Microwave-ultrasonic assisted extraction of lignin to synthesize new nano micellar organometallic surfactants for refining oily wastewater.

In this work, a beneficial approach for efficient depolymerization of lignin and controllable product distribution is provided. Lignin, an abundant aromatic biopolymer, has the potential to produce various biofuels and chemical adsorption agents and is expected to benefit the future circular economy. Microwave-ultrasonic (MW/US) assisted efficient depolymerization of lignin affords some aromatic materials used in manufacturing the starting material to be investigated. Some nano organometallic surfactants (NOMS) based on Ni2+, Cu2+, Co2+, Fe3+, and Mn2+ besides 2-hydroxynaphth-sulphanilamide are synthesized to enhance oil recovery (EOR). In this work, the assessment of the NOMS's efficiency was improving the heavy oil recovery via the study of the dynamic interfacial tension (IFT), contact angle, and chemical flooding scenarios. The NOMS-Ni2+ exhibited the maximum reduction of viscosity and yield values. Dropping the viscosity to 819.9, 659.89, and 499.9 Pa s from blank crude oil viscosity of 9978.8, 8005.6, and 5008.6 Pa s respectively at temperatures of 40, 60, and 80 °C was investigated. The reduction of τB values was obtained also by OMS-Ni2+. The minimum IFT was recorded against the Ni2+ derivatives (0.1 × 10-1 mN m-1). The complete wettability alteration was achieved with the NOMS-Ni2+ surfactant (ɵ ≅ 6.01 ) . The flooding test has been steered in 3 sets using the sand-packed model as a porous media at surfactant concentrations (1, 1.5, 2 and 2.5%) at 50 °C and 499 psi as injection pressure. The best value (ORs) formed for NOMS-Ni2+ were 62, 81, 85.2, and 89% respectively as compared with other NOMS-M2+ at the same concentrations. The mechanism of alternating wettability was described in the text. The rheology of the used heavy crude oil was investigated under temperatures of 40, 60, and 80 °C.

Modeling and equilibrium studies on the recovery of praseodymium (III), dysprosium (III) and yttrium (III) using acidic cation exchange resin.

In this research, the possibility of using hydrogenated Dowex 50WX8 resin for the recovery and separation of Pr(III), Dy(III) and Y(III) from aqueous nitrate solutions were carried out. Dowex 50WX8 adsorbent was characterized before and after sorption of metal ions using Fourier-transform infrared spectroscopy (FT-IR), Scanning Electron Microscope (SEM) and Energy Dispersive X-Ray Analysis (EDX) techniques. Sorption parameters were studied which included contact time, initial metal ion concentration, nitric acid concentration and adsorbent dose. The equilibrium time has been set at about 15.0 min. The experimental results showed that the sorption efficiency of metal ions under the investigated conditions decreased with increasing nitric acid concentration from 0.50 to 3.0 M. The maximum sorption capacity was found to be 30.0, 50.0 and 60.0 mg/g for Pr(III), DY(III) and Y(III), respectively. The desorption of Pr(III) from the loaded resin was achieved with 1.0 M citric acid at pH = 3 and found to be 58.0%. On the other hand, the maximum desorption of Dy(III) and Y(III) were achieved with 1.0 M nitric acid and 1.0 M ammonium carbonate, respectively. The sorption isotherm results indicated that Pr(III) and Y(II) fitted with nonlinear Langmuir isotherm model with regression factors 0.995 and 0.978, respectively; while, Dy(III) fitted with nonlinear Toth isotherm model with R2 = 0.966. A Flow sheet which summarizes the sorption and desorption processes of Pr(III), DY(III) and Y(III) using Dowex 50WX8 from nitric acid solution under the optimum conditions is also given.

Improving heavy oil recovery, part (I): synthesis and surface activity evaluation of some novel organometallic surfactants based on salen-M complexes.

