[Treatment of exacerbation of asthma: what are today's issues?]

During past decades, major progress has been accomplished in the management of acute asthma. Most recent recommendations include evidence-based rationale. The improved quality of clinical guidelines makes them efficient models for medical education. The pediatric pharmacopoeia provides a great variety of choices of drugs as well as for asthma medical devices. These innovations dramatically facilitated the medical management of asthmatic children, but they did not solve all problems. Physicians now use higher doses of salbutamol, but the early prescription of systemic glucocorticoids for moderate exacerbation of asthma is still underused, given the most recent clinical guidelines and meta-analysis. Furthermore, repeated emergency department visits to the wards and lack of primary care physician should systematically be appraised when evaluating severity, as they are both major risk factors for severe exacerbations, even though they are not considered in acute asthma severity scores. Finally, initiating (or reinforcing) patient education at the time of exacerbation also presents important challenges, as emergency visits are a favorable moment to commence the therapeutic education of the child and his family. Indeed, framing the controller medications and educating families about how to manage the disease and to improve their domestic environment are the genuine tools available for the prevention of asthma exacerbations, and particularly those most severe.

The endocarditis that was not: an unusual case of heparin-induced thrombocytopenia with unusual complications

The complications of heparin-induced thrombocytopenia have been well described previously. However, evidence of the possibility that heparin-induced thrombocytopenia can trigger a thyroid storm has never been published before. A catastrophic evolution of a man referred with a high endocarditis suspicion previously treated with heparin, who successively developed arterial thrombosis and thyroid storm, is described.

Vulvar vestibulitis syndrome: reliability of diagnosis and evaluation of current diagnostic criteria

OBJECTIVE

To assess the reliability of the diagnosis of vulvar vestibulitis as defined by Friedrich and to evaluate the usefulness of Friedrich's criteria in the diagnostic process.

METHODS

In a university hospital, 146 women with dyspareunia had two sets of gynecologic examinations involving vulvar pain ratings, took part in structured interviews, and completed the McGill-Melzack Pain Questionnaire.

RESULTS

Kappa values for the vulvar vestibulitis diagnosis ranged from 0.66 to 0.68 for inter-rater agreement and from 0.49 to 0.54 for test-retest reliability. Mean vestibular pain ratings ranged from 2.45 at the 12 o'clock site to 7.58 at the 9-12 o'clock site; ratings for all sites correlated significantly between gynecologists. Pain in the labia majora and labia minora was minimal for both sets of examinations, with mean participant pain ratings ranging from 0 to 1.49. Gynecologists' erythema ratings did not correlate significantly with respect to either inter-rater agreement or test-retest reliability. Of Friedrich's three diagnostic criteria, only tenderness to pressure within the vulvar vestibule differentiated dyspareunia patients with and without vulvar vestibulitis. In reference to their coital pain, 88.1% of women with vulvar vestibulitis chose adjectives from the McGill-Melzack Pain Questionnaire describing a thermal quality, and 86.6% chose adjectives describing an incisive pressure sensation.

CONCLUSION

Vulvar vestibulitis can be reliably diagnosed in women with dyspareunia. Pain is limited to the vulvar vestibule and can be rated and described in a consistent fashion by these women. Erythema does not appear to be a useful diagnostic criterion.

A phase I clinical, pharmacological, and biological trial of interleukin 6 plus granulocyte-colony stimulating factor after ifosfamide, carboplatin, and etoposide in children with recurrent/refractory solid tumors: enhanced hematological responses but a high incidence of grade III/IV constitutional toxicities

