Successful treatment of idiopathic hypereosinophilic syndrome with imatinib mesylate: a case report

Patients with idiopathic hypereosinophilic syndrome (HES) show persistent hypereosinophilia of unknown etiology that is associated with end-organ damage. Different treatments, including the use of corticosteroids and cytotoxics, have been investigated for HES with modest success. We describe a patient with HES who had significant end-organ damage from hypereosinophilia and remained refractory to conventional therapy. Therapy with imatinib mesylate, a selective tyrosine kinase inhibitor that is highly effective in treating patients with BCR-ABL-positive chronic myeloid leukemia, was tried with the patient. The result was impressive, with hematologic remission achieved after 12 days of administration. Our finding concurs with recent reports that imatinib mesylate may be a promising agent in the treatment of some cases of HES.

Bouveret’s syndrome complicated by a distal gallstone Ileus

AIM: Gastric outlet obstruction caused by duodenal impaction of a large gallstone migrated through a cholecystoduodenal fistula has been referred as Bouveret’s syndrome. Endoscopic lithotomy is the first-step treatment. However, surgery is indicated in case of failure or complication during this procedure.

METHODS: We report herein an 84-year-old woman presenting with features of gastric outlet obstruction due to impacted gallstone. She underwent an attempt of endoscopic retrieval which was unsuccessful and was further complicated by distal gallstone ileus. Physical examination was irrelevant.

RESULTS: Endoscopy revealed multiple erosions around the cardia, a large stone in the second part of the duodenum causing complete obstruction, and wide ulceration in the duodenal wall where the stone was impacted. Several attempts of endoscopic extraction by using foreign body forceps failed and surgical intervention was mandatory. Preoperative ultrasound evidenced pneumobilia whilst computerized tomography showed a large stone, 5 × 4 × 3 cm, logging at the proximal jejunum and another one, 2.5 × 2 × 2 cm, in the duodenal bulb causing closed-loop syndrome. She underwent laparotomy and the jejunal stone was removed by enterotomy. Another stone reported as located in the duodenum preoperatively was found to be present in the gallbladder by intraoperative ultrasound. Therefore, cholecystoduodenal fistula was broken down, the stone was retrieved and cholecystectomy with duodenal repair was carried out. She was discharged after an uneventful postoperative course.

CONCLUSION: As the simplest and the least morbid procedure, endoscopic stone retrieval should be attempted in the treatment of patients with Bouveret’s syndrome. When it fails, surgical lithotomy consisting of simple enterotomy may solve the problem. Although cholecystectomy and cholecystoduodenal fistula breakdown is unnecessary in every case, conditions may urge the surgeon to perform such operations even though they carry high morbidity and mortality.

Coagulopathy, marantic endocarditis, and cerebrovascular accidents as paraneoplastic features in medullary thyroid cancer--case report and review of the literature

Medullary thyroid cancers account for approximately 7% of primary thyroid malignancies and are often associated with paraneoplastic syndromes. We discuss the case of a 59-year-old man who presented with a hypercoagulable state, nonbacterial endocarditis, and recurrent strokes in the setting of widespread medullary thyroid cancer. The patient was anticoagulated and underwent thyroidectomy, modified radical neck dissection, and subsequent axillary lymphadenectomy. Despite no recurrent thromboembolic events, the patient ultimately succumbed to his disease 8 months after diagnosis and 6 months after initial thyroidectomy. This is the first report, to our knowledge, of this unique presentation in a patient with thyroid cancer. The literature pertaining to the diagnosis and management of hypercoagulability states in patients with cancer, in general, and thyroid cancer, in particular, is reviewed.

Brain stimulation: history, current clinical application, and future prospects

The dramatic effects of chronic brain stimulation in the treatment of movement disorders have spurred a renewed interest in this technique for treating a variety of other conditions. This technique has only recently begun to reach its vast clinical potential, due to a number of significant advances in basic and clinical neurosciences. Current image-guided navigation systems and intraoperative physiological mapping techniques offer more efficient, consistent, and precise targeting. Advances in neurophysiology have helped elucidate the pathophysiology of a number of disease states and thus provided for rational target selection for therapy. The latest generation of stimulation equipment allows for precise tailoring of stimulation parameters to maximize clinical benefit. These techniques are now being applied to a variety of other conditions including chronic pain, epilepsy, and psychiatric disorders.

