Successful algorithm for selective liver biopsy in the right hepatic lobe live donor (RHLD)

Routine versus selective predonation liver biopsy (LBx) remains controversial for assuring the safety of right hepatic lobe live donor (RHLD). Between December 1999 and March 2007, 403 potential RHLD were evaluated; 142 donated. Indications for selective LBx were: abnormal liver function tests or imaging studies, body mass index (BMI) >28, history of substance abuse or family history of immune mediated liver disease. All donors had a LBx at the time of surgery. Of 403 potential RLD, 149(36.9%) were accepted as donors, 25(6.3%) had their recipient receive a deceased donor graft, 94(23.4%) were rejected, 52(12.9%) stopped the evaluation process, 76(18.8%) withdrew from the process and 7(1.7%) are currently completing evaluation. Eighty-seven (21.5%) met criteria and were biopsied. Seventy-three (83.9%) had either normal (n = 24) or macrosteatosis <10% (n = 49); 51 of these donated. Abnormal LBx eliminated 15 potential donors. No significant abnormalities were found in donation biopsies of donors not meeting algorithm criteria. Three of 87 (3.4%) had complications requiring overnight admission (2 for pain, 1 for bleeding; transfusion not required). Use of this algorithm resulted in 78% of potential donors avoiding biopsy and potential complications. No significant liver pathology was identified in donors not meeting criteria for evaluation LBx. Routine predonation LBx is unnecessary in potential RHLD.

Social determinants of health inequalities in Bosnia and Herzegovina

OBJECTIVE

To examine the social determinants of inequalities in health in Bosnia and Herzegovina in the post-conflict period, and to test if the relative effects vary across the two entities of the Federation of Bosnia and Herzegovina and the Republika Srpska.

STUDY DESIGN

Cross-sectional data come from the first wave of the Bosnia and Herzegovina Household Panel Study conducted in 2001, which collected data from 7482 respondents aged 17 years and older based on over 3000 households.

METHODS

Distributions and odds ratios for physical limitations and poor mental well-being were calculated over a number of known social determinants. Multivariate logistic regression and t-tests were used to compare risks across entities within the state of Bosnia and Herzegovina.

RESULTS

The prevalence of poor mental well-being and physical limitations was significantly higher in the Republika Srpska. Significant differences in poor mental well-being and physical limitations were observed across most determinants within each entity, but only a few of these relative effects differed between entities.

CONCLUSIONS

Efforts to tackle absolute differences in poor health between the entities within Bosnia and Herzegovina should be pursued, along with reducing social inequalities.

Phase II study of the combination of cisplatin + temozolomide in malignant glial tumours in children and adolescents at diagnosis or in relapse (cistem2/nct00147160)

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Background: Temozolomide has been shown moderately effective in pediatric high-grade glioma (HGG). By decreasing the activity of MGMT, principal mechanism of resistance to temozolomide, cisplatin may increase the activity of this alkylating agent. Methods: Patients aged 4 to 21y with HGG outside the brainstem were treated at diagnosis or at relapse every 28 days with a combination of cisplatin 80 mg/m2 intravenously on day-1 and temozolomide 200 mg/m2 orally on days 2–6, according to the pediatric phase I recommendations. Patients treated at diagnosis had to proceed to involved field radiotherapy after the chemotherapy window. According to initial response, patients were offered additional courses, up to seven. We considered that this combination would be of interest if the response rate was superior or equal to 20%, using a two-stage Simon design in 3 cohorts: evaluable non measurable (infiltrative) at diagnosis (cohort A1); measurable disease (nodular) at diagnosis (A2); recurrent disease (B). The primary endpoint was complete or partial response after two courses, confirmed by central review. Up to 29 evaluable pts were to be entered in each cohort. If fewer than 4/29 responses were observed, it would be concluded that the combination is ineffective. Results: 56 pts were entered from 10/2003 through 07/2006 in 25 centers. One was excluded after central pathology review and 3 due to insufficient radiology work-out. 42 had grade III and 13 grade IV gliomas, including 21 tumors with oligodendroglial features. No response was observed in the first 11 pts in cohort A1 and in the first 12 pts in cohort B. Two partial and 4 minor responses were confirmed in 29 pts of cohort A2 leading to a 7% response rate (95% CI, 1–23%). Median time to progression was 1.7, 7.1 and 6.9 months in cohorts A1, A2 and B, respectively. Toxicity was manageable except in pts with large infiltrative lesions who did not tolerate hydration. Conclusion: CISTEM combination has insufficient efficacy in pediatric compared to adult HGG despite efficient down-regulation of MGMT activity. To overcome resistance to temozolomide in children and adolescents, one may need to target other known resistance mechanisms such as mismatch-repair deficiency.

