Retrospective comparison of convalescent plasma with continuing high-dose methylprednisolone treatment in SARS patients

Treatment of severe acute respiratory syndrome (SARS) is experimental, and the effectiveness of ribavirin-steroid therapy is unclear. Forty SARS patients with progressive disease after ribavirin treatment and 1.5 g of pulsed methylprednisolone were given either convalescent plasma (n = 19) or further pulsed methylprednisolone (n = 21) in a retrospective non-randomised study. Good clinical outcome was defined as discharge by day 22 following the onset of symptoms. Convalescent plasma was obtained from recovered patients after informed consent. Patients in the plasma group had a shorter hospital stay (p 0.001) and lower mortality (p 0.049) than the comparator group. No immediate adverse effects were observed following plasma infusion.

Current indications and results of VATS in the evaluation and management of hemodynamically stable thoracic injuries

OBJECTIVE

Thoracic injuries are among the most severe forms of trauma and also a leading cause of morbidity and mortality. Video Assisted Thoracic Surgery (VATS) has recently provided an alternative method to simultaneously diagnose and manage patients sustaining chest injuries. We analyze our experience with VATS in the setting of thoracic trauma detailing indications for exploration, procedures performed and results of surgery.

METHODS

A 6-year single institution review of patients undergoing VATS due to injuries sustained from both blunt and penetrating chest trauma at a Level I trauma center and university teaching hospital. Comparisons were made between groups of blunt and penetrating trauma as to Injury Severity Score (ISS), presence of extra-thoracic injuries, initial thoracostomy drainage and length of postoperative stay.

RESULTS

VATS was successfully performed in 19 consecutive patients without conversion to thoracotomy. Indications for exploration included acute hemorrhage, retained hemothorax, suspected diaphragmatic injuries (DI), suspected cardiac injury, intra-thoracic foreign body, persistent airleak and chronic empyema. Procedures performed consisted of evacuation of retained hemothorax, hemostasis of intra-thoracic bleeders, repair of DI, wedge lung resections and decortication. Mean postoperative length of stay was 5.86 days. There were no morbidities. One patient with severe intra-abdominal injuries expired on the first postoperative day.

CONCLUSION

In hemodynamically stable patients with thoracic injuries, VATS provides an accurate assessment of intra-thoracic organ injury and can be utilized to definitively and effectively manage injuries sustained as a result of blunt or penetrating thoracic trauma. VATS should be used with caution in patients sustaining severe and life threatening intra-abdominal injuries.

Radiation induced mucositis: co-ordinating a research agenda

AIMS

A one-day workshop was hosted by the Symptom Control Committee of the National Cancer Institute of Canada, Clinical Trials Group (NCIC-CTG), in conjunction with the October 2002 annual meeting of the Canadian Association of Radiation Oncologists in Toronto, Ontario. The primary intention of the workshop was to direct the future research agenda of the Symptom Control Committee. Large group presentations were held initially to review the contemporary research issues of four selected areas of interest: fatigue, brain metastasis, bone metastasis and radiation-induced mucositis. Panel members were then charged with the identification of specific research proposals that could be considered for further development. Research questions were to be clinically relevant and currently appropriate. Any additional information needed before the launch of any potential trial was also requested. In this paper, we will review and summarise the outcomes from the radiation-induced mucositis sessions.

MATERIALS AND METHODS

Thirty-four participants participated in the large group sessions and contributed to one of four panel discussions on selected supportive care issues relevant to radiation oncologists.

RESULTS

Three potential and non-overlapping research questions were identified; two involving mucositis management in patients receiving radical radiation for head and neck cancer, and a third for patients with advanced lung cancer undergoing combined radiation and chemotherapy and at risk for the development of symptomatic oesophagitis.

CONCLUSION

The workshop successfully identified three potential research questions. The large group and the smaller panel discussions successfully established consensus on important aspects of future study designs. The current 'standard of care', appropriate experimental treatments, primary outcomes of interest and study population parameters were each important issues that were discussed. The importance of developing meaningful biological assays was reviewed, as was the need to ensure the appropriate storage of biological samples from patients for future study.

Five to 15 year follow-up of resolved idiopathic central serous chorioretinopathy

PURPOSE

To recognize the long-term sequelae of resolved idiopathic central serous chorioretinopathy (ICSC) in relation to visual acuity, contrast sensitivity, and lesion size between time elapsed since disease onset.

METHODS

Patients were recruited from fluorescein angiogram records between January 1985 and December 1995 with confirmed ICSC. Visual acuity, contrast sensitivity, and digital fundus photographs were recorded on follow-up. Comparison with the initial red-free photographs were made.

RESULTS

There was no statistically significant deterioration of visual acuity over time compared to eyes with ICSC after initial resolution and the normal eyes. The change of lesion size over time was also statistically insignificant. Contrast sensitivity compared to visual acuity showed positive correlation in both ICSC and normal eyes, but the results were statistically insignificant. Lesion size correlates negatively with visual acuity and contrast sensitivity although this was statistically insignificant.

