of suspicion to direct expedient therapy. What is Known: • Immune thrombocytopenia is typically associated with minor bleeding tendency. • Corpus luteum hemorrhage is generally asymptomatic; however, in women with bleeding disorders, it has the potential to result in substantial intra-abdominal bleeding. What is New: • Corpus luteum hemorrhage leading to intra-abdominal bleeding is a potential severe complication of immune thrombocytopenia in adolescent females.

The efficacy and safety of intra-articular injection of triamcinolone acetonide versus triamcinolone hexacetonide for treatment of juvenile idiopathic arthritis

OBJECTIVES

Juvenile idiopathic arthritis (JIA) is the most common childhood rheumatic disease. Intra-articular corticosteroids joint injection (IAJI), with triamcinolone hexacetonide (TH) or triamcinolone acetonide (TA), is an effective additional treatment for oligo and polyarticular JIA. Previous studies have shown the benefits of TH over TA; however, TA is still used in many pediatric rheumatology centers. Our unit has experience with both regimens, and therefore we aimed to compare the efficacy and safety of TA versus TH for JIA patients.

METHODS

Chart review of JIA patients who were randomly (based on drug availability) treated with TA or TH IAJI during 2010-2019. Primary outcomes for efficacy were defined as full recovery from arthritis one month after IAJI and a relapse rate of arthritis 3 months after IAJI. Primary outcome for safety was defined as the occurrence of adverse events (AEs) during the follow up period after IAJI.

RESULTS

Overall, 292 joints of 102 JIA patients were treated (138 TA/154 TH joints). Complete recovery after one month was documented in 107 (69.6%) of TA treated joints and 96 (69.5%) of TH treated joints (P = 0.232). However, rate of relapse after 3 months was significantly higher for TA treated joints (27 (20.1%) vs. 13 (8.8%), respectively, P < 0.01). No AEs were documented except minor scars at four joint injection sites.

CONCLUSION

The recovery from arthritis was similar (~ 70%) with both regimens, however relapse rate was more than double in TA as compared to TH injected joints. These findings are important due to a contemporary shortage of TH in the US market.

Autonomic Nervous System Indices in Patients with Systemic Sclerosis without Overt Cardiac Disease

BACKGROUND

Systemic sclerosis (SSc) is a connective tissue disease that may affect the heart and the autonomic nervous system (ANS). There is little knowledge regarding the degree of ANS involvement in SSc patients with unknown cardiac disease.

OBJECTIVES

To evaluate cardiac and pupillary autonomic functions in patients before cardiac involvement has emerged.

METHODS

The study comprised 19 patients with SSc and 29 healthy controls. Heart rate variability (HRV) analysis for time and frequency domains, as well as deep breathing test and Ewing maneuvers, were performed in all patients. Automated pupillometry for the evaluation of pupillary diameter and pupillary light reflex was completed in 8 SSc patients and 21 controls.

RESULTS

Both groups had similar characteristics, except for medications that were more commonly or solely prescribed for SSc patients. Compared with control subjects, the SSc patients had significantly lower HRV parameters of NN50 (15.8 ± 24.4 vs. 33.9 ± 33.1, P = 0.03), pNN50 (4.9 ± 7.4% vs.10.8 ± 10.8%, P = 0.03), and triangular index (11.7 ± 3.4 vs. 15.7 ± 5.8, P = 0.02). Abnormal adaptive responses in heart rate changes were recorded during deep breathing tests and Ewing maneuvers. There was no significant difference in any of the pupillometric indices or other HRV parameters within groups.

CONCLUSIONS

SSc patients may manifest cardiac autonomic dysfunction, while their autonomic pupillary function is seemingly spared. The role of certain medications, the significance of differential organ involvement, as well as the prognostic value of our findings should be evaluated in future studies.

