Benefits and risks of a percutaneous endoscopic gastrostomy (PEG) for decompression in patients with malignant gastrointestinal obstruction.

PURPOSE: Gastrointestinal obstruction presents many burdens for patients with end-stage abdominal cancer, such as nausea and vomiting. Few detailed data on the efficacy of a percutaneous endoscopic gastrostomy (PEG) for decompression exists. This retrospective cohort study investigates the quantity of symptom relief realized with PEG and the corresponding complications. METHODS: Chart reviews of 75 patients with malignant gastrointestinal obstruction, who received a PEG for decompression, were performed. Abstracted data includes symptoms (vomiting, nausea, abdominal pain) and medication up to 7 days before and after the intervention, complications, demographics, potential influencing factors and survival. Generalized estimating equations (GEE) models determined symptom reduction. RESULTS: PEG decreased the mean frequency of vomiting per day from 2.2 (95% confidence interval (CI) 1.7-2.7) to 0.4 (95% CI 0.3-0.6) (p < 0.001). The probability of the occurrence of nausea on a given day was 80% (95% CI 74-85%) prior to the PEG placement and 40% (95% CI 34-47%) afterwards (p < 0.001). One hundred twelve complications were reported in 56 patients (none 19/75 patients (25%), minor 52/75 (69%), major 18/75 (24%)). Stomal leakage (18/75 patients), mild wound pain (17/75) and tube occlusion (13/75) occurred most frequently. The failure of the first attempt of the PEG placement (7/75) presented as the leading major complication. CONCLUSIONS: The PEG for decompression significantly reduces vomiting and nausea in patients with malignant gastrointestinal obstruction (p < 0.001). Minor complications are common and should be discussed prior to the intervention. Nevertheless, the PEG appears to demonstrate prevailing benefits in comparison to the risks.

Exanthematous infantile psoriasis.

Childhood psoriasis is a disease with manifold clinical presentations which can make the correct diagnosis sometimes difficult. In a female infant, slightly itching, erythematous papules and plaques with discrete scaling spread over large parts of the integument starting from age three months. Histological examination supported the diagnosis of exanthematous infantile psoriasis. Topical treatment with dithranol in petrolatum led to slow clearance of the skin lesions.

Nonsteroidal anti-inflammatory drug hypersensitivity: fable or reality?

In the medical community lectures and publications about nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity have led to an increasing awareness and diagnosis of this condition. Frequently, the diagnosis NSAID hypersensitivity is based only on history, which is a vague and unreliable indicator. A two-stage diagnostic procedure with skin tests (to exclude IgE-mediated allergy) followed by single-blinded, placebo-controlled oral challenges was carried out on patients attending our clinic from 1997 to 2003 with the diagnosis of a NSAID hypersensitivity. Out of 260 patients tested, 61.5% described their NSAID hypersensitivity as cutaneous (urticaria, angioedema), 24.2% had respiratory symptoms (asthma, rhinitis), 3.5% had anaphylactoid reactions, and 10.8% described uncertain signs. In fact 55.0% of all patients previously labelled as NSAID sensitive tolerated NSAID when assessed by oral challenge, whereas 13.8% were truly NSAID sensitive. In 31.2% of patients the challenge test with the suspicious drug was either not done or rejected by the patient; but all showed a proven tolerance of alternative NSAID. Our study demonstrates that oral challenge tests are safe, practical and useful in ruling out NSAID hypersensitivity in approximately 50% of the patients who have previously been labelled as such.

Militarinone A, a neurotrophic pyridone alkaloid from Paecilomyces militaris.

[structure: see text] A new pyridone alkaloid, militarinone A (1), was isolated by bioassay-guided fractionation from the mycelium of the entomogenous fungus Paecilomyces militaris. Its structure was established by extensive spectroscopic analysis. The compound features an unprecedented side chain and a 1,4-substituted cyclohexyl moiety not previously encountered in microbial metabolites. Militarinone A had a pronounced neurotrophic effect in PC-12 cells at 10 microM concentrations.

(+)-N-Deoxymilitarinone A, a neuritogenic pyridone alkaloid from the insect pathogenic fungus Paecilomyces farinosus.

A new pyridone alkaloid, (+)-N-deoxymilitarinone A (1), was isolated from Paecilomyces farinosus RCEF 0097 along with the related metabolites, militarinone D and militarinone B. The sterol 22E,4R-ergosta-7,22-diene-3beta,5alpha,6beta,9alpha-tetraol was also identified. The structures were established by spectroscopic methods, in particular with the aid of extensive NMR experiments. Compound 1 induced neurite sprouting in PC 12 cells when tested at 33 and 100 microM concentrations. A cytotoxic effect was observed in human neurons (IMR-32) at a concentration of 100 microM.

A dangerous liaison--pheochromocytoma in patients with malignant disease.

BACKGROUND: Adrenal masses in patients with known malignancy may be interpreted as metastasized disease, although a significant proportion of these tumors are of adrenal origin. Despite improved imaging techniques, it remains difficult to distinguish an adrenal metastasis from a pheochromocytoma or a lipid-poor adrenocortical adenoma. PATIENTS AND METHODS: We report a case series of four patients with established or suspected malignant disease (melanoma, transitional cell carcinoma and prostate carcinoma, thyroid carcinoma, colorectal carcinoma) harboring an adrenal mass. None of these patients showed clinical symptoms indicative for a pheochromocytoma. RESULTS: Surgery unrelated to the adrenal lesion (n = 3) or biopsy of the adrenal mass (n = 1) was performed without prior endocrine work-up. Pronounced hemodynamic instability including hypertensive crisis was observed during surgery in all patients. In contrast, in the same patients preoperative alpha-blockade with phenoxybenzamine and an increased awareness of the potential risks led to improved hemodynamic stability following adrenalectomy for pheochromocytoma. CONCLUSION: Our series is a strong reminder of the risks associated with surgery in patients harboring an unsuspected pheochromocytoma and underscores the need to exclude a pheochromocytoma in all patients with an adrenal mass and without a definitive diagnosis of the mass, especially when they are scheduled for surgery or adrenal biopsy. Otherwise, life-threatening hypertensive crisis can be precipitated even in the previously asymptomatic patient.

