[A 34-year-old man with hemorrhagic cystitis]

BACKGROUND

A 34-year-old male presented with macroscopic haematuria, abdominal pain and dysuria while being treated with penicillin for bacterial endocarditis. All blood cultures yielded Streptococcus mutans. After four weeks of treatment he developed haemorrhagic cystitis, thrombophlebitis and eosinophilia. The symptoms disappeared when he was taken off penicillin. After change of medication to ceftriaxone, the patient developed reversible neutropenia and recovered completely.

INTERPRETATION

Haemorrhagic cystitis caused by penicillin can be potentially fatal; two cases have earlier been described. Because of cross reaction this patient also developed reversible neutropenia. It is well known that beta-lactam antibiotics can induce severe neutropenia.

A study for the evaluation of safety and tolerability of intravenous high-dose iron sucrose in patients with iron deficiency anemia due to gastrointestinal bleeding

INTRODUCTION

The provision of adequate iron to support erythropoiesis in iron deficient patients is a time-consuming process which may present compliance problems for patients in the outpatient setting. The aim of the present study was to evaluate the safety and tolerability of intravenous high-dose iron sucrose therapy specifically in patients with iron deficiency anemia (IDA) due to gastrointestinal blood loss.

METHODS

A single dose of iron sucrose of 7 mg iron/kg body weight (not exceeding 500 mg) was infused over 3.5 hours in 31 consecutive patients with IDA due to gastrointestinal blood loss. Safety and tolerability of the therapy was assessed by the occurrence of adverse events under therapy and up to one week after completion of the study. Further examinations comprised vital parameters, ECG, and clinical chemistry including iron indices.

RESULTS

A total of 14 adverse events were observed in 10 patients, of which two adverse events in two patients were considered as being definitely related to drug administration. None of the patients had to be withdrawn from therapy. Significant changes in vital parameters and ECG during therapy and follow-up were not observed and clinical chemistry remained unchanged.

DISCUSSION

A single intravenous high-dose iron sucrose therapy in patients with IDA due to gastrointestinal blood loss appears to be safe and therefore is a therapeutic option which may save time and improve patient compliance.

Women report more pain on injection of a precurarization dose of rocuronium: a randomized, prospective, placebo-controlled trial

BACKGROUND

The purpose of this study was to investigate whether gender influences the perception of pain on injection of rocuronium.

METHODS

In this prospective, placebo-controlled trial 120 patients were randomized into four groups to receive rocuronium 0.03 mg kg(-1) (40 female and 40 male patients) or saline (20 female and 20 male patients). The incidence and severity of the injection pain after administration of the study drug was compared between female and male patients using a numerical rating scale (0-10). Signs of local irritation, i.e. erythema and thrombophlebitis, were assessed up to 48 h after surgery.

RESULTS

In 26 (32.5%) of the 80 patients receiving rocuronium, pain on injection was observed. This occurred significantly more frequently in the female compared with male patients: 18 (45%) vs. eight (20%), respectively (P = 0.032). The severity was more pronounced in the women than in the men (P = 0.020). The incidence of the rocuronium-associated pain was significantly increased compared with the Saline groups (P < 0.001). After surgery no patient complained of any residual pain and no local signs were observed in any patient during the study period.

CONCLUSIONS

Women experienced more pain on injection of rocuronium than men, moreover this is an additional evidence for gender-related differences in pain perception. When rocuronium is used as a precurarization agent, an analgesic pretreatment (e.g. opioids) should be considered, especially for female patients.

Diagnosis of Deep Septic Thrombophlebitis in Cancer Patients by Fluorine-18 Fluorodeoxyglucose Positron Emission Tomography Scanning: A Preliminary Report

Purpose

To determine the role of the fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) scan in the diagnosis and management of deep septic thrombophlebitis (STP).

Patients and Methods

We conducted a prospective observational evaluation of FDG-PET in patients with cancer and suspected STP. Retrospective evaluation of patients with cancer and deep venous thrombosis (DVT) who underwent FDG-PET and extremity duplex scan (DS) was also performed.

Results

Strong venous uptake was observed in FDG-PET of nine STP episodes versus 0 of 27 DVT episodes (P < .001). FDG-PET identified central vein STP in five patients, whereas DS and venography were negative in five and two of these patients, respectively. FDG-PET diagnosis of STP resulted in therapeutic changes in all patients. In four patients, follow-up FDG-PET confirmed resolution.

Conclusion

In cancer patients, FDG-PET identifies STP even in areas not optimally visualized by DS or venography, distinguishes STP from DVT, and leads to significant therapeutic changes.

