Splenic abscesses in childhood brucellosis: a case-based review.

OBJECTIVE: Human brucellosis is a zoonosis with an extremely wide spectrum of clinical manifestations. Focal splenic involvement is very uncommon, particularly in the pediatric age group, during the illness' acute phase. CASE REPORT: A 4-year-old boy, already receiving third-generation cephalosporin treatment, was transferred from a local hospital to the University Pediatric Department for fever, anemia, increased inflammation index, and multiple, hyper-echogenic splenic lesions on abdominal ultrasound. Initial diagnostic laboratory investigations for Brucella infection, including the Widal-Wright test, were found to be negative. However, further diagnostic laboratory analysis using the chemiluminescent immunoassay was positive for Brucella IgM antibodies. Treatment with rifampicin at a dose of 150 mg/Kg/twice daily and co-trimethoprim at a dose of 80 mg/Kg/twice daily was started and continued for 7 weeks. IgM antibodies were undetectable after 2 weeks of treatment, and after 6 weeks of treatment, abdominal ultrasound documented a reduction of the diameter of the major splenic infiltrate from 1 to 0.5 cm. At 3 and 5 months of follow-up, re-evaluation of the abdominal lesions displayed complete resolution of the splenic lesions and a complete clinical recovery. CONCLUSIONS: The present case and a literature review are presented in this study since a standard diagnostic laboratory evaluation for brucellosis may miss the diagnosis, and in suspected cases, the laboratory analysis should be extended. Splenic abscesses are known to be rare in brucellosis, but the diagnosis should be considered in children with severe focal lesions, as specific antibiotic treatment may result in complete clinical recovery.

Radiotherapy for the treatment of thyroid eye disease-a prospective comparison: Is orbital radiotherapy a suitable alternative to steroids?

BACKGROUND AND AIMS: To evaluate the efficacy of orbital radiotherapy (OR) for the treatment of thyroid eye disease (TED). METHODS: Thirty-five consecutive patients with active TED with contraindications to steroid therapy received a course of OR. Bilateral retrobulbar irradiation was performed with a total dose of 20 Gy. 7-points clinical activity score (7-CAS), ocular motility, visual acuity (VA), exophthalmos and eyelid retraction were prospectively evaluated at 3, 6 and 12 months and compared with baseline data. RESULTS: There was a statistically significant improvement in 7-CAS at 3, 6 and 12 months post-treatment (p < 0.05). Ocular motility disturbances improved at 6 and 12 months (p < 0.05). Visual acuity remained stable; there was no significant change in exophthalmos (mean 24 mm, SD 3 mm) or eyelid retraction (marginal reflex distance mean 6 mm, SD 1.5 mm) during the follow-up period. No side effects were registered. CONCLUSIONS: This study suggests that OR might be effective in reducing 7-CAS and ocular motility disturbances. No significant improvement in proptosis or eyelid retraction should be expected from this treatment. OR might be considered a suitable alternative treatment in TED for patients who cannot tolerate steroids.

Pulse pressure variation as a predictor of fluid responsiveness in mechanically ventilated patients with spontaneous breathing activity: a pragmatic observational study.

INTRODUCTION: Pulse pressure variation predicts fluid responsiveness in mechanically ventilated patients passively adapted to the ventilator. Its usefulness in actively breathing ventilated patients was examined only by few studies with potential methodological shortcomings. This study sought to describe the performance of pulse pressure variation as a predictor of fluid responsiveness in hypotensive critically ill patients who trigger the ventilator. METHODS: We studied forty two hypotensive, mechanically ventilated patients with documented spontaneous breathing activity in whom a fluid challenge was deemed necessary by the attending physician. All patients were ventilated with a Maquet Servo-i Ventilator in different ventilatory modes with a flow-regulated inspiratory trigger set on position 4. Pulse pressure variation, mean and systolic arterial pressure were observed before and after the fluid challenge, which consisted in the intravenous administration of a 250 ml bolus of 6% hetastarch. Fluid responsiveness was defined as a more than 15% increase in arterial pressure after volume expansion. RESULTS: The area under the receiver operator characteristic curve for pulse pressure variation was 0.87 (95% CI 0.74 -0.99; p<0.0001) and the grey zone limits were 10% and 15%. Pulse pressure variation was correlated with increase in systolic arterial pressure (r2=0.32; p<0.001) and mean arterial pressure (r2=0.10; p=0.037). CONCLUSIONS: Pulse pressure variation predicts fluid responsiveness in patients who actively interact with a Servo-i ventilator with a flow-regulated inspiratory trigger set on position 4.

Safety and efficacy of oral vinorelbine and capecitabine combination for metastatic breast cancer.