[Table: see text]

Safety and efficacy of pegfilgrastim administration on the same day as myelosuppressive chemotherapy (CT) in women with ovarian or primary peritoneal cancer

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Background: According to prescribing information, pegfilgrastim should not be administered within 14 days prior to, or within 24 hours after, the administration of cytotoxic CT. However, little data exist to support this recommendation. The purpose of the current study is to determine the safety and efficacy of administering pegfilgrastim on the same day as myelosuppressive CT in patients with ovarian or primary peritoneal carcinoma. Methods: A retrospective review was conducted of all ovarian and primary peritoneal cancer patients that received prophylactic pegfilgrastim on the same day as CT from May 2003 to June 2006. Results: Forty-six patients (mean age: 57, range: 21–82) were treated for the following malignancies: 35 (76%) epithelial ovarian, 6 (13%) primary peritoneal, and 5 (11.0%) ovarian germ cell or stromal cell carcinoma. Twenty-six patients (56%) had primary cancers and 20 (44 %) had recurrent disease. All patients met the ASCO or NCCN recommendations of using colony-stimulating factors for prophylaxis against febrile neutropenia (FN) (Risk of FN > 20%). A total of 269 cycles of CT were administered including 125 cycles (46.5%) docetaxel + carboplatin, 39 cycles (14.5%) gemcitabine + platinum, 30 cycles (11.1%) intravenous paclitaxel + carboplatin, 28 cycles (10.4%) liposomal doxorubicin, 19 cycles (7.1%) paclitaxel + intraperitoneal platinum, 6 cycles (2.2%) docetaxel, 6 cycles (2.2%) liposomal doxorubicin + cisplatin, 5 cycles (2%) bleomycin + etoposide + cisplatin, 4 cycles (1.5%) topotecan, 3 cycles (1.1%) of paclitaxel, 2 cycles (0.7%) vincristine + actinomycin-D + cyclophosphamide, and 2 cycles (0.7%) docetaxel + gemcitabine. All patients received pegfilgrastim within one hour of the completion of CT administration. Grade 1 or 2 neutropenia developed in 10 cycles (3.7%) out of the 269 cycles, mean absolute neutrophil count = 4926 (range, 1293 -24300). No patients had FN episodes, hospitalizations or antibiotic use secondary to neutropenia, or dose-reductions and CT delays due to neutropenia. Conclusions: Administration of pegfilgrastim on the same day as CT in ovarian and primary peritoneal cancer patients is more convenient to the patient and appears safe and effective.

No significant financial relationships to disclose.

[Epidemiology of malaria in a village of Sudanese savannah in Mali (Bancoumana). Anti-TRAP and anti-CS humoral immunity response]

Vaccine development research is an important component of malaria control strategies. Thrombospondin related anonymous protein (TRAP) and the circumsporozoite (CS) protein are two antigens of sporozoite surface. Immune response to these two antigens may contribute to the development of anti-sporozoite vaccine. Recent studies suggest that antibodies anti-TRAP may partially block sporozoites penetration in hepatocyte, and thereby reducing malaria morbidity. We carried out a study to assess the seroprevalence of anti-TRAP and anti-CS antibodies and to identify a possible role of these antibodies on malaria morbidity in children 1-9 years old living in a rural hyperendemic village. We performed 5 cross sectional surveys and a longitudinal follow up in 1993 and 1994. During each cross sectional study, children were examined for fever and splenomegaly; all febrile children received thick film examination, and serologic analysis was performed in one third of these, randomly selected. The results show that the seroprevalence of anti-TRAP and anti-CS varied with age and season (p < 0.05). Association between the prevalence of anti-TRAP and splenomegaly was observed during two cross sectional surveys (June and October 1993). The presence of anti-TRAP antibody was associated with Plasmodium falciparum infection at the beginning of the transmission season (June 1993 and July 1994). A negative association between the level of anti-TRAP title and parasitemia was observed (March and October 1994). These findings suggest no clear evidence of the protective role of anti-TRAP antibodies in uncomplicated malaria, possibly due to the limited persistence of these antibodies under natural situations.