Repolarization dispersion in patients with systemic sclerosis

OBJECTIVE

Systemic sclerosis (SSc) is associated with increased cardiac morbidity and mortality. Whether some electrocardiographic markers of arrhythmias predispose to early cardiogenic death in SSc remains controversial. This study evaluated the occurrence of previously reported as well as unstudied markers of repolarization in patients with SSc and assessed their prognostic implications.

METHODS

A total of 21 patients with SSc and 31 unaffected controls were included in this prospective study. Electrocardiograms were conducted under strict standards. Repolarization and dispersion parameters and markers of late ventricular potentials were determined using designated computer software. Results of multiple beats were averaged.

RESULTS

There were no significant differences between the SSc and control groups in average QT intervals, average corrected QT intervals, average QT interval dispersion (QTd), average QT corrected dispersion (QTcd), and QT dispersion ratio. However, average QT apex dispersion, average JT dispersion, average JT corrected dispersion, and Tpeak-Tend corrected were significantly higher in patients with SSc than in controls. Late ventricular potentials were not found in patients with SSc or in controls. Increased QTd and QTcd were recorded in 1 patient who experienced ventricular arrhythmia before inclusion in the study. None of the remaining patients with SSc or the controls developed arrhythmia during the 9-year follow-up.

CONCLUSION

Abnormal repolarization parameters may be observed in patients with SSc. However, their prognostic significance with regard to increased risk for repolarization-associated ventricular arrhythmias and increased cardiac death could not be determined in this study. Our findings endorse additional studies on this matter.

Risk factors for early invasive fungal infections in paediatric liver transplant recipients

Invasive fungal infections (IFIs) postliver transplantation are a frequent cause of morbidity and mortality; however, studies reporting on these infections in the paediatric population are scarce. To investigate the incidence and risk factors of IFIs in paediatric liver transplant recipients during the early posttransplantation period (≤3 months). Data were collected for all paediatric liver transplant recipients registered in a national transplantation center from 2004 to 2014. Using a stepwise logistic regression to identify independent risk factors for IFIs, a predictive model was formulated. Ten IFIs were identified in 81 liver transplant recipients (12.3%) all occurring during the first month posttransplantation. Candida species were responsible for nine cases (90%), of which four were non-albicans Candida (44%). Significant risk factors were identified; recipient of multiple blood product transfusions during transplantation, prolonged use of indwelling intravenous catheter, prolonged IV antibiotic treatment, surgical complications, pulse steroid treatment and living donor liver transplantation. The predictive model used two clinical parameters to define high-risk patients: a living donor transplantation and duration of IV antibiotic treatment (area under the ROC curve 0.918). IFIs are a significant complication occurring in the first month posttransplantation. Future studies are required to assess efficacy of targeted antifungal prophylaxis in high risk patients.

Design and Development of a Mobile System for Supporting Emergency Triage

Objectives: Our objective was to design and develop a mobile clinical decision support system for emergency triage of different acute pain presentations. The system should interact with existing hospital information systems, run on mobile computing devices (handheld computers) and be suitable for operation in weak-connectivity conditions (with unstable connections between mobile clients and a server).

Methods: The MET (Mobile Emergency Triage) system was designed following an extended client-server architecture. The client component, responsible for triage decision support, is built as a knowledge-based system, with domain ontology separated from generic problem solving methods and used for the automatic creation of a user interface.

Results: The MET system is well suited for operation in the Emergency Department of a hospital. The system’s external interactions are managed by the server, while the MET clients, running on handheld computers are used by clinicians for collecting clinical data and supporting triage at the bedside. The functionality of the MET client is distributed into specialized modules, responsible for triaging specific types of acute pain presentations. The modules are stored on the server, and on request they can be transferred and executed on the mobile clients. The modular design provides for easy extension of the system’s functionality. A clinical trial of the MET system validated the appropriateness of the system’s design, and proved the usefulness and acceptance of the system in clinical practice.

Conclusions: The MET system captures the necessary hospital data, allows for entry of patient information, and provides triage support. By operating on handheld computers, it fits into the regular emergency department workflow without introducing any hindrances or disruptions. It supports triage anytime and anywhere, directly at the point of care, and also can be used as an electronic patient chart, facilitating structured data collection.