Neoadjuvant chemotherapy in squamous cell carcinoma of the esophagus using low dose continuous infusion 5-fluorouracil and cisplatin: results of a prospective study

BACKGROUND

Surgery is the treatment of choice for localized esophageal squamous cell carcinoma (ESCC). Despite curative surgical resection, the majority of patients develop local and systemic recurrence with poor 5-year survival.

AIMS

To study the role of low dose continuous infusion (CI) 5-fluorouracil (5-FU) and cisplatin as neoadjuvant chemotherapy in ESCC.

SETTINGS AND DESIGN

A non-randomized prospective study conducted over a period of two years (1996-1998) in the Department of Surgery, All India Institute of Medical Sciences, India.

MATERIAL AND METHODS

Twenty-two patients with ESCC were included in the study. Chemotherapy consisted of a continuous 30-day infusion of 5-FU (350 mg/m2/day) and cisplatin (7.5 mg/m2/day), 5 days/week for 4 weeks. All patients had surgery following chemotherapy.

RESULTS

A full course of chemotherapy was completed in 18 patients (82%). Chemotherapy was not completed due to non-compliance (n=2), thrombophlebitis (n=1), and vomiting (n=1). Grade-1 haematological and hepato-toxicity was observed in four patients. Thirteen patients developed thrombophlebitis. After chemotherapy, improvement in dysphagia was observed in 13 of 22 (59%) patients. Radiological partial response was observed in 8 patients (36.4%). 19 patients underwent surgical resection (86.4%) with zero mortality. Post-operative morbidity was observed in six patients (27%). Complete and partial pathological response was observed in two (11%) and one patient (5.5%) respectively. The overall median survival was 18 months and 4-year survival was 42%.

CONCLUSIONS

Low dose CI 5-FU and cisplatin is well tolerated with minimal toxicity. Histopathological response rates and survival figures are comparable with the more toxic neoadjuvant chemotherapeutic regimens.

Pharmacological characteristics and side effects of a new galenic formulation of propofol without soyabean oil*

We compared the pharmacokinetics, pharmacodynamics and safety profile of a new galenic formulation of propofol (AM149 1%), which does not contain soyabean oil, with a standard formulation of propofol (Disoprivan 1%). In a randomised, double-blind, cross-over study, 30 healthy volunteers received a single intravenous bolus injection of 2.5 mg.kg-1 propofol. Plasma propofol levels were measured for 48 h following drug administration and evaluated according to a three-compartment model. The pharmacodynamic parameters assessed included induction and emergence times, respiratory and cardiovascular effects, and pain on injection. Patients were monitored for side effects over 48 h. Owing to a high incidence of thrombophlebitis, the study was terminated prematurely and only the data of the two parallel treatment groups (15 patients in each group) were analysed. Plasma concentrations did not differ significantly between the two formulations. Anaesthesia induction and emergence times, respiratory and cardiovascular variables showed no significant differences between the two treatment groups. Pain on injection (80 vs. 20%, p < 0.01) and thrombophlebitis (93.3 vs. 6.6%, p < 0.001) occurred more frequently with AM149 than with Disoprivan. Although both formulations had similar pharmacokinetic and pharmacodynamic profiles the new formulation is not suitable for clinical use due to the high incidence of thrombophlebitis produced.

Thrombophlebitis associated with intravenous injection anaesthetics: influence of arm positioning

BACKGROUND

Thrombophlebitis (TP) is a frequent complication of the intravenous application of injection anaesthetics. We investigated the influence of different arm positions on the incidence of such a complication in patients undergoing shoulder arthroscopy.

PATIENTS AND METHODS

This prospective, randomised study was done in 86 consecutive major shoulder arthroscopies. In order to evaluate the influence of different arm positions, the arm not operated on was positioned either cranial (n = 31) or caudal (n = 55) to the level of the right atrium. The number of TP in the 5 days following the arthroscopy was detected clinically and proven by ultrasound studies.

RESULTS

8 TP occurred in the group of patients with caudal arm positioning and none in the other group. Statistically, the incidence of TP was not associated with the weight or the height of the patients nor with the duration of the anaesthesia or the doses of anaesthetics used in each patient (p < 0.05).

CONCLUSION

An elevated position of the arm used for anaesthesia during shoulder arthroscopy is suggested in order to prevent TP.