Sedation with propofol plus midazolam versus propofol alone for interventional endoscopic procedures: a prospective, randomized study

AIM

Adequate patient sedation is mandatory for most interventional endoscopic procedures. Recent anaesthesiologic studies indicates that propofol and midazolam act synergistically in combination and therefore may be superior to sedation with propofol alone in terms of sedation efficacy, recovery and costs (due to a presumed lower total dose of propofol needed).

METHODS

A total of 239 consecutive patients undergoing therapeutic EGD or ERCP (EGD/ERCP-ratio, 1:1) randomly received either propofol alone (n=120, group A, loading dose 40-60 mg intravenously, followed by repeated doses of 20 mg) or propofol plus midazolam (n=119, group B, initial midazolam dose of 2. 5-3.5 mg intravenously, followed by repeated doses of 20 mg of propofol) for sedation. Vital signs (heart rate, blood pressure, oxygen saturation, electrocardiogram) were continuously monitored. Procedure-related parameters, the recovery time and quality (post-anaesthesia recovery score) as well as the patient's co-operation and tolerance to the procedure (visual analogue scale) were prospectively assessed.

RESULTS

Patients of group A and B were well matched with respect to demographic and clinical data, endoscopic findings, and the type of associated procedures. In group A, a mean dose of 0.25 +/- 0.13 mg.min/kg propofol was used compared to 0.20 +/- 0.09 mg.min/kg of propofol in group B (P < 0.01, plus additional 2.9 +/- 0.5 mg of midazolam). Clinically relevant changes in vital signs were observed at comparable frequencies with a lowering of the systolic blood pressure < 90 mmHg in six out of 119 patients in group B and one out of 120 patients in group A (P=0.07). The sedation efficacy was rated similarly in both groups, whereas the mean recovery time (group A, 19 +/- 7 min vs. group B, 25 +/- 8 min, P < 0.05) as well as the recovery score (post-anaesthesia recovery score group A, 8.0 +/- 1.1 vs. post-anaesthesia recovery score group B, 7.3 +/- 1.2, P < 0.001) were significantly better with propofol alone than with propofol plus midazolam.

CONCLUSION

During therapeutic endoscopy, sedation with propofol and midazolam requires a lower total dose of propofol, but otherwise has no superior sedation efficacy and is associated with a slower post-procedure recovery than sedation with propofol alone.

Risk factors for surgery and postoperative recurrence in Crohn's disease

OBJECTIVE

To assess the impact of possible risk factors on intestinal resection and postoperative recurrence in Crohn's disease (CD) and to evaluate the disease course.

SUMMARY BACKGROUND DATA

The results of previous studies on possible risk factors for surgery and recurrence in Crohn's disease have been inconsistent. Varying findings may be explained by referral biases and small numbers of patients in some studies.

METHODS

Data on initial intestinal resection and postoperative recurrence were evaluated retrospectively in a population-based cohort of 1,936 patients. The influence of concomitant risk factors was assessed using uni- and multivariate analyses.

RESULTS

The cumulative rate of intestinal resection was 44%, 61%, and 71% at 1, 5, and 10 years after diagnosis. Postoperative recurrences occurred in 33% and 44% at 5 and 10 years after resection. The relative risk of surgery was increased in patients with CD involving any part of the small bowel, in those having perianal fistulas, and in those who were 45 to 59 years of age at diagnosis. Female gender and perianal fistulas, as well as small bowel and continuous ileocolonic disease, increase the relative risk of recurrence.

CONCLUSIONS

Three of four patients with CD will undergo an intestinal resection; half of them will ultimately relapse. The extent of disease at diagnosis and the presence of perianal fistulas have an impact on the risk of surgery and the risk of postoperative recurrence. Women run a higher risk of postoperative recurrence than men. The frequency of surgery has decreased over time, but the postoperative relapse rate remains unchanged.

Health effects of passive smoking-10: Summary of effects of parental smoking on the respiratory health of children and implications for research

BACKGROUND

Two recent reviews have assessed the effect of parental smoking on respiratory disease in children.

METHODS

The results of the systematic quantitative review published as a series in Thorax are summarised and brought up to date by considering papers appearing on Embase or Medline up to June 1998. The findings are compared with those of the review published recently by the Californian Environmental Protection Agency (EPA). Areas requiring further research are identified.