A Phase I trial was conducted to determine the safety, biological activity, and hematopoietic recovery by the combination of interleukin 6 (IL-6) and granulocyte-colony stimulating factor (G-CSF) after myelosuppressive chemotherapy in children. Patients <22 years of age at diagnosis with either recurrent or refractory solid tumors received ifosfamide 1,800 mg/m2/day x 5 days, carboplatin 400 mg/m2/ day x 2 days, and etoposide 100 mg/m2/day x 5 days, followed by daily s.c. G-CSF (5 microg/kg/day) and IL-6 (2.5, 3.75, or 5.0 microg/kg/day). Pharmacokinetic, proinflammatory mediator levels, hematopoietic colony assays, and cytokine receptor expression studies were performed during course one. Nineteen patients were evaluable for toxicity and received IL-6 at doses of 2.5 (n = 8), 3.75 (n = 5), or 5.0 (n = 6) microg/kg/day. Dose-limiting constitutional toxicity occurred in two of six patients at 5.0 microg/kg/day, two of five patients at 3.75 microg/kg/day, and two of eight patients at 2.5 microg/kg/day. The maximum tolerated dose (MTD) exceeded the lowest dose tested. Because of lack of drug availability, an MTD was not established. The maximum concentration of IL-6 (2.5 microg/kg/day) was 0.799 +/- 1.055 ng/ml (mean +/- SD). During the first course, the median time to absolute neutrophil count > or = 1,000/mm3 and platelets > or = 100,000 mm3 was estimated at 19 and 23 days, respectively. Peripheral blood progenitor cells expressing receptors to IL-3, IL-6, and G-CSF increased significantly over baseline (P < 0.05). After the first dose of IL-6, IFN-gamma levels were abnormal in 13 patients, and IL-1beta levels were abnormal in 10 patients. IL-6 has a high incidence of constitutional toxicity and a lower MTD in children compared with adults. In vivo use of IL-6 in children after chemotherapy remains limited. However, IL-6 may be more optimally investigated in children under ex vivo conditions.

A search for natural bioactive compounds in Bolivia through a multidisciplinary approach. Part I. Evaluation of the antimalarial activity of plants used by the Chacobo Indians

Thirty extracts of plants traditionally used by the Chacobos, a native community living in the Amazonian part of Bolivia, were screened in vitro and/or in vivo for antimalarial activity. Two of the four species designated as antimalarial, Geissospermum laeve and Maquira coriacea, displayed rather good activity, corroborating their traditional uses. However, they did show a rather high toxicity in vivo. Among twelve species used to cure symptoms relevant to malaria, five showed good activity: Apuleia leiocarpa, Bauhinia guianensis, Nectandra cuspidata, Sparattanthelium amazonum, Tanaecium jaroba. Two species, Qualea paraensis and Sclerolobium aff. guianense, used to treat scabies, showed interesting antimalarial activity in vivo; three other species (Iryanthera laevis, Prunus amplifolia, Pterocarpus aff. amazonum) used for various medicinal purposes, apparently not related with a Plasmodium infection, also showed antimalarial activity. Finally, one species (Derris amazonica) used as a piscicide displayed good in vitro activity, in the same way as one Annonaceae, Guatteria aff. schomburgkiana, used for construction purposes.

A Phase I study of granulocyte-macrophage-colony stimulating factor/interleukin-3 fusion protein (PIXY321) following ifosfamide, carboplatin, and etoposide therapy for children with recurrent or refractory solid tumors: a report of the Children's Cancer Group

BACKGROUND

This Phase I trial was developed to determine the safety, biologic activity, and effects on hematopoietic recovery of PIXY321 following ifosfamide, carboplatin, and etoposide chemotherapy for children with recurrent or refractory solid tumors.

METHODS

Children (age < 22 years at diagnosis) received ifosfamide 1800 mg/m2/day x 5 days, carboplatin 400 mg/m2/day x 2 days, and etoposide 100 mg/m2/day x 5 days, followed by daily subcutaneous administration of PIXY321. Dose-limiting toxicity was defined as Grade IV toxicity related to PIXY321. Pharmacokinetic and endogenous cytokine production studies were conducted during Course 1, and peripheral blood (PB) progenitor cell and receptor expression studies were conducted during Course 1 when the white blood cell count recovered to > or=1000/mm3.

RESULTS

Twenty-four children received ifosfamide, carboplatin, and etoposide chemotherapy plus PIXY321, the latter at doses of 500 /g/m2/day (n=3), 750 microg/m2/day (n=6), 1000 microg/m2/day (n=9), or 500 microg/m2/twice a day (n=6). PIXY321 was well tolerated, with only 1 dose-limiting toxicity (chills, occurring at a dose of 750 microg/m2/day). The maximum tolerated dose was not reached in this study. The median days to absolute neutrophil count recovery (> or =1000/mm3) and platelet recovery (>100,000/mm3) during Course 1 following PIXY321 (1000 microg/ m2/day) were 22 days (range, 5-33 days) and 20 days (range, 5-31 days), respectively. There was a 2500, 5000, 3000, and 390% increase in PB granulocyte-macrophage colony-forming units, erythrocyte blast-forming units, granulocyte erythrocyte macrophage and megakaryocyte colony-forming units, and CD34+ cells, respectively.

CONCLUSIONS

In summary, this pediatric Phase I trial demonstrated that PIXY321 was well tolerated by children and resulted in platelet recovery a median of 20 days after ICE chemotherapy and an increase in the number of PB progenitor cells above baseline. However, based on recent negative results with PIXY321 in randomized Phase II/III trials involving adult subjects, PIXY321 is not currently available for future trials involving children.