Clinical Decision Support System for Point of Care Use

Objectives: The objective of this research was to design a clinical decision support system (CDSS) that supports heterogeneous clinical decision problems and runs on multiple computing platforms. Meeting this objective required a novel design to create an extendable and easy to maintain clinical CDSS for point of care support. The proposed solution was evaluated in a proof of concept implementation.

Methods: Based on our earlier research with the design of a mobile CDSS for emergency triage we used ontology-driven design to represent essential components of a CDSS. Models of clinical decision problems were derived from the ontology and they were processed into executable applications during runtime. This allowed scaling applications’ functionality to the capabilities of computing platforms. A prototype of the system was implemented using the extended client-server architecture and Web services to distribute the functions of the system and to make it operational in limited connectivity conditions.

Results: The proposed design provided a common framework that facilitated development of diversified clinical applications running seamlessly on a variety of computing platforms. It was prototyped for two clinical decision problems and settings (triage of acute pain in the emergency department and postoperative management of radical pros-tatectomy on the hospital ward) and implemented on two computing platforms – desktop and handheld computers.

Conclusions: The requirement of the CDSS heterogeneity was satisfied with ontology-driven design. Processing of application models described with the help of ontological models allowed having a complex system running on multiple computing platforms with different capabilities. Finally, separation of models and runtime components contributed to improved extensibility and maintainability of the system.

Induced-Charge Capacitive Deionization: The Electrokinetic Response of a Porous Particle to an External Electric Field

We demonstrate the phenomenon of induced-charge capacitive deionization that occurs around a porous and conducting particle immersed in an electrolyte, under the action of an external electric field. The external electric field induces an electric dipole in the porous particle, leading to its capacitive charging by both cations and anions at opposite poles. This regime is characterized by a long charging time, which results in significant changes in salt concentration in the electrically neutral bulk, on the scale of the particle. We qualitatively demonstrate the effect of advection on the spatiotemporal concentration field, which, through diffusiophoresis, may introduce corrections to the electrophoretic mobility of such particles.

Neuro-QOL: brief measures of health-related quality of life for clinical research in neurology

OBJECTIVE

To address the need for brief, reliable, valid, and standardized quality of life (QOL) assessment applicable across neurologic conditions.

METHODS

Drawing from larger calibrated item banks, we developed short measures (8-9 items each) of 13 different QOL domains across physical, mental, and social health and evaluated their validity and reliability. Three samples were utilized during short form development: general population (Internet-based, n = 2,113); clinical panel (Internet-based, n = 553); and clinical outpatient (clinic-based, n = 581). All short forms are expressed as T scores with a mean of 50 and SD of 10.

RESULTS

Internal consistency (Cronbach α) of the 13 short forms ranged from 0.85 to 0.97. Correlations between short form and full-length item bank scores ranged from 0.88 to 0.99 (0.82-0.96 after removing common items from banks). Online respondents were asked whether they had any of 19 different chronic health conditions, and whether or not those reported conditions interfered with ability to function normally. All short forms, across physical, mental, and social health, were able to separate people who reported no health condition from those who reported 1-2 or 3 or more. In addition, scores on all 13 domains were worse for people who acknowledged being limited by the health conditions they reported, compared to those who reported conditions but were not limited by them.

CONCLUSION

These 13 brief measures of self-reported QOL are reliable and show preliminary evidence of concurrent validity inasmuch as they differentiate people based upon number of reported health conditions and whether those reported conditions impede normal function.

Triage of the child with abdominal pain: A clinical algorithm for emergency patient management

OBJECTIVE

To create a simplified clinical algorithm for the triage of children with abdominal pain.

DESIGN

Retrospective analysis.

SETTING

Emergency room at the Children's Hospital of Eastern Ontario, Ottawa, Ontario.