The aim of this prospective open-label study was to evaluate the efficacy and safety of oral vinorelbine in combination with capecitabine in patients with metastatic breast cancer (MBC). 51 patients with MBC received oral vinorelbine and capecitabine. The safety profile was analyzed through NCI-CTCAE v3.0 and response was evaluated using RECIST criteria. The overall response rate was 37.2%: there were four complete responders (8%) and fifteen partial responders (29.4%); practically all the responders were patients previously treated with anthracyclines and taxanes. Sixteen patients (31.3%) experienced stable disease. The clinical benefit rate was 68.5%. The median time to progression was 8 months (range 2-43; 95% CI: 6-10.8). Vinorelbine in combination with capecitabine is an effective and safe schedule for patients with MBC especially after pretreatment with anthracycline/ taxane-based regimens. The clinical benefit suggests that this may be a promising schedule in the MBC initial treatment.

Weekly combination of non-pegylated liposomal doxorubicin and taxane in first-line breast cancer: wALT trial (phase I-II).

BACKGROUND: Through different pharmacodynamic-kinetic interactions, weekly administration of proved efficacy agents can overcome resistance with lower toxicity and greater benefit. Based on this assumption, we designed a phase I-II trial with weekly non-pegylated liposomal anthracycline and taxane in first-line breast cancer patients. PATIENTS AND METHODS: We enrolled 56 previously untreated metastatic breast cancer patients; they were randomly assigned to receive paclitaxel (Taxol) (50 mg/mq) or docetaxel (Taxotere) (30 mg/mq) combined with non-pegylated liposomal anthracycline (25 mg/mq) on days 1, 8 and 15 every 4 weeks. The primary end points were the clinical benefit and treatment-related toxic effects assessment. Secondary end points were time-to-disease progression (TTP) and overall survival (OS). RESULTS: The overall clinical benefit was 87.04%. World Health Organization G3-4 toxic effects included neutropenia (45%), anemia (44%), complete alopecia (83%), severe onycholysis and neuropathy. The 24% of patients developed left ventricular ejection fraction reduction but none >10% with recover after treatment completion. The median absolute decrease from baseline was 1%. Median TTP was 11 months and median OS was 23 months. CONCLUSIONS: Combined weekly administration of taxane and non-pegylated liposomal anthracycline is well tolerated and clinical benefit data encourage phase III study design.

B-type natriuretic peptide as a predictor of outcome in a general intensive care unit.

BACKGROUND: B-type natriuretic peptide is a hormone secreted by the heart in response to ventricular wall stress. Increased B-type natriuretic peptide plasma levels are also found as a consequence of noncardiac conditions including sepsis, surgery-induced systemic inflammatory response syndrome and kidney failure. Since these conditions are common in general intensive care unit patients, we hypothesized that B-type natriuretic peptide could be a helpful marker in predicting outcome in this setting. METHODS: We measured plasma B-type natriuretic peptide concentrations in 228 patients at admission to our general intensive care unit. The primary aim of the study was to investigate the relationship between B-type natriuretic peptide and hospital mortality. The secondary aim of the study was to investigate the association between B-type natriuretic peptide and severity of disease, quantified by the Simplified Acute Physiology Score II. RESULTS: Logistic regression revealed a positive association between B-type natriuretic peptide level and in-hospital death (OR= 1.59; 95% CI 1.30 to 1.95; p<0.0001) and a Cox proportional hazards regression model showed that B-type natriuretic peptide was significantly associated with the risk of death (HR=1.27; 95% CI 1.11 to 1.46; p=0.0005). B-type natriuretic peptide was higher in patients who died in the hospital than in those who survived (371.20 pg/ml vs. 127.10 pg/ml; p<0.0001). There was a positive correlation between B-type natriuretic peptide and Simplified Acute Physiology Score II (r=0.50; 95% CI 0.40 to 0.59; p<0.0001). DISCUSSION: B-type natriuretic peptide on admission is an independent prognostic marker of outcome in an unselected cohort of critically ill patients.

Erroneously low continuous ScvO2 reading due to red blood cells transfusion.

Hemoglobin oxygen saturation in superior vena cava (ScvO(2)) is used as a parameter to guide hemodynamic management in shock patients and it can be continuously read through a central venous catheter equipped with a fiberoptic spectrophotometric probe (Edwards PreSep catheter) connected to a specific monitor (Edwards Vigileo). We report of an episode of erroneous ScvO(2) reading by this technology in a patient with septic shock who was receiving an erythrocytes transfusion through the PreSep catheter main lumen. We think this artifact should be known by intensivists since it can lead to ScvO(2) misinterpretation and subsequent erroneous therapeutic decisions.

Remifentanil to treat hypertension in overweight patients during a fentanyl-based cardiac anesthesia A case series.