CONCLUSION

This study shows little, if any, correlation between time and progression of retinal pigment epitheliopathy following resolution of ICSC. Visual acuity did not seem to worsen over time. Our data were not statistically significant, but it does give insight into the natural history of what is still a relatively poorly understood disease.

Heterogeneity of amiodarone-induced thyrotoxicosis: evaluation of colour-flow Doppler sonography in predicting therapeutic response

BACKGROUND

Amiodarone-induced thyrotoxicosis (AIT) presents a therapeutic challenge because of its resistance to standard antithyroid therapy. In iodine-deplete environments, colour-flow Doppler sonography (CFDS) has allowed distinction between two types of AIT: (i) Type I AIT, associated with increased vascularity (CFDS I-III) and response to thionamide antithyroid drug and (ii) type II AIT, with no/little thyroid vascularity (CFDS 0) and prednisolone responsiveness.

AIM

To clarify if CFDS patterns correlated with treatment outcomes in a retrospective study of 24 patients with AIT in an iodine-replete environment.

METHODS

Medical records of patients who presented to a teaching hospital between January 1998 to December 2000 were reviewed. Results of CFDS, ultrasound measurement of thyroid size and technetium scanning of the thyroid were correlated with treatment responses, especially prednisolone responsiveness.

RESULTS

Thirteen of 24 patients showed CFDS 0. Twelve of these 13 were evaluable for prednisolone responsiveness, of whom seven (58%) were prednisolone-responsive. Of 11 patients with CFDS I-III, four (36%) responded to antithyroid medication alone and only one of seven (14%) was prednisolone-responsive. Euthyroidism was achieved twice as rapidly in patients with CFDS 0 than those with CFDS I-III. Because of medical treatment failure, seven patients, from both CFDS groups, required urgent near-total thyroidectomy which was successful and uncomplicated in all cases.

CONCLUSIONS

CFDS is useful in the management of AIT because CFDS 0 correlates better with prednisolone response (58%) than CFDS I-III (14%). However, unlike experience in iodine-deficient regions, the results of the present study revealed that treatment responses to thionamide or prednisolone were heterogeneous within uniform CFDS patterns. Thus, prednisolone--responsiveness was not consistently predicted by CFDS 0, but the presence of flow appeared to correlate with non-response to prednisolone.

Supportive care management of brain metastases: what is known and what we need to know. Conference proceedings of the National Cancer Institute of Canada (NCIC) Workshop on Symptom Control in Radiation Oncology

OBJECTIVES

To review the results of published randomised controlled trials in the treatment of brain metastases and, from the knowledge gained from these trials, to identify potential study questions.

MATERIALS AND METHODS

The literature was searched for randomised controlled trials that dealt with the management of brain metastases. Potential research questions were identified on the basis of the results of the literature review.

RESULTS

A number of research questions were identified. In the context of the NCIC Symptom Control Group, a trial of supportive care alone vs supportive care and whole-brain radiotherapy (WBRT) in a subset of patients with the diagnosis of brain metastases was deemed to be of highest priority. We discussed a number of issues relating to the feasibility of such a trial.

CONCLUSIONS

The optimal management of brain metastases remains elusive. Despite the results of numerous randomised controlled trials, many questions remain unanswered. The magnitude of benefit using WBRT above supportive care alone is uncertain. A trial of supportive care alone vs supportive care and WBRT may be successful once target population, feasibility and methodological issues are thoroughly solved.

A Consensus Development Approach to Define National Research Priorities in Bone Metastases: Proceedings from NCIC CTG Workshop

AIMS

A 1-day workshop was conducted to gather interested Canadian radiation oncologists to identify priority research questions that could be answered through clinical trials under the auspices of the National Cancer Institute of Canada--Clinical Trials Group (NCIC-CTG) Symptom Control committee.

MATERIALS AND METHODS

In preparation for the workshop, a survey of Canadian radiation oncologists resulted in four research areas in symptom control, including radiation-induced mucosal reactions, fatigue, radiotherapy for brain metastases and radiotherapy for bone metastases. The first half of the workshop consisted of plenary sessions where the research setting and perspective was defined for each area. This was followed by deliberations by a subgroup of researchers with special interest in the topic area. The bone-metastases subgroup deliberated the clinical context, the scientific merits and the required methodology of research questions related to the role of radiotherapy in early treatment of bone metastases, the role of re-irradiation, the role of systemic radiotherapy and patient selection for different fractionation schedules. A list of prioritised clinical studies was proposed.

RESULTS

The question of single vs multi-fraction re-irradiation for symptomatic bone metastases was identified as most pertinent to the Canadian radiation oncologists present. A multi-centre, international intergroup study is undergoing protocol development. Other study concepts, such as an alternative dose-schedule of 17 Gy/2 fractions/1 week for intermediate-prognosis patients, and early referral for radiation oncologist assessment of early or mildly symptomatic bone metastases for good-prognosis patients, require further methodological development before a clinical trial can be proposed.