METHODS

A data mining methodology (rough sets analysis) was applied to a randomized data set obtained from 175 emergency room admission charts of patients. Patients were placed into two diagnostic decision classes: appendicitis confirmed by a pathological report, and resolution (this classification implied the resolution of all clinical complaints and physical findings, with no pathological diagnosis and no operative procedure).

RESULTS

Nine clinical symptoms and signs were identified as being important in the management of children with abdominal pain. A clinically based algorithm for the triage of such children was developed.

CONCLUSIONS

It is possible to develop a clinical algorithm for the triage of children with abdominal pain that can also be used by nonmedical professionals. A template for such an algorithm can be used as the basis for diagnosing other paediatric emergencies, such as chest pain, headaches and joint pain.

[Coronary embolism due to an adherent right atrium thrombus through a patent foramen ovale]

This observation relates to the discovery of native coronary paradoxical embolism secondary to thrombus adherent to the right atrium through a patent foramen ovale (PFO). A patient of 64 years, with a history of mitral regurgitation not followed, was hospitalized for acute respiratory distress due to a mitral insufficiency (MI) with a ruptured chordae and pulmonary embolism. Coronary angiography was performed and revealed two typical images of coronary embolism associated to a non-atheromatous coronary tree. The patient underwent a mitral valve replacement. After the establishment of cardiopulmonary bypass, adherent fibrin and cruoric thrombus of the right atrium and a PFO were found. The analysis of the valves did not reveal any arguments for infective endocarditis. A CT scan, performed as the patient remained unconscious after surgery, showed several cerebral infarcts. Paradoxical embolism coronary was diagnosed in front of the combination of adherent thrombus in the right atrium, pulmonary embolism and systemic coronary and cerebral embolism with a PFO. Coronary embolism rarely happens. It is mainly due to three causes: iatrogenic origin in most cases, direct causes due to micro emboli, particularly from infectious endocarditis and paradoxical embolic origin. There are two types of right atrial thrombus; the most common is the mobile thrombus from the peripheral venous system. The other one, which is more rare, is the adherent thrombus, which occurs in situ. Coronary embolism of paradoxical origin represents a small proportion of the causes of coronary embolism. However, this diagnosis must be considered.

[Primary myxoid mediastinal liposarcoma]

Mediastinal liposarcomas (LPS) are rare tumours. We report a case of primary myxoid LPS in a 22-year-old woman suffering from cough, dyspnoea on exercise and asthenia for 3 weeks. Thoracic MRI showed a large tumour on the right side. After neoadjuvant chemotherapy, a complete resection was performed, followed by adjuvant thoracic irradiation. Eighteen months after the diagnosis, no sign of recurrence was detected. Mediastinal LPS include a heterogeneous group of bulky tumours, the progression of which depends on the histological type. The prognosis is dominated by the operability of the tumour. Adjuvant therapies are not established.

Is staging beneficial for Fowler-Stephens orchiopexy? A systematic review

PURPOSE

Fowler and Stephens showed that by dividing the spermatic vessels a high intra-abdominal testis could be placed in the scrotum. Testicular atrophy is a potential complication of this technique. We conducted a systematic review to determine whether single or 2-stage Fowler-Stephens orchiopexy results in better testicular viability.

MATERIALS AND METHODS

We searched electronic databases, clinical trial registries and gray literature. We included reports describing boys younger than 18 years with a primary outcome of "testicular viability and position." We performed a meta-analysis using random effects models. Heterogeneity was assessed using forest plot and I(2) statistic.

RESULTS

We identified 1,807 citations and included 61 articles. Single stage Fowler-Stephens orchiopexy was discussed in 9 articles, a 2-stage procedure in 36 and both approaches in 16. There were no randomized controlled trials, and most studies were cohort or case series. The pooled estimate of success rates was 80% for single stage Fowler-Stephens orchiopexy (95% CI 75 to 86) and 85% for 2-stage Fowler-Stephens orchiopexy (95% CI 81 to 90). The pooled odds ratio of single stage vs 2-stage Fowler-Stephens orchiopexy was 2.0 (95% CI 1.1 to 3.9) favoring the 2-stage procedure. There was no difference in the success rate between laparoscopic and open techniques in either single or 2-stage Fowler-Stephens orchiopexy. There was no evidence of asymmetry on the funnel plot. There were no complications reported with single stage, while ileus, hematoma and infection were the most common complications with 2-stage Fowler-Stephens orchiopexy.