This study focuses on preparing a new family of organometallic surfactants based on five ion complexes, namely Co2+, Ni2+, Cu2+, Fe3+, and Mn2+. The first step is the preparation of 5-chloromethyl salicylaldehyde (Salen, S). The second step is the formation of sodium alkoxide of Pluronic F-127 (AP). The third step is the formation of the modified AP-Salen (new ligand). This ligand was reacted with the metal chlorides as mentioned earlier to obtain the organometallic surfactants (OMS) named AP-Salen-M complexes. FT-IR, 1H-NMR, SEM, and EDX justified the chemical structure of the as-prepared materials. The surface tension of these surfactants was measured for surfactant solutions at different concentrations to determine the CMC and calculate their surface-active properties. The interfacial tension at CMC was measured against heavy crude oil to predict the availability and use these surfactants in the enhanced oil recovery (EOR) process. From the results, this class of surfactants exhibited good surface-active properties and high efficiency on the interface adsorption; besides, they reduced the interfacial tension in the order between 10-1 and 10-2 mN m-1, which gives a good indication to use these surfactants in EOR application for the heavy crude oil.

Challenges to laboratory hematology practice: Egypt perspective.

Laboratory hematology is an integral part of all clinical laboratories along the extensive healthcare facilities in Egypt. The aim of this review is to portrait the laboratory hematology practice in Egypt including its unique socioeconomic background, blood disease pattern, education and training, regulatory oversight, and the related challenges. Current practice varies widely between different parts of the healthcare system in terms of the range of tests, applied techniques, workforce experience, and quality of service. The national transfusion service (NBTS) in Egypt has been recently upgraded and standardized according to the World Health Organization (WHO) guidelines. Formal postgraduate education roughly follows the British system. Laboratory hematology specialization is achieved through 2-3 years masters' degree followed by 2-4 years doctorate degree in clinical pathology with training and research in hematology. Improvement of laboratory hematology education is recently undergoing a reform as a part of the modernization of higher education policy and following the standards developed by the National Quality Assurance and Accreditation Agency (NQAAA). Accreditation of medical laboratories is recently progressing with the development of the "Egyptian Accreditation Council" (EGAC) as the sole accreditation body system and training of assessors. Current laboratory system has many challenges, some are related to the inadequate system performance, and others are unique to laboratory hematology issues. The rapid technological advances and therapeutic innovations in hematology practice call for an adapting laboratory system with continuous upgrading.

Prograf five milligrams versus Tacrolimus medis in healthy volunteers: a bioequivalence study.

For FDA approval, bioequivalence of a generic version of Tacrolimus must be demonstrated in a randomized, two-treatments, two-periods, two-sequences, single-dose crossover study in healthy adult volunteers. Currently there are at least 3 differents generic equivalent for Tacrolimus, that are approved by the EMA and the FDA, with a USA market share of nearly 50%. However, the market share of generic immunosuppressive drugs in the Middle East region is still very low due to the reluctance of the physician to accept Tacrolimus generics, considered to be a narrow therapeutic window drug, that are approved using the standard bioequivalence criteria of 80% to 125%. Herein we present a bioequivalence study of a new Tacrolimus generic, Tacrolimus Medis 5 mg developed by Medis Tunisia batch number 12G3003 compared with Prograf® 5 mg batch number 7202 manufactured by Astellas Toyama Co., Ltd. Japan and HIKMA Pharmaceuticals, Amman-Jordan in healthy adult volunteers using the 90%-111% criteria recommended for drugs with narrow therapeutic window. The study was, balanced, randomized, two-treatments, two-periods, two-sequences, single dose, crossover, comparative oral bioavailability study in healthy adult human volunteers. The study was carried out in accordance with the Basic Principles defined in the U.S. 21 CFR Part 312.20, the principles enunciated in the Declaration of Helsinki (World Medical Association Declaration of Helsinki). Thirty six non-smoking healthy, as determined by medical history, volunteers, 18 years and older, were included. Following randomization using a computer software (pharma solution) the volunteers were given a single oral dose of 5 milligrams following a 12 hour fast with a wash out period of 7 days. Pharmacokinetics profile with blood levels at: 0, 0.5, 1, 1.5, 2, 2.5, 3, 4, 6, 8, 10, 12, and 24 hours were performed following each dose. Tacrolimus plasma level was determined using an HPLC validated method (Transmedical For Life S.A.R.L. Beirut Lebanon), for accuracy, suitability, reproducibility, precision , long-term stability and robustness. Physical examinations, hematology, urine analysis and serum chemistry tests were performed at screening and before dosing in each period and at end of the study. Volunteers were monitored for safety and adverse events throughout the study. Both products were bioequivalent at the entire pharmacokinetic parameters tested. The LSM were 95.31%-101.21% for AUC, 94.65%-101.11% for AUC0-inf, 97.15%-100.02% for Cmax and 91.54%-103.75% for Half-life. Respectively all of which are within the EU and FDA approval limits (90-111%) indicating that the 2 products are equivalent and switchable.