Cardiac surgery is associated with intense nociceptive and autonomic stimulation especially during sternotomy and aortic root dissection and moderate-to-high dose opioids are required to blunt the hemodynamic and neuroendocrine response to this kind of procedures. However, episodes of unwanted sympathetic activation leading to intraoperative hypertension are not always preventable with a fentanyl-based anesthesia regimen and antihypertensive drugs without anesthetic properties are added to obtain hemodynamic stability. We report on five cardiac surgical cases in which intraoperative hypertension unresponsive to incremental doses of fentanyl was successfully treated adding a remifentanil target-controlled infusion instead of a non-anesthetic vasoactive drug. This approach could help to avoid the dilemma: when should we stop adding anesthetics and switch to antihypertensive drugs in cardiac surgery? 

Diversity of essential oil glands of clary sage (Salvia sclarea L., Lamiaceae).

The Lamiaceae is rich in aromatic plant species. Most of these species produce and store essential oils in specialised epidermal oil glands, which are responsible for their specific flavour. Two types of glands producing essential oil and possessing different morphological structure can be found in Salvia sclarea: peltate and capitate glands. The content of single oil glands from different positions on the plant (corolla, calyx and leaf) were sampled using an SPME fibre and analysed by gas chromatography in order to study variability of the essential oil composition. It was found that the composition of terpenoids is quite variable within an individual plant. Capitate oil glands mainly produce three essential oil compounds: the monoterpenes linalool and linalyl acetate, and the diterpene sclareol. Peltate oil glands, however, accumulate noticeable concentrations of sesquiterpenes and an unknown compound (m/z = 354). Furthermore, the oil composition varies within each gland type according to the plant organ. Linalool and linalyl acetate are characteristic substances of flowers, whereas the sesquiterpenes occur in higher proportions in leaves. Even within one gland type on a single leaf, the chemical variability is exceedingly high.

PCB concentrations in some foods from four European countries.

Samples of salmon, butter and cabbage from Belgium, Italy, Spain and Portugal were analysed for their content in total, non-dioxin-like (as represented by the so-called seven indicator-PCBs: congeners 28, 52, 101, 118, 138, 153 and 180) and dioxin-like PCBs (mono-ortho and non-ortho PCBs). Salmon and cabbage from Belgium, and butter from Portugal and Belgium, contained less total and non-dioxin-like PCBs than those from other countries. Samples from Italy had the highest concentrations. Similar patterns were observed for dioxin-like PCBs (as represented by the TCDD-equivalents of toxicity, WHO-TEQs), with the lowest values in Belgium and Portugal for salmon, in Portugal for butter and in Belgium for cabbage. Differences up to five-fold in PCB concentrations and TEQ values were seen among commodities from the four countries. The implication is that it might be worthwhile monitoring, with selection of the least contaminated commodities, to reduce the PCB exposure of the general population. This could have health consequences, because daily intakes are higher than the tolerable levels for a considerable part of the European population.

Antiangiogenic metronomic chemotherapy and hyperthermia in the palliation of advanced cancer.

Among a large series of cancer patients treated with a combination of chemotherapy and sessions of hyperthermia, particular attention was given to a specific group of patients with advanced cancer who refused standard, aggressive, treatment. In these cases, hyperthermia was associated to low-dose (metronomic) chemotherapy. No toxicity was reported in any of our patients, while a marginal benefit in terms of tumour progression was observed. During therapy, we could detect a coagulative perturbation that deserves careful discussion. In our opinion, this experience should be matter of debate to conclude if current response criteria (WHO/UICC and RECIST) in treating cancer patients are really suitable tools to evaluate new, and non-aggressive anticancer strategies.

Performance of the AutoPap Primary Screening System in the detection of high-risk cases in cervicovaginal smears.

OBJECTIVE: To assess the performance of the AutoPap Primary Screening System (APSS) (TriPath Imaging, Inc., Burlington, North Carolina, U.S.A.) for the detection of high grade cervical squamous intraepithelial lesions and invasive cervical cancer. STUDY DESIGN: A total of 14,779 consecutive conventional Pap smears were processed by the APSS. All slides designated as "Review" by the device were manually screened according to the Bethesda System. The ranking scores obtained from the device were compared with the cytologic interpretations in all cases and with the final histologic diagnoses in the cases with cytologic severe abnormalities. RESULTS: The device classified 10,349 slides as Review (78%) and 2,912 (22%) as "No Further Review." In the 78% Review cases, the samples were ranked in descending order of potential abnormality, broken into quintiles. The correlation between the slide quintile ranks and the manual cytologic diagnosis indicated that 90% of abnormal smears were categorized by the device as in the first and second quintile rank, and the correlation between the rank report of the device and the histologic diagnosis showed that all cases of HSIL or invasive carcinoma were in the top two ranks. No significant abnormalities were observed in any of the smears categorized as No Further Review. CONCLUSION: This study confirmed the effectiveness of APSS for the detection of Pap smears with severe abnormalities.