Temozolomide in malignant gliomas of childhood: a United Kingdom Children's Cancer Study Group and French Society for Pediatric Oncology Intergroup Study

PURPOSE

To determine the response rate of the malignant gliomas of childhood to an oral, daily schedule of temozolomide.

PATIENTS AND METHODS

A multicenter, phase II evaluation of an oral, daily schedule of temozolomide (200 mg/m(2) on 5 consecutive days) was undertaken in children with relapsed or progressive, biopsy-proven, high-grade glioma (arm A) and progressive, diffuse, intrinsic brainstem glioma (arm B). Evidence of activity was defined by radiologic evidence of a sustained reduction in tumor size on serial magnetic resonance imaging scans.

RESULTS

Fifty-five patients were recruited (34 to arm A and 21 to arm B) and received 215 cycles of chemotherapy. Grade 3/4 thrombocytopenia was the most frequent toxic event (7% of cycles). Prolonged myelosuppression resulted in significant treatment delays and dose reductions (17% and 22% of cycles, respectively). Two toxic deaths were documented and were related to myelosuppression and sepsis in one patient and pneumonia in a second. The overall (best) response rate was 12% for arm A (95% confidence interval [CI], 3 to 28 in the study cohort, and 2 to 31 for eligible patients) and 5% and 6%, respectively, for arm B (95% CI, 0 to 26 in the study cohort, and 0 to 27 for eligible patients). Stabilization of disease was also documented and was most noteworthy for brainstem gliomas, where two patients achieved both radiologic static disease and discontinued steroid medication.

CONCLUSION

Despite moderate toxicity, objective response rates to temozolomide have been low, indicating that temozolomide has minimal activity in the high-grade gliomas of childhood.

Executive functioning in adults and children with developmental dyslexia

The performance of developmentally dyslexic children and adults was studied upon a range of tasks that involved executive functioning. Both adult and child samples of dyslexics were found to under-perform on the group-embedded figures test. This test required the identification of constituent parts from within complex visual arrays, with good performance necessitating the inhibition of the processing of the surrounding context. A general deficit on visual-spatial tasks was eliminated as an explanation as dyslexics performed normally upon a range of other non-verbal assessments. The dyslexics consistently demonstrated a deficit in digit span tasks, a decrement that was increased with distractors, again suggesting difficulties in inhibiting the processing of the surrounding context. A deficit was also identified upon a verbal fluency task without a deficit in vocabulary level. Additionally, a specific deficit in the recollection of the temporal order of the presentation of items was in evidence, without a deficit in the recognition of the items themselves. The findings taken as a whole suggest that dyslexic individuals show deficiencies in executive functions relating to inhibition of distractors and to sequencing of events, a set of tasks associated with left prefrontal cortex functioning in the acquired neuropsychology literature.

Third ventricular plasma-cell lesion with delayed intraventricular transudation of contrast medium

We report a patient presenting with hydrocephalus secondary to a posterior third ventricular plasma-cell lesion which exhibited delayed transudation of contrast medium into the adjacent aqueduct and fourth ventricle.

Congenital small bowel diverticulosis and intestinal atresia: a rare association

An unusual case of multiple intestinal atresias with multiple small bowel diverticulae is presented. To the best of our knowledge this is the first reported case of its kind in the literature.

GERD progressing to diffuse esophageal spasm and then to achalasia

The pathophysiology of achalasia is not completely understood. Several reports have suggested that esophageal motility disorders may progress from one type to another. We report a patient with symptoms and esophageal motility findings consistent with gastroesophageal reflux who subsequently developed a diffuse esophageal spasm and then achalasia. We believe this to be the first report showing such a progression in esophageal motility.

Wilms' tumor: a 25-year review of the role of preoperative chemotherapy

PURPOSE

This 25-year population based, single institution review was conducted to investigate the impact of preoperative chemotherapy on surgical and histological staging in patients with Wilms' tumors.