The use of microwave plasma-assisted CVD on nanostructured iron catalysts to grow isolated bundles of carbon nanotubes.

Catalysts play a key role in the growth of carbon nanotubes. The microwave plasma-assisted chemical vapor deposition (MPACVD) method is now commonly used for directional and conformal growth of carbon nanotubes (CNTs) on substrates. In this work, we report on the effect of H(2) plasma pre-treatment on the diameter and density of iron catalyst nanoparticles for different iron layer thicknesses in order to grow isolated bundles of CNTs. Atomic force microscopy shows first that as plasma power density increases, iron nanoparticle diameters decrease, which is due to the increasing of gas dissociation giving more ion bombardment energy, and second that the diameter of nanoparticles decreases with the catalyst thickness. The growth of CNT was carried out under different CH(4) concentrations for different iron film thicknesses. Transmission electron microscopy and Raman spectroscopy show that the synthesized CNT were of good quality and had an outer diameter between 5 and 10 nm.

An assay for the determination of sirolimus levels in the lymphocyte of transplant patients.

UNLABELLED: Both tacrolimus (TAC) and sirolimus (SRL) bind to the same immunophilin FKBP12; however, their mechanisms of action are distinct. SRL inhibits mammalian target of rapamycin (TOR), which is an enzyme critical to the immune function. TOR inhibition blocks the signal that mediates T-cell proliferation by preventing cell-cycle progression from G1 to S phase. Moreover, TOR inhibition results in a decrease in antibody production by blocking B-cell proliferation and maturation into antibody producing cells. The use of SRL has resulted in a decrease in the number of rejection episodes. As with other immunosuppressive agents, SRL can cause dose-related side effects, the most notable of which are hypercholesterolemia, hyperlipidemia, anemia, and thrombocytopenia. Thus, therapeutic drug monitoring to assess efficacy and toxicity has became a necessity. SRL blood levels do not correlate with its bioactivity and are affected by the concomitant use of other immunosuppressive drugs. To determine the bioactivity of SRL we have developed an assay to determine the level of Sirolimus per lymphocyte of transplant patients. The levels were correlated with lymphocyte count. METHODS: Whole blood samples from patients on SRL were collected in Ethylene Diamine Tetra-acetic acid (EDTA) vacutainer tubes. Immediately the lymphocytes from 2 mL of blood were separated using 1.5 mL of Ficoll gradient, by centrifugation for 30 minutes at 2500 RPM. The lymphocytes were washed three times with phosphate-bufferd saline and the pellet suspended in 150 microL of Middle East research institute (MERI) drug extraction solution (Beirut, Lebanon), which was then added to 300 microL of IMx solublizing reagent. The cytoplasmic SRL concentrations in lymphocytes were measured using kits supplied from Abbott diagnostics or by high-performance liquid tomography. A corresponding whole blood sample from each patient was used to measure blood levels. To determine the level per lymphocyte, the value obtained was divided by the number of lymphocytes and expressed as Pg/cell. A pharmacokinetic profile for both blood and lymphocytes was constructed for each patient using data corresponding to predose C(0), 1 hour (C(1)) and 2 hours (C(2)) after the dose. The lymphocyte enumeration for C(0), C(1), and C(2) was performed using the FACS Calibur Flow Cytometer from Becton Dickinson. The average dose was 2.86 +/- 1.27 mg/d with a C(0) = 8.05 +/- 4.24, C(1) = 21.9 +/- 8.9 ng/mL, and C(2) = 23 +/- 0.03 ng/mL. Although there was a significant correlation (P=.0975) between the dose and C(0), there was no correlation between the dose and C(0) level on the lymphocyte count P=.897. However, there was a strong correlation between SRL lymphocyte levels (pg/cell) and the lymphocyte count (r(2)=.6.06). The higher the concentration of the drug the lower the lymphocyte counts. The assay is sensitive to within 0.45 pg/cell, reproducible with a coefficient of variance (CV) of 6.4% within assay and 7.5% for intraassay.

