Gastric MALT-Lymphoma: more than Helicobacter Pylori.

In this case report, we describe two cases of gastric mucosaassociated lymphoid tissue (MALT) lymphoma. The first patient, who presented with complaints of indigestion, nausea and epigastralgy, had a solid ulcer on endoscopy. Biopsies showed, next to MALT, presence of Helicobacter Pylori. The second patient was admitted with hematemesis. The multiple ulcerations in his stomach were thought to be cocaine-induced. Only after multiple biopsies the diagnosis of MALT was made. No presence of Helicobacter Pylori could be detected. The first patient was successfully treated with Helicobacter Pylori eradication therapy. Localized radiotherapy resulted in complete remission in our second patient. Hence, in absence of Helicobacter Pylori, more aggressive treatment modalities are needed.

Economic evaluation of systemic treatments for cytomegalovirus retinitis in patients with AIDS.

OBJECTIVE: To determine the cost of using systemic therapy to treat newly diagnosed cytomegalovirus (CMV) retinitis in persons with AIDS. DESIGN: Incidence-based simulation model of CMV treatment from a government payer perspective. SETTING: Swiss healthcare system. PATIENTS AND PARTICIPANTS: Patients with AIDS and newly diagnosed CMV retinitis. INTERVENTIONS: Patients were assigned to 1 of 4 treatment regimens for induction and maintenance therapy: (i) intravenous (IV) cidofovir induction and maintenance (cidofovir IV/IV); (ii) IV foscarnet induction and maintenance (foscarnet IV/IV); (iii) IV ganciclovir induction and maintenance (ganciclovir IV/IV); and (iv) IV ganciclovir induction and oral (PO) ganciclovir maintenance (ganciclovir IV/PO). Following a second relapse, patients were assigned to one of the other regimens. MAIN OUTCOME MEASURES: Time to first and subsequent progression, duration of maintenance treatment and direct medical expenditures [1998 Swiss francs (SwF)] . RESULTS: The median time to first progression was longest for cidofovir IV/IV, followed by foscarnet IV/IV, ganciclovir IV/IV and ganciclovir IV/PO. Mean survival was 13 months and mean costs for this period in the base case were lowest in those initially treated with cidofovir (SwF146,742), followed by initial treatment with foscarnet IV/IV (SwF194,809), ganciclovir IV/PO (SwF195,190) and ganciclovir IV/IV (SwF243,964). Costs were most sensitive to changes in efficacy estimates. CONCLUSIONS: Of the regimens studied, initiation of treatment with systemic cidofovir appears least costly over a 13-month period.

Hepatotoxicity related to itraconazole: report of three cases.

BACKGROUND: The antimycotic synthetic azole compounds are known to lead to toxic liver injury. The occurrence of acute hepatitis is best known for ketoconazole. With itraconazole, hepatotoxic reactions have only very rarely been reported, and histologic data are lacking. We report on three patients who developed acute liver damage during therapy with itraconazole, and in whom liver biopsy specimens were obtained. METHODS: Three patients with apparent itraconazole-induced liver injury were studied. Clinical, laboratory, serologic, and histologic data of all three cases were analyzed. RESULTS: All three patients developed a biochemical-histologic pattern of cholestatic liver injury with damage to the interlobular bile ducts. Beginning ductopenia was present in two, suggesting that itraconazole might be responsible for the occurrence of prolonged drug-induced cholangiopathy. Jaundice was the presenting symptom in all three. It was not accompanied by clinical hallmarks of hypersensitivity, which is suggestive for metabolic rather than for immunoallergic idiosyncrasy. CONCLUSIONS: Itraconazole-induced liver injury presents with a cholestatic pattern of injury with damage to the interlobular bile ducts, possibly leading to ductopenia. We suggest that itraconazole should be added to the list of drugs that may be responsible for a drug-induced vanishing bile duct syndrome. Further histologic documentation in other cases is necessary to strengthen our current findings.

Lipid peroxidation of intravenous lipid emulsions and all-in-one admixtures in total parenteral nutrition bags: the influence of trace elements.

An iodometric titration was used to assess the influence of a daily portion of trace elements on lipid peroxidation of pure lipid emulsions and lipid-containing all-in-one (AIO) admixtures by measuring the peroxide value (PV; mmol peroxides/L). A pure lipid emulsion (Intralipid 20%; Pharmacia & Upjohn, Dubendorf, Switzerland) was stored in ethylvinylacetate bags under light protection (LP) at 40 degrees C with and without trace elements. In absence of trace elements the PV of Intralipid 20% was significantly lower (day 14: 2.77 vs 18.04; p < .001). After the same time period with the same storage conditions the drop in pH was two times higher in presence of trace elements (1.54 vs 0.77). In an AIO admixture with LP stored at 2 degrees C to 8 degrees C, trace elements increased the PV from 0.04 to 0.19 mmol/L (day 29; p < .01). The drop in pH was 0.01 and 0.02 units, respectively. When stored at 20 degrees C to 30 degrees C and exposed to daylight, the PV of the AIO admixture containing trace elements reached 1.92 compared with 0.52 in their absence (day 19; p < .001) with a pH drop of 0.03 and 0.11, respectively (day 29). Although trace elements led to a much higher drop in pH in pure lipid emulsions, no obvious influence on the pH of AIO admixtures was demonstrated. To minimize lipid peroxidation, AIO admixtures should be stored light-protected and refrigerated without trace elements. The latter should be added immediately before administration or should be given separately.