Width and partial widths of unstable particles.

In the gauge theory context, a definition of branching ratios and partial widths of unstable particles is proposed that satisfies the basic principles of additivity and gauge independence. A simpler definition, similar to the conventional one, is examined in the Z0-boson case. In order to establish contact with experiment, we show that it leads to a peak cross section that justifies the expression used by the LEP Electroweak Working Group through next-to-next-to-leading order, provided that the pole rather than the on-shell mass and width of the Z0 boson is employed.

Analysis of EEG data from weak-field magnetic stimulation of mesial temporal lobe epilepsy patients.

Ten patients suffering from mesial temporal lobe epilepsy were exposed to weak, DC magnetic field stimulation following computer-controlled protocols established in previous studies. Poisson statistical analysis of the ten patients undergoing semi-invasive (foramen ovale) electrode monitoring reveals that for at least one experimental protocol, application of DC magnetic fields alters interictal epileptiform spike activity in five of ten patients. Similar results also have been observed in the analysis of both human and rat brains by employing weak, alternating magnetic field stimulation. Further study is necessary in order to optimize the magnetic field exposure protocol.

Magnetic analysis of human brain tissue.

Fourteen samples of human hippocampal tissue were resected during amygdalo-hippocampectomies performed on patients suffering from Mesial Temporal Lobe Epilepsy (MTLE). In addition, eight tissue samples from the hippocampus, cortex basalganglia, cerebellum and leptomeninges were resected from cadavers during routine autopsy and were not chemically fixed. All samples were preserved in liquid nitrogen and magnetic properties were measured at 77K and 273K. Measurements indicate that there are no systematic variations in magnetic particle concentrations or magnetic properties between MTLE patients and non-pathologic tissue from the cadavers. The presence of superparamagnetic particles can be inferred due to differences in the saturation remanence acquired at 77K and 273K. This is a further indication that biogenic magnetite and/or maghemite present in the human brain likely is not primarily associated with geomagnetic field sensing as it is known to occur in other organisms.

TEM investigations of biogenic magnetite extracted from the human hippocampus.

Modification of chemical and magnetic extraction techniques has yielded biogenic magnetite/maghemite from human hippocampal tissue. Particles were identified using high resolution transmission electron microscopy, electron diffraction and elemental analysis. Though its presence has been inferred from magnetic analyses, this is the first direct observation of magnetic biominerals from the hippocampus.

[Populational study of investigation of perinatal and infant deaths: methodology, validity of diagnosis and under-registration]. / Estudo populacional de investigação de óbitos perinatais e infantis: metodologia, validade do diagnóstico e sub-registro.

OBJECTIVE: The main objectives of the present study were to evaluate the percentage of under-registration of infant mortality in 1993 and compare it with the ones found 1982; to analyze the agreement between the official death certificates and the ones made by the referees. METHODS: The infant mortality of all children born in Pelotas, in 1993, was monitored through daily visits to hospitals, as it was done in 1982; monthly, cemeteries and public registration offices were visited to detect any deaths outside the hospitals. Besides the official death certificates, two independent referees established the underlying cause of death based on information from pediatricians, case-notes, autopsies and through a home visit to the parents of the children. RESULTS: The percentage of under-registration fell substantially from 24%, in 1982, to 5.4%, in 1993. The agreement between the official death certificates and the ones made by the referees showed satisfactory Kappas, unless for ill defined diseases such as sudden infant death, where the agreement was null. CONCLUSIONS: The authors conclude that there was a significant fell of the under-registration for infant death in Pelotas, and the ill defined causes such as sudden infant death have been hidden by the diagnosis of pneumonia.

Magnetic properties of human hippocampal tissue--evaluation of artefact and contamination sources.

To investigate the possibility that postmortem chemical alteration or contamination is responsible for recent results indicating the presence of magnetite in human brain tissue and to determine whether magnetite is present in living brain tissue, we examined tissue samples resected from six patients during amygdalohippocampectomy operations. The tissue samples were sealed in sterilized vials in the operating theater and placed into liquid nitrogen directly after removal to prevent changes in tissue chemistry after the death of the brain cells. The low temperature magnetic properties of the tissue were measured to determine the presence of ferro- or ferrimagnetic material in the tissue. The results of these experiments indicate that magnetite is present in the tissue. In addition, results of experiments designed to control for airborne contamination and contamination during cauterization of vessels during surgery indicate that these are not significant sources of magnetite contamination in the tissue.