Bioavailability of a new generic formulation of mycophenolate mofetil MMF 500 versus CellCept in healthy adult volunteers.

Several studies have revealed a decreased incidence of early graft rejection with the use of mycophenate mofetil (MMF). The cost of the drug is, however, prohibitive especially in developing countries with limited resources. We compared the pharmacokinetic profile of a new MMF generic formulation (MMF 500 batch number: 06T3001; Medis Tunis) with those of Cellcept, (batch number: M1427; Hoffmann La Roche, Switzerland) in healthy volunteers. The study was double-blinded to investigator and volunteers. It had a balanced randomized, two-treatment, two-period, two-sequence, single-dose, crossover, comparative oral bioavailability design in adult healthy human volunteers. The study was designed, performed, and monitored by CRO Transmedical s.a.l International (Beirut, Lebanon) in accordance with the Basic Principals defined in the US 21 CFR Part 312.20, and the principals enunciated in the World Medical Association Declaration of Helsinki. We included nonsmoking healthy volunteers between the ages of 22 and 45 years. The subjects were admitted to the hospital one night prior to blood sampling. After volunteers received the same dinner, they were fasted overnight and for 2 hours postdosing. At 8 am each person received a single oral dose of 500 mg of either formulation. Blood samples were collected to construct the pharmacokinetic profiles as follows: 0, 0.15, 0.30, 0.45 minutes and 1, 1.15, 1.30, 2, 4, 6, 10, 12, and 24 hours. Water and food intake were the same for all volunteers during the whole study period. Following an 8-day washout period, the subjects were crossed over. Plasma mycophenolic acid concentrations were determined using a high-performance liquid chromatography validated enzyme-linked immunosorbent assay-based method (TransMedical, Beirut Lebanon). Physical examinations, hematology, urinanalysis, serum chemistry tests, and liver enzymes were performed at screening and at the end of each period. Subjects were monitored for safety and adverse events throughout the study by two physicians (one from the hospital and one from TransMedical). The Cmax, Tmax, and AUC for MMF 500 were 10.14 ng/mL, 51.82 minutes, and 18.33 ng/mL/h vs 10.94 ng/mL, 49.09 minutes, and 17.46 ng/mL/h for CellCept, respectively. The 90% confidence intervals (LSM) of Cmax, Tmax, and AUC for MMF 500 were 92.7%, 105.6%, and 105%, respectively, which is within the Food and Drug Administration (FDA)-assigned range for immunosuppressive drugs (90% to 111%). These results indicated that the products are equivalent and switchable according to FDA rulings.

Cyclosporine lymphocyte maximum level monitoring in de novo kidney transplant patients: a prospective study.