RESULTS

Overall there is a very consistent picture with odds ratios for respiratory illnesses and symptoms and middle ear disease of between 1.2 and 1.6 for either parent smoking, the odds usually being higher in pre-school than in school aged children. For sudden infant death syndrome the odds ratio for maternal smoking is about 2. Significant effects from paternal smoking suggest a role for postnatal exposure to environmental tobacco smoke. Recent publications do not lead us to alter the conclusions of our earlier reviews. While essentially narrative rather than systematic and quantitative, the findings of the Californian EPA review are broadly similar. In addition they have reviewed studies of the effects of environmental tobacco smoke on children with cystic fibrosis and conclude from the limited evidence that there is a strong case for a relationship between parental smoking and admissions to hospital. They also review data from adults of the effects of acute exposure to environmental tobacco smoke under laboratory conditions which suggest acute effects on spirometric parameters rather than on bronchial hyperresponsiveness. It seems likely that such effects are also present in children.

CONCLUSIONS

Substantial benefits to children would arise if parents stopped smoking after birth, even if the mother smoked during pregnancy. Policies need to be developed which reduce smoking amongst parents and protect infants and young children from exposure to environmental tobacco smoke. The weight of evidence is such that new prevalence studies are no longer justified. What are needed are studies which allow comparison of the effects of critical periods of exposure to cigarette smoke, particularly in utero, early infancy, and later childhood. Where longitudinal studies are carried out they should be analysed to look at the way in which changes in exposure are related to changes in outcome. Better still would be studies demonstrating reversibility of adverse effects, especially in asthmatic subjects or children with cystic fibrosis.

The role of estrogen support during the luteal phase of in vitro fertilization-embryo transplant cycles: a comparative study between progesterone alone and estrogen and progesterone support

OBJECTIVE

To evaluate the possible role for estrogen supplementation to the P luteal phase support of GnRH agonists (GnRH-a)- and hMG-induced IVF-ET cycles.

SETTING

In vitro fertilization unit in a tertiary care university hospital.

DESIGN

A prospectively randomized study.

PATIENTS

One hundred consecutive patients undergoing ET after IVF were assigned into one of two luteal supplementation regimens.

INTERVENTIONS

In all patients enrolled in the study, ovulation was induced using the midluteal regimen for pituitary down regulation with GnRH-a followed by follicular stimulation with hMG. The first group received IM P 50 mg/d, as luteal phase support, starting the day of ET. The second group received the same dosage of P, combined with oral E2 valerate, 2 mg/d. Serum levels of P and E2 were monitored every 4 days for 16 days after ET.

MAIN OUTCOME MEASURES

Pregnancy rates (PRs) and live birth rates per ET.

RESULTS

No significant difference in E2 or P levels throughout the cycle was observed between groups. Similar PRs per ET and the live birth rates were also observed between group A and B (28% versus 26.5% and 78.6% versus 76.1%, respectively).

CONCLUSION

No advantage was found in the addition of E2 valerate to P luteal phase support of GnRH-a- and hMG-induced IVF-ET cycles.

Association between mediastinal germ cell tumors and hematologic malignancies. Report of two cases and review of the literature

A hematologic malignancy occurred simultaneously with a malignant mediastinal germ cell tumor in two men. In one instance the blood disorder was acute nonlymphocytic leukemia, and in the other, malignant histiocytosis. We subsequently identified nine additional patients, all male (age range 12-48 years), with a mediastinal germ cell tumor and either acute nonlymphocytic leukemia or malignant histiocytosis. Six of the 11 patients had not received either radiation or chemotherapy before development of the hematologic malignancy. One patient developed malignant histiocytosis and was found to have a malignant mediastinal germ cell tumor after having received steroid therapy for a renal allograft. The four remaining patients developed acute nonlymphocytic leukemia 5-32 months after initiation of irradiation or chemotherapy for a mediastinal germ cell tumor. In four patients with acute leukemia, karyotypic analysis established the clonal nature of the leukemic process. Although the leukemia may be therapy-related in four or possibly five patients, this explanation cannot be applied to the remaining six patients. These six patients, coupled with studies of in vitro growth characteristics of teratocarcinoma cells described previously, suggest that a previously unrecognized association between malignant mediastinal germ cell tumors and hematologic malignancies may exist in humans.