RESULTS

Forty-nine patients under the age of 15 years were identified from case notes to have had histologically verified Wilms' tumors over the 25-year period from January 1972 to December 1996. Twenty-six patients were treated initially with preoperative chemotherapy, 23 with immediate surgery. Eleven had treatment randomized within the UKCCSG WT9101 trial (UKWT3), and the remainder received initial treatment according to unit policy. Surgical stages in the two groups (preoperative chemotherapy and immediate surgery) were respectively, stage 1:14(28.5%) and 11 (22.5%), stage II: one (2%) and eight (16.3%), stage III: 11 (22.5%) and four (8.2%). Seven patients had clinical stage IV disease at presentation. Histology results were favorable in 45 patients and unfavorable in four. All patients received chemotherapy during treatment, whereas 25 (51%) also received radiotherapy. No significant difference was evident in the two groups with respect to treatment-related morbidity. Five patients relapsed, three of whom died within the period of review, but a fourth has since died.

CONCLUSIONS

This study suggests that the use of preoperative chemotherapy does not put the patient at increased risk of postoperative morbidity or reduced survival. The distribution of surgical stages suggests that limited tumor downstaging may have occurred as a result of preoperative chemotherapy.

Heparanases produce distinct populations of heparan sulfate glycosaminoglycans in Chinese hamster ovary cells

Once internalized, cell-associated heparan sulfate proteoglycans are degraded to short glycosaminoglycans by the action of endoglycosidases or heparanases. We have begun to address the question of how many heparanases are responsible for this process by analyzing short heparan sulfate chains produced in vivo by Chinese hamster ovary (CHO) cell heparanases. Short heparan sulfate chains were purified from CHO cells and labeled at the reducing end with [3H]NaBH4. Hydrolysis of the chains to monosaccharides and analysis of the 3H-sugar alcohols indicate that heparanase activities in CHO cells are endo-beta-glucuronidases. The modification state of the heparanase-derived glycosaminoglycans was examined by treating the [3H]heparan sulfate chains with nitrous acid or bacterial heparin lyases, which cut the chain at specific sequences, and analyzing the products by P2 gel filtration chromatography. Two populations of short chains were identified that differ in the extent of modification on the nonreducing side of the heparanase cleavage site. One class of chains is unmodified for at least 9 residues from the reducing end, while the other group has a modified domain within 3-7 residues from the heparanase cleavage site. Our results suggest a model of heparanase action where the enzymes recognize differences in sulfate content between modified and unmodified regions and bind to sites that encompass both domains. The enzymes then cleave the glycosaminoglycan at junctions between the modified and unmodified sequences to produce the different populations of short heparan sulfate chains.

Congenital hereditary endothelial dystrophy associated with nail hypoplasia

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Focal myositis: an unusual cause of bilateral upper eyelid swellings

Focal myositis is considered a rare self-limiting inflammatory swelling of skeletal muscle. Focal involvement of individual muscle or muscle groups with severe myopathic and inflammatory changes characterizes the histology. We report the development of progressive focal myositis in both upper eyelids of a 34 year old man that responded to immunosuppressive therapy.

A study of the local toxicity of agents used for variceal injection sclerotherapy

Injection sclerotherapy is widely used in the treatment of oesophageal varices. However, few studies have compared the local toxicity of sclerosant agents which may be important if serious local complications are to be avoided. In this study the depth of injury caused by submucosal injection of increasing concentrations of sodium tetradecyl sulphate, polidocanol, 5% ethanolamine oleate and 5% varicosid in rabbits stomach, has been compared by histopathological examination. Macroscopic ulceration was seen in 14.6% of injection sites. Increasing concentrations of sodium tetradecyl sulphate and polidocanol produced increasingly extensive microscopic inflammation. Five percent varicosid caused more inflammation than 5% ethanolamine and only 3% polidocanol and 5% varicosid caused full thickness inflammation. Only 5% ethanolamine produced inflammation consistently confined to the mucosa and submucosa. On the basis of this study we feel that 5% ethanolamine is the most suitable agent for injection sclerotherapy.

Previous induced abortion and ante-natal depression in primiparae: preliminary report of a survey of mental health in pregnancy

One hundred and nineteen primiparae, who were routinely attending ante-natal clinics, were interviewed repeatedly between the 12th and 36th weeks of their pregnancies. The incidence of depression was highest in the first trimester and, overall, about a fifth of the sample was found to be suffering from clinically significant neurotic disturbances. In a proportion of these expectant mothers there was an association between depression and anxiety early in pregnancy and a previous history of induced abortion; this phenomenon may reflect a reactivation of mourning which was previously suppressed.