Farinosones A-C, neurotrophic alkaloidal metabolites from the entomogenous deuteromycete Paecilomyces farinosus.

Two new yellow pigments, farinosones A (1) and B (2), were isolated from the mycelial extract of the entomogenous fungal strain Paecilomyces farinosus RCEF 0101, together with farinosone C (3), a new metabolite derived from an early step of pyridone alkaloid biosynthesis. The structures were determined by spectroscopic means, in particular by extensive NMR experiments. Compounds 1 and 3 induced neurite outgrowth in the PC-12 cell line at concentrations of 50 microM, while compound 2 was inactive. No cytotoxicity was observed for compounds 1-3 in PC-12 cells when tested at 50 microM concentration in the MTT assay.

Capnography in non-tracheally intubated emergency patients as an additional tool in pulse oximetry for prehospital monitoring of respiration.

UNLABELLED: Victims of minor trauma transported by paramedic-based rescue systems are usually monitored with pulse oximetry. Under the difficult surroundings of prehospital trauma care, pulse oximeters show considerable periods of malfunction. We tested the hypothesis that capnography is a good, easy to use tool for monitoring in nonintubated trauma victims. Seventy nonintubated trauma victims were included in this study. Vital variables and number and time of malfunctions were sampled for oximeter and capnometer recordings. Total number of alerts (63 versus 10), number of alerts per patient (3.3 [1.9] versus 0.3 [0.9]) (mean [SD]), total time of malfunction (191.5 [216.7] s versus 11.8 [40.2] s), time of malfunction per alarm (58.3 [71.4] s versus 5.5 [14.6] s), and the percentage of malfunction time during transport (13.2% [15.3%] versus 0.8% [2.8%]) differed significantly (P < 0.01) between oximetry and capnography. Although pulse oximetry is a standard method of monitoring in emergency care, we found capnography to be helpful as a monitoring device. We consequently recommend the use of capnography on transport as an additional monitoring tool to reduce periods lacking supervision of the vital variables. IMPLICATIONS: Capnography is a useful tool to improve respiratory monitoring in nonintubated trauma victims on emergency transport and an easy to use supplement to pulse oximetry.

Subacute prurigo variant of bullous pemphigoid: autoantibodies show the same specificity compared with classic bullous pemphigoid.

We describe a 76-year-old white woman with a 6-month history of intensive pruritus and excoriated papules resembling subacute prurigo. Histopathology showed signs of chronic dermatitis, whereas findings by direct and indirect immunofluorescence microscopy were compatible with bullous pemphigoid (BP). The patient's serum contained IgG autoantibodies that recognized epitopes on both BP180 and BP230 by Western blot analysis of epidermal extracts. In addition, we found strong reactivity with recombinant NC16A, an immunodominant region of BP180 targeted in the majority of BP sera, whereas no antibodies against the keratinocyte-derived soluble BP180 ectodomain (LAD-1) or the recombinant intracellular domain of BP180 were detected. The patient's disease responded well to oral methylprednisolone and mycophenolate mofetil. Disease activity correlated with enzyme-linked immunosorbent assay reactivity of antibodies to BP180 but not with titers of antibodies to the dermoepidermal junction as determined by indirect immunofluorescence on salt-split skin. Our findings suggest that the subacute prurigo form of BP is a true variant of BP.

Auricular acupressure as a treatment for anxiety in prehospital transport settings.

BACKGROUND: Auricular acupuncture at the relaxation point has been previously shown to be an effective treatment for anxiety in the preoperative setting. The purpose of this prospective, randomized, blinded study was to determine whether auricular acupressure can reduce stress and anxiety during ambulance transport. METHODS: Patients who required ambulance transport secondary to medical conditions were randomized to receive auricular acupressure at the relaxation point (n = 17) or at a sham point (n = 19). A visual analog scale was used to assess state anxiety as well as patient anticipation of hospital medical treatment (estimated waiting period for treatment, anticipated pain during treatment, attitude toward the physicians, and treatment outcomes). These variables were assessed at baseline and on arrival to the hospital. RESULTS: Patients in the relaxation group reported significantly less anxiety than patients in the sham group on arrival to the hospital (visual analog scale mean +/- SD: 37.6 +/- 20.6 to 12.4 +/- 7.8 mm vs. 42.5 +/- 29.9 to 46.7 +/- 25.9 mm, respectively; P = 0.002). Similarly, patient perception of pain during treatment (mean visual analog scale +/- SD: 32.7 +/- 27.7 to 14.5 +/- 8.1 mm vs. 17.2 +/- 26.1 to 28.8 +/- 21.9 mm, respectively; P = 0.006) and treatment outcomes of their illnesses (mean visual analog scale +/- SD: 46.7 +/- 29.4 to 19.1 +/- 10.4 mm vs. 35.0 +/- 25.7 to 31.5 +/- 20.5 mm, respectively; P = 0.014) were significantly more positive in the relaxation group than in the sham group. No differences were found in the other variables assessed. CONCLUSION: It was concluded that auricular acupressure is an effective treatment for anxiety in prehospital emergency settings.