Lipid peroxidation of i.v. lipid emulsions in TPN bags: the influence of tocopherols.

Four commercial i.v. lipid emulsions containing soybean oil were investigated to determine the tocopherol content. A sensitive high-performance liquid chromatography (HPLC) on a diol column was established to quantitate the tocopherol isomers in lipid emulsions. A previously described iodometric titration was used to assess the peroxide value (mmol peroxides/L). The pH was measured also. The initial tocopherol concentration ranges in three of the four commercial soybean oil-based 20% lipid emulsions studied were compared ([mg/L]: alpha: 17-23, beta: 4, gamma: 88-129, delta: 40-44). One product showed an increased alpha-tocopherol content (172 mg/L) due to supplementation during manufacture. During storage in an ethylvinyl acetate (EVA) bag at 40 degrees C under light-protection (LP) for 34 d, a lipid emulsion 20% with a natural alpha-tocopherol content showed a peroxide value (PV) of 9.18 (about 450 times the value of controls in glass bottles) with a concomittant reduction of the tocopherol isomers to 61.6% (alpha), 86.5% (gamma), and 88.9% (delta) compared to the initial values. Comparison of two lipid emulsions with different amounts of alpha-tocopherol (Lipidem 20%, B. Braun, Switzerland: 156.29 mg/L vs. Intralipid 20%, Pharmacia Upjohn, Switzerland: 8.75 mg/L) for their antioxidative capacity using the same stress conditions revealed for the emulsion with the high alpha-tocopherol content a significantly higher PV over the whole test period (after 5 wk: 33.63 vs. 6.23; P < 0.001) and an increased alpha-tocopherol decomposition (51.6% vs. 8.7%). The drop in pH was higher, also (1.9 vs. 1.0 pH units). In contrast to ordinary concentrations of about 20 mg/L, alpha-tocopherol in 20% lipid emulsions showing antioxidative properties, a supplementation with about 160 mg/L showed a prooxidative effect when exposed to ambient atmosphere in an EVA bag.

In vitro oxidation of i.v. lipid emulsions in different all-in-one admixture bags assessed by an iodometric assay and gas-liquid chromatography.

Polyunsaturated fatty acids (FAs) of intravenous (IV) lipid emulsions can peroxidize to potentially harmful lipid hydroperoxides. In order to assess in vitro peroxidation of IV fat emulsions in all-in-one (AIO) admixture bags, an iodometric titration to determine lipid hydroperoxide content expressed by the peroxide value (PV) and a gas-liquid chromatographic (GLC) assay to determine changes of the FA pattern were established. A long-chain triglyceride (LCT) and medium-chain triglyceride-LCT emulsion were compared for the PV and the pH during storage at room temperature and daylight in AIO bags made of ethylvinylacetate (EVA) and polypropylene:polyamide 7:3 (V90). In contrast to storage in glass bottles, significant peroxidation was detected in both emulsions with 0.5-3.4 mmol peroxides/L after 28 d (150 times the control PV). A pH drop of at least 0.3 (EVA) and 1.2 (V90) units was measured. Initial PVs and peroxidation kinetics of the emulsions were different; V90 material showed better barrier properties against oxygen. PV was increased by higher temperature and light exposure. The FA pattern of an LCT emulsion with a PV > 6 (storage: 40 degrees C in a dark room for 28 d in AIO bags) assayed by GLC remained unchanged. The iodometric peroxide and the GLC assay were reproducible and easy to handle. Only the iodometric method was sensitive enough to detect peroxidation effects (detection limit: 0.02 mmol peroxides/L). IV fat emulsions can be checked for lipid hydroperoxide content with the rapid iodometric assay to guarantee optimal quality of IV lipids used for AIO admixtures. To prevent peroxidation, lipids in AIO bags should be stored light-protected in a refrigerator an oxygen-tight overwrap is mandatory for extended periods.

[Successful therapy of salicylate poisoning using glycine and activated charcoal]. / Erfolgreiche Therapie akuter Salizylatintoxikationen mit Glycin und Aktivkohle.