CONCLUSIONS

Both techniques have a fairly high success rate but 2-stage Fowler-Stephens orchiopexy appears to carry a higher rate of success than the single stage approach (85% vs 80%, OR 2 in favor of 2-stage). Laparoscopic and open techniques had the same success rate. However, the level of evidence of the studies was low, and a study of a more robust design, such as a randomized controlled trial, should be performed.

A Phase I Trial of a Pegylated Liposomal Anthracycline (Doxil TM) and Lapatinib Combination in the Treatment of Metastatic Breast Cancer: Dose-Escalation Results of an Anthracycline and Lapatinib Combination Trial

Background: Liposomal formulations such as pegylated liposomal doxorubicin (PLD) were developed to improve the therapeutic index and overall benefit of the anthracyclines (A). Lapatinib (L) is a selective and highly competitive inhibitor of ErbB1 and ErbB2 tyrosine kinases. The combination of conventional doxorubicin and an ErbB2 targeting agent (trastuzumab) was effective but led to an unacceptable risk of cardiac toxicity. The combination of PLD and L however may be effective with less cardiac risk. Methods: This is an open-label, phase I, dose-escalation trial of PLD at 20, 30, 45 and 60 mg/m2 IV every 4 weeks (maximum of 8 doses) and L, 1500 mg po daily until progression in patients (pts) with metastatic breast cancer (MBC). EGFR and/or ErbB2 positivity was not required. Prior chemotherapy, endocrine therapy and trastuzumab were allowed however prior A use was limited to 240 mg/m2 of doxorubicin or 600 mg/m2 of epirubicin. Initially, prior EGFR targeting therapies were not allowed however the trial was subsequently amended to allow prior lapatinib. Concomitant CYP3A4 inducers/ inhibitors were not allowed. A left ventricular ejection fraction (LVEF) of ≥ 50% was required. The primary objective was to evaluate the safety, tolerability and feasibility of the combination of PLD and L, particularly with respect to cardiac safety. MUGAs were performed at entry and every 8 weeks thereafter. Results: 16 patients (PLD: 20 mg/m2 - 4 pts; 30 mg/m2 - 3 pts; 45 mg/m2 – 6 pts; 60 mg/m2- 3 pts) with a mean age of 53 yrs (range, 33-68) have been treated for a total of 30 treatment cycles. Dose-limiting toxicity (DLT) was not reached. One pt experienced an LVEF drop to &lt; 50% after 4 cycles however this was accompanied by a pericardial effusion felt to be secondary to progressive disease. Adverse events observed include: grade IV- mucus plugging and knee pain in 1 pt each; grade III- fatigue and hand-foot-syndrome (HFS) in 2 pts each and edema, diarrhea, dizziness, headache, stomatitis and skin toxicity in 1 pt each; grade I/II in ≥2 pts- anemia, leucopenia, fatigue, shortness of breath, pain, nausea, stomatitis, anorexia, diarrhea, increased alkaline phosphatase or transaminases, hypoalbuminemia and hyperglycemia. Preliminary response data in 11 evaluable pts reveals 1 PR, 3 SD, and 8 PD. Event-free and overall survival curves are as shown.Conclusions: In the first 16 pts treated, the combination of PLD and L has been well tolerated without treatment-related cardiac toxicity. One pt experienced an LVEF drop to &lt; 50%, however this was felt likely to be disease-related. DLT was not reached however grade 3 HFS occurred in 2 out of 3 pts in the 60 mg/m2 cohort. A pharmacokinetic interaction cohort at the 45 mg/m2 dose is planned.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3096.