Vulvar vestibulitis syndrome: a critical review

OBJECTIVE

Vulvar vestibulitis syndrome (VVS) is thought to be the most frequent cause of dyspareunia in premenopausal women and is one of the major subtypes of vulvodynia. Vulvar vestibulitis is a chronic, persistent clinical syndrome characterized by severe pain on vestibular touch or attempted vaginal entry, exquisite tenderness to a cotton-swab palpation of the vestibular area, and physical findings confined to vestibular erythema. The purpose of this paper is to critically review the descriptive, diagnostic, etiologic, and treatment studies on VVS. Methodological problems are highlighted, and future guidelines for research are proposed.

DATA SOURCES

References were obtained from a MEDLINE search covering the period from January 1984 until June 1995. The indexing term "vulvar vestibulitis" was used, and the search was constrained to English-language articles. References from other relevant sources, such as texts and bibliographies, were also included.

STUDY SELECTION

All articles pertaining to VVS were reviewed.

DATA EXTRACTION

All data relevant to the descriptive, diagnostic, etiologic, and treatment aspects of VVS were included.

DATA SYNTHESIS

Pain symptomatology tends to be underemphasized in the current descriptive studies. The trend in etiological research is to focus on biomedical factors such as candidiasis and human papillomavirus (HPV). Only a few studies adopt a nonreductionnist approach. Surgery is the treatment option with the highest reported success rate. Medical management is underinvestigated, considering its widespread use. Pain management techniques such as biofeedback and behavior therapy show promising results.

CONCLUSIONS

A pain syndrome conceptualization is suggested as the most useful approach for solving current empirical and clinical problems.

The surgical treatment of vulvar vestibulitis syndrome: a follow-up study

This study evaluated the effectiveness of vestibulectomy in relieving coital pain and improving sexual function in women diagnosed with vulvar vestibulitis. Vulvar vestibulitis syndrome, a chronic, nonspecific inflammation of the vulvar vestibule, probably represents the most frequent subtype of premenopausal dyspareunia. Participants were 38 women who underwent vestibulectomy at a university hospital between 1986 and 1994. Telephone interviews were conducted to assess whether vestibulectomy or other subsequent treatments affected coital pain and sexual functioning. Length of postoperative follow-up ranged from 1.1 to 10 years, with a mean of 3.3 years. Vestibulectomy yielded a positive outcome for 63.2% of the participants and moderate to no improvement for the other 36.8%. The surgery was linked to a significant increase in intercourse frequency for the entire sample and to an increase in oral and manual stimulation for the women with successful surgical outcomes. No other factors were significantly associated with treatment outcome.

[Tetanus vaccination. Evaluation of a program of health promotion in a family medicine unit]

OBJECTIVE

To assess the effectiveness of a tetanus immunization poster at a medical clinic in encouraging patients to request immunization against tetanus with d2T5.

DESIGN

Quasi-experimental study.

SETTING

The Family Medicine Unit (F.M.U.) at the Centre hospitalier de l'Université Laval (C.H.U.L.), a tertiary hospital in the region of Quebec City.

PARTICIPANTS

All patients over 7 years of age at CHUL's FMU between February 22 and March 19, 1993.

INTERVENTIONS

Poster promoting tetanus immunization displayed in waiting room during test weeks 2 and 4 and withdrawn during control weeks 1 and 3.

MAIN OUTCOME MEASURE

Proportion of patients vaccinated with d2T5.

RESULTS

The proportion of patients vaccinated during the test weeks was the same as the proportion vaccinated during the control weeks. Week 1: 1/507 (0.20); Week 2: 1/394 (0.25); Week 3: 1/441 (0.23); Week 4: 1/486 (0.21).

CONCLUSION

The presence of the posters in the waiting room had no impact on tetanus immunization at CHUL's FMU.

Cognitive development and reading achievement in pervasive-add, situational-add and control children

Studies on hyperactivity have shown the importance of distinguishing hyperactive children according to the pervasiveness of their symptoms. To verify the meaningfulness of this distinction in Attention Deficit Disorders, an epidemiological study was undertaken. Sixteen pervasive-ADD, nine situational-ADD and 28 non-ADD children selected from a general population were compared using different measures. The results show that pervasive-ADD differ from non-ADD children on verbal IQ and reading difficulties and support the distinction of ADD according to the pervasiveness of the symptoms.