Acute intoxications with salicylates are common. In a dosage of 150-300 mg/kg they are severe, and above 500 mg/kg potentially fatal. To commit suicide 4 patients ingested 375-460 mg/kg acetylsalicylic acid; 3-8 hours after ingestion salicylate blood levels of up to 760 mg/l were observed. The patients were treated for a period of 16 hours with oral charcoal and glycine (1 g/kg initially, followed every 4 hours by 0.5 g/kg, and 8 g initially, followed by 4 g, respectively). To increase urinary pH (7-9) they received i.v. NaHCO3. Blood levels of salicylic acid including its metabolites dropped initially with a virtual half-life of 2-4 hours. 18 hours after hospital admission every patient was in good general condition; none of them required hemodialysis. The urinary excretion of total salicylate reached only 6-14% of the dose within the first 12 hours of therapy, clearly indicating the importance of combined therapy with glycine and charcoal in achieving a good clinical outcome.

Stability of high-dose morphine chloride injection upon heat sterilization: comparison of UV-spectroscopy and HPLC.

The stability of a preservative-free morphine chloride solution for intravenous or intrathecal use manufactured at a concentration of 40 mg/ml, near the solubility limit in water, was studied. The influence of heat and oxygen on morphine content was measured with and without autoclaving, and after additional thermal and oxidative stress. The morphine injection was stable during steam sterilization at 121 degrees C for up to 180 min if the solution was adjusted to a pH of 3.2 and if oxygen was eliminated by saturating the solution and flushing the vial with nitrogen before sealing. By adding an oxidizing agent (200 microliters H2O2 3% per 20 ml vial) before 15 min of sterilization, a decomposition of approximately 20% of morphine resulted when compared to oxygen-free control samples (P < 0.01, n = 3) High-performance liquid chromatography with UV detection (HPLC) and direct UV spectroscopy (UV) (the latter available in most hospital pharmacies for analytical purposes) were compared for specificity, precision and appropriateness for content and stability assessment of morphine solutions. UV could only be used for quantification of undecomposed morphine. Morphine degradation products of stressed solutions interfered with the direct UV assay of morphine at 286 nm, whereas these interfering components were separated by the ion-pair reversed-phase HPLC used. The results demonstrate that even in the absence of stabilizers, morphine chloride solutions may safely be sterilized for 15 min at 121 degrees C. The HPLC method was shown to be sufficiently sensitive and specific for quality control and stability assessment of morphine preparations, and, therefore, appropriate for the validation of the manufacture of morphine injection solutions in hospital pharmacies, where morphine solutions are manufactured in special strengths and volumes for individual patients' needs.

Aortic pressure pain: clinical significance. Any relationship to the irritable bowel syndrome?

Pressure pain over the abdominal aorta is a clinical sign of undetermined significance. Ultrasonographic criteria were used to define and further evaluate this variety of epigastric tenderness. The incidence of aortic pressure pain, aortic characteristics, and gastrointestinal symptoms were scored in 250 consecutive patients. The incidence was approximately 7%. All the patients with aortic pressure pain had gastrointestinal symptoms, with a significantly higher mean symptom score. The occurrence of pressure pain was independent of any of the examined aortic characteristics, age, or body mass index. We further compared the incidence of aortic pressure pain between 25 patients with irritable bowel syndrome and 25 patients without apparent functional gastrointestinal disease. It was present in approximately 50% of the patients with irritable bowel syndrome. We found pressure pain over the abdominal aorta to be associated with significant gastrointestinal discomfort. A causal relationship is possible but not proven. Aortic pressure pain can be provoked in a significant subgroup of patients with the irritable bowel syndrome.

Endoscopic drainage of pancreatic pseudocysts.

Endoscopic drainage is a recent method in the management of pancreatic pseudocysts. It has been developed as an alternative to surgical treatment in high risk patients. Our experience with this technique is illustrated by a well documented case report which is followed by a brief review of the literature.

Tool feed influence on the machinability of CO(2) laser optics.

Influence of tool feed on reflectivity of diamond-machined surfaces was evaluated using materials (gold, silver, and copper) from which CO(2) laser optics are primarily produced. Fifteen specimens were machined by holding all machining parameters constant, except tool feed. Tool feed was allowed to vary by controlled amounts from one evaluation zone (or part) to another. Past experience has verified that the quality of a diamond-machined surface is not a function of the cutting velocity; therefore, this experiment was conducted on the basis that a variation in cutting velocity was not an influencing factor on the diamondturning process. Inspection results of the specimens indicated that tool feeds significantly higher than 5.1 micro/rev (200 microin./rev) produced detrimental effects on the machined surfaces. In some cases, at feeds as high as 13 microm/rev (500 microin./rev), visible scoring was evident. Those surfaces produced with tool feeds less than 5.1 microm/rev had little difference in reflectivity. Measurements indicat d that their reflectivity existed in a range from 96.7% to 99.3% at 10.6 microm.