OBJECTIVES: To determine prospectively the temporal variations of cyclosporine-A lymphocyte maximum level, whole blood maximum concentration, and total lymphocyte count in patients with de novo kidney transplantation. MATERIALS AND METHODS: Lymphocyte maximum level, whole blood maximum concentration, and total lymphocyte count were prospectively measured in 35 patients at 1, 2, and 3 months after kidney transplantation. Two groups--a biopsy-proven acute rejection group (REJ+) and a rejection-free group (REJ-)--were compared. RESULTS: Both groups had similar lymphocyte maximum levels, whole blood maximum concentrations, and total lymphocyte counts at the first month after transplantation. REJ+ patients had significantly lower lymphocyte maximum levels at 2 and 3 months (59+/-34 and 33+/-9 pg/Lc) and higher total lymphocyte counts (0.00204+/-0.00078x10(9)/L and 0.00203+/-0.00022x10(9)/L) when compared with their REJ- counterparts (87+/-56 and 63+/-30 pg/Lc, P<.05 and P<.007) and (0.00137+/-0.00074x10(9)/L and 0.0015+/-0.0006x10(9)/L, P<.02 and P<.003) respectively. Whole blood maximum concentrations were significantly higher in patients in the REJ+ group (2050+/-623 vs 1414+/-536 ng/mL, P<.02) at 2 months. At 3 months, the 2 groups were comparable (1158+/-340 vs 1365+/-525 ng/mL, P=NS). CONCLUSIONS: These results suggest that acute rejection is associated with a relatively low cyclosporine- A lymphocyte maximum level and high total lymphocyte count in the early posttransplant period. Cyclosporine-A whole blood maximum concentration failed to correlate with clinical outcome. Cyclosporine-A lymphocyte maximum level seems to offer a more reliable alternative than does whole blood maximum concentration for cyclosporine-A monitoring in patients with kidney transplantation.

Switchability of neoral and equoral according to Food and Drug Administration rules and regulations.

According to the US Food and Drug Administration (FDA), if a drug product contains a drug substance that is chemically identical and is delivered to the site of action at the same rate and extent as another drug product, then it is equivalent and can be substituted (switchable) for that drug product. Methods used to define bioequivalence as stated by the FDA rules (FDA 21 CFR 320, 24) are (1) pharmacokinetic (PK) studies in healthy volunteers, (2) comparative clinical trials, and (3) pharmacodynamic (PD) studies (bioactivity). We evaluated the switchability of Equoral (IVAX-USA) with Neoral (Novartis Switzerland using all FDA rules. In a single oral dose, we undertook a comparative bioavailability study of Equoral (IVAX, USA) Neoral (Novartis, USA), and Neoral (Novartis UK). The pharmacokinetics of Equoral and Neoral were determined with blood levels at 0, 0.25, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 2.5, 3, 3.5, 4, 5, 6, 8, 10, 12, 16, 24, 30, 36, 42, and 48 hours. The area under curve (AUC), AUC extrapolated to infinity (AUC0-inf), rate of absorption (Tmax), extent of absorption (Cmax), half time (t1/2) of Equoral and Neoral were all within the 90% confidence interval of 80% to 125% boundaries. A comparative multinational multicenter clinical trial in stable renal transplant patients included 70 patients (22 women and 48 men) of mean age of 33 years (range, 26 to 43) was performed in Turkey, Lebanon, and Pakistan. In this study the ratios of LSM and the 90% confidence intervals for the Nontransformed/Parameters (AUC0-t, AUCinf, Tmax, and Cmax) of Equoral and Neoral SGC were 98% and 95%, respectively, which are within the 80% to 125% FDA acceptance range. For immunosuppressive drugs, the site of action is the lymphocyte and the measurable response is the decrease in lymphocyte count caused by the relative concentration of the drug in the lymphocyte. In a controlled switch, fixed-dose study, both Equoral and Neoral achieved the same concentration in the lymphocytes and caused the same degree of lymphocyte count reduction. The results of the testing (bioavailability-bioequivalence, clinical studies, and pharmacodynamic-bioactivity) required by FDA for interchangeability ("switchability") of immunosuppressive agents suggests that Neoral and Equoral are switchable.

The role of generics in transplantation: TM-MMF versus Cellcept in healthy volunteers.