CONCLUSION

An NCIC-CTG workshop provided an update on current evidence-based knowledge in palliative radiotherapy for bone metastases. New trial concepts were discussed among practitioners and clinical investigators to promote dialogue and collaboration. The proposal of an international intergroup randomised trial of single vs multiple fraction re-irradiation for painful bone metastases received the most support among participants.

Effect of nitric oxide synthase inhibitor (L-NAME) on substance P-induced vasodilatation in the dental pulp

AIM

To investigate the vasodilator mechanisms of pulpal vessels, especially the involvement of nitric oxide (NO), during pulpal inflammation.

METHODOLOGY

Eleven cats were prepared for intra-arterial administration of test agents through a lingual artery. The pulpal blood flow was measured by laser Doppler flowmetry from ipsilateral mandibular canine teeth. By using the NO synthase (NOS) inhibitor N(G)-nitro L-arginine methyl ester (L-NAME), the effects of L-NAME on various vasodilators, such as Substance P (SP)-, calcitonin-gene related peptide (CGRP)-, and papaverine-induced vasodilatation, were compared in vivo in 11 feline dental pulps.

RESULTS

L-NAME pretreatment potentiates SP-induced vasodilatation for a duration of approximately 5 h. The increase of pulpal blood flow ranged from 91.47 to 109.91%, which was significantly different from SP injection alone (48.79%, P < 0.05). Other vasodilators such as CGRP and papaverine did not respond to L-NAME pretreatment.

CONCLUSIONS

This study demonstrates that NOS inhibitor L-NAME administration alone has insignificant effects on pulpal blood flow, although L-NAME pretreatment can potentiate SP-induced vasodilatation, probably via increased activity in the enzyme guanylate cyclase. CGRP and papaverine did not respond to L-NAME pretreatment, indicating that they are not mediated via an endothelium-dependent mechanism.

Idiopathic pneumonia syndrome after high-dose chemotherapy and autologous hematopoietic stem cell transplantation for high-risk breast cancer

Our aim was to describe the incidence, clinical course, and risk factors for idiopathic pneumonia syndrome (IPS) after high-dose chemotherapy with cyclophosphamide, carmustine, and thiotepa followed by autologous stem cell transplantation for high-risk breast cancer. Charts for patients who underwent high-dose chemotherapy for high-risk breast cancer at a single center from 1992 to 2000 were retrospectively reviewed, and potential risk factors for development of IPS were sought with the log-rank test. Of 164 patients reviewed, 20 developed IPS at a median onset of 87 days after the transplant (range, 2-257 days). The actuarial incidence of IPS in the first 100 days after the transplant was 8%, and 95% of patients developed symptoms within the first 6 months after transplant. Patient age, smoking status, breast cancer stage at diagnosis, and pretransplant lung function did not predict development of IPS. Three patients died of progressive pulmonary failure and the IPS resolved in the other 17. We concluded that IPS is an important cause of morbidity and mortality in patients with high-risk breast cancer undergoing high-dose chemotherapy. Given the absence of predictive factors, any pulmonary symptoms appearing in the first year after the transplant should be evaluated carefully.

Strong association between N-acetyltransferase 2 genotype and PD in Hong Kong Chinese

BACKGROUND

The slow acetylator genotype for N-acetyltransferase 2 (NAT2 genotype) may be associated with PD in white subjects and the genotype is common in both white and Chinese populations. Whether there is a relationship between NAT2 genotype and PD in Chinese subjects is not known.

OBJECTIVE

To investigate the association between the slow acetylator genotype for N-acetyltransferase 2 and PD in a Chinese population.

METHODS

The authors obtained DNA samples and documented sex, age, and smoking history in 99 Chinese patients with PD and in 126 control subjects from two major Hong Kong hospitals. PCR-restriction fragment length polymorphism was used to identify M1, M2, and M3 mutant polymorphisms of the slow acetylator genotype for N-acetyltransferase 2. Logistic regression analyses were carried out to investigate the relationships between the different variables and PD.

RESULTS

The frequency of the slow acetylator genotype for N-acetyltransferase 2 in the PD group was significantly higher than that of the control group (68.7% vs 28.6%) with an OR of 5.53 (95% CI 3.08 to 9.92) after adjusting for age, sex, and smoking history. In a subgroup analysis smoking had no modifying effect on the association between genotype and PD.

CONCLUSIONS

There is a significant association between PD and the slow acetylator genotype for N-acetyltransferase 2 in Hong Kong Chinese. The OR found is among the highest reported so far in all susceptibility gene studies for PD in both Chinese and white subjects and provides evidence for a possible functional relationship between NAT2 slow acetylator genotype and PD in both racial groups.