Because several studies having revealed a relation between early graft rejection and long-term graft survival, potential benefits have been attributed to MMF. The cost of the drug is, however, prohibitive, which renders its long-term use in countries with limited income. We thus compared the pharmacokinetic profiles of a new MMF generic formulation (MM-Cept developed by Ivax CR) with those of Cellcept (Hoffman La Roche) in healthy volunteers. This open label, balanced randomized, two-treatment, two-period, two-sequence, single-dose, crossover, comparative oral bioavailability study was conducted in non-smoking adult male healthy volunteers between the ages of 18 and 45 years. The study was performed in accordance with the basic principles defined in the US 21 CFR Part 312.20 and the principles enunciated in the Declaration of Helsinki (World Medical Association Declaration of Helsinki). The subjects were given a single oral 1 g dose with a washout period of 10 days. Pharmacokinetic profiles included blood levels at 0, 0.25, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 2.5, 3, 4, 6, 10, 12, 16, 20, 24, 30, 36, and 48 hours following each dose. The formulations were MMCept 500 mg tablets and Cellcept 500 mg tablets. Subjects were fasted overnight and for 4 hours postdosing. Mycophenolic acid (MPA) concentrations were determined using HPLC. Physical examinations, hematology, urinalysis, and serum chemistry tests including liver enzymes were performed at screening and at the end of the study. Subjects were monitored for safety and adverse events throughout the study. Both products showed similar bioavailability. The LSM were within the limits for FDA approval (80 to 125), suggesting that the two products are equivalent and switchable.

The pharmacokinetics of equoral versus neoral in stable renal transplant patients: a multinational multicenter study.

We studied the pharmacokinetics (PKs) of the new generic cyclosporine formulation, Equoral capsules, after the switch from original formulation Neoral capsules in stable renal transplant patients. The study was carried out in accordance with the basic principles defined in the US 21 CFR Part 312.20 and the principles of the Declaration of Helsinki. The study included clinically stable first renal transplant patients maintained on cyclosporine with no rejection episode during the past 6 months. Hematology, biochemistry, and urine chemistry were determined on day 7, and day 21. The patients were all switched to Neoral (lot number 416MFD0601) on day 0 when the first sparse sampling PK was performed. On day 14 a 12-hour PK profile included predose, 30 minutes; 1 hour; 1 hour 30 minutes; 2 hours; 3 hours; 4 hours; 5 hours; 6 hours; 8 hours; 10-hours and 12-hour samples. Cyclosporine levels were determined using a CYA kit (Abbott TDx). On day 15 the patients were switched from Neoral capsules to Equoral capsules (lot 5T111014) at an equivalent dosage (mg/mg). The second sparse sampling PK was performed on day 21 and a 12-hour PK was performed on day 28. On the morning of day 29 patients were switched from Equoral capsules to Neoral capsules at an equivalent dosage (mg/mg). Additional concentrations were measured on days -7, 18, and 35. Safety parameters were monitored at each visit. The pharmacokinetics of both formulations were equivalent. The mean AUC for Neoral and Equoral was 2856 and 2892, respectively. The ratios of LSM and the 90% confidence intervals for the in-transformed parameters (AUC o-t, AUC inf, and Cmax) of Equoral and Neoral SGC were 98% and 95%, respectively, suggesting that Equoral and Neoral SGC are bioequivalent.

Screening for paroxysmal nocturnal hemoglobinuria (PNH) clone in Egyptian children with aplastic anemia.

Aplastic anemia and paroxysmal nocturnal hemoglobinuria (PNH) are clinically related. In addition to their concurrent or sequential appearance in individual patients, PNH and aplastic anemia share several pathophysiologic features. The aim of the present study was to screen for PNH clone in Egyptian aplastic anemia pediatric patients before the initiation of any specific therapy and to evaluate the clinical status of studied patients 3-6 months after initiation of immunosuppressive therapy. We studied 11 pediatric patients with newly diagnosed acquired aplastic anemia and followed them up clinically for 3-6 months after initiation of immunosuppressive therapy. In addition to routine clinical and laboratory evaluation, sucrose lysis test and staining of bone marrow for CD59 were performed in all subjects. All studies cases had severe aplastic anemia (SAA) except one case which had very severe aplastic anemia (VSAA). Sucrose lysis test was negative in all studied cases. Presence of PNH clone (as evident by loss of normal staining of hematopoietic cells for CD59 = CD59 negative cells) was evident in four subjects. All cases with PNH clone were >6 years old and one of them developed splenic vein thrombosis. As regards the laboratory data WBC < or = 2.8 x 10(3)/mm3 and reticulocytes > or = 0.6 per cent were the most frequent factors associated with PNH clone found in all PNH subjects, but only in 28.6 per cent and 14.3 per cent respectively, of non-PNH subjects. Mortality rate was higher in non-PNH subjects (28.5 per cent) compared to 25 per cent of PNH subjects. We conclude that immunohistochemical staining of bone marrow sections is a sensitive tool to detect the emergence of PNH clone in aplastic anemia patients. Thrombotic complications should be anticipated in cases with aplastic anemia having a PNH clone.

Protein- and pH-dependent binding of nascent pectin and glucuronoarabinoxylan to xyloglucan in pea.

Nascent pectin and glucuronoarabinoxylan, synthesised in vitro by membrane-bound enzymes from etiolated pea (Pisum sativum L.) epicotyls, were found to bind to pea xyloglucan in a pH-dependent manner. The binding was maximum at low pH (3-4), and decreased to almost zero at pH 6. The binding was probably non-covalent and reached saturation within 5 min. Removal of the fucose residues of xyloglucan decreased the degree of binding. Removal by protease of the proteins attached to nascent pectin and glucuronoarabinoxylan greatly reduced the maximum binding and abolished the pH-dependence. The observed binding may be of considerable significance in the process of cell-wall assembly and in the control of cell extension.

Aggressive combination treatment for invasive fungal sinusitis in immunocompromised patients.

Invasive sinonasal fungal disease is a potentially fatal complication of chemotherapy-induced immunosuppression and neutropenia. We reviewed the outcomes of seven cancer patients who had been diagnosed with invasive fungal sinusitis; six patients had hematologic malignancies and one had breast cancer. At the time of their sinus diagnosis, all patients had been hospitalized and were receiving combination chemotherapy for their underlying malignancy. Impairment of their immune function was characterized by an absolute neutrophil count of less than 1,000/mm3. Aggressive management of their sinonasal fungal disease consisted of surgical debridement and systemic amphotericin B for all patients, and treatment with granulocyte colony-stimulating factor for two patients. Invasive Aspergillus infection was identified in six patients and invasive Candida albicans infection in one. Although the prognosis for these patients was poor and two patients died of the fungal infection, the aggressive treatment strategy resulted in long-term survival for the remaining five patients.

Bilateral simultaneous orbital decompression for Graves' orbitopathy with a combined endoscopic and Caldwell-Luc approach.

Graves' orbitopathy can lead to cosmetic deformity, orbital pain, and visual impairment. Surgical intervention can improve proptosis, cosmetic appearance of the eyelids, vision, and orbital pain with minimal morbidity. Ten patients with dysthyroid orbitopathy underwent concurrent bilateral orbital decompressions. Of these, 9 underwent simultaneous bilateral endoscopic and transantral decompressions, and 1 had only bilateral endoscopic decompressions. Medical management of keratopathy was attempted before surgery. All patients were previously treated with radioiodine and high-dose corticosteroids, and 2 patients had prior low-dose orbital irradiation. Preoperative and postoperative visual acuity, color vision testing, and measurement of proptosis were recorded for all patients. In addition, photographs and CT scans of the orbit and sinuses were done. After surgery, visual acuity improved in 8 patients and remained unchanged in 2 patients. Diplopia in the primary and downward gaze improved in 1 patient and remained unchanged in the 3 others who had it before surgery. Color vision deficits in the blue/yellow range were present in 8 patients before surgery and all reversed within 2 weeks after surgery. Proptosis decreased by an average of 4.83 mm (range 4-7 mm) in patients undergoing the combined decompression and decreased by 4 mm in the 1 patient who had the endoscopic decompression only. Ethmoid sinusitis developed in 1 patient but resolved with oral antibiotics, and another patient had an asymmetric result requiring additional unilateral surgery, which corrected the asymmetry. Overall, this approach avoids external incisions and allows excellent visualization in the regions of the orbital apex and ethmoid roof, facilitating maximal decompression without the increased risk of bleeding or visual disturbances.