Venous limb gangrene during overlapping therapy with warfarin and a direct thrombin inhibitor for immune heparin-induced thrombocytopenia

We report two patients with deep-vein thrombosis complicating immune heparin-induced thrombocytopenia who developed venous limb gangrene during overlapping therapy with a direct thrombin inhibitor (lepirudin or argatroban) and warfarin. In both patients, therapy with the direct thrombin inhibitor was interrupted during persisting severe athrombocytopenia while warfarin administration continued. Both patients exhibited the typical feature of a supratherapeutic international normalized ratio (INRs, 5.9 and 7.3) that has been linked previously with warfarin-associated venous limb gangrene. These data suggest that warfarin anticoagulation be postponed in patients with acute heparin-induced thrombocytopenia until substantial recovery of the platelet count has occurred.

Deep venous thrombosis and venous thrombophlebitis associated with alprostadil treatment for erectile dysfunction

We report a patient who developed deep vein thrombosis of the calf and thrombophlebitis after treatment with intracorporeal alprostadil (Viridal). The reaction recurred on rechallenge with Viridal. This adverse effect has not been reported in the literature but six patients have been reported to the Medicines Control Agency in Great Britain. The history of deep venous thrombosis or thrombophlebitis may not be a formal contraindication to treatment with alprostadil, but the patient should be made aware of this possible complication before embarking on this form of treatment.

Female hormones and thrombosis

Exogenous hormones are used by more than a hundred million women worldwide as oral contraceptives or for postmenopausal hormone replacement. Oral contraceptives increase the risk of venous thrombosis, of myocardial infarction, and of stroke. The risk is highest during the first year of use. The venous thrombotic risk of oral contraceptives is high among women with coagulation abnormalities and with so-called third-generation contraceptives (containing desogestrel or gestodene). The risk of myocardial infarction does not appear to depend on coagulation abnormalities or the type of oral contraceptive. Hormone replacement therapy increases the risk of venous thrombosis. This risk is also highest in the first year of use and among women with coagulation abnormalities. The risk becomes very high in women with a previous venous thrombosis. Randomized trials have not confirmed a beneficial effect of postmenopausal hormones on the occurrence of myocardial infarction.

Relationship between factor VII activity and clinical efficacy of recombinant factor VIIa given by continuous infusion to patients with factor VIII inhibitors

A multicenter prospective study of recombinant activated factor VII (rFVIIa) given by continuous infusion (CI) to treat severe hemorrhages and to handle surgical procedures was carried out. Relations between clinical efficacy, dosages used and levels of FVII coagulant activity (FVII:C) achieved in plasma were also evaluated. Case material included 25 patients with hemophilia (9 children and 16 adults) with high-responding inhibitors and 3 patients with acquired factor VIII inhibitors. Overall, 35 CI courses were given for 10 spontaneous bleeding episodes, 11 major surgical procedures and 14 minor surgical procedures. Bolus doses of 90 to 150 microg/kg (median: 100) were followed by CI given at median rates of 20 microg/kg/h for major surgery and of 17 and 16 microg/kg/h for minor surgery and spontaneous hemorrhages. Satisfactory hemostasis was obtained in 30 of 35 courses (88%). rFVIIa CI was ineffective in 2 hemophiliacs undergoing surgical operations and in another hemophiliac with hemoperitoneum who had to be switched to other treatments (high doses of porcine or human factor VIII concentrates). rFVIIa CI was partially effective in 2 hemophiliacs who had mild local bleeding after minor surgery. The CI rates and the corresponding FVII:C levels in plasma were similar in effective, partially effective and ineffective courses (median rate: 17, 20 and 20 microg/kg/h, respectively; median FVII:C:14, 18 and 18 IU/ml, respectively). A single adverse event was observed, superficial thrombophlebitis. This study confirms that rFVIIa given by CI is effective in a high proportion of patients with factor VIII inhibitors. It also demonstrates that FVII:C levels attained in plasma do not always predict efficacy because similarly high levels were attained during successful treatments and in those that failed.

Phase I trial of weekly paclitaxel plus oral estramustine phosphate in patients with hormone-refractory prostate cancer

OBJECTIVES

To exploit the favorable dose intensity and safety profile of weekly paclitaxel, we conducted a Phase I trial of paclitaxel by 3-hour infusion in combination with estramustine phosphate (EM) in men with hormone-refractory prostate cancer (HRPC). The antimicrotubule drug combination of paclitaxel by 96-hour infusion plus EM is active in HRPC.

METHODS

Twenty-four patients with metastatic HRPC and progressive tumor after antiandrogen withdrawal were enrolled in this study. Oral EM was taken at a dose of 600 mg/m(2) daily for the initial 21 patients and on a reduced schedule of 280 mg twice daily for the final 3 patients. Paclitaxel was escalated from 60 to 118 mg/m(2).

RESULTS

The major toxicities were gastrointestinal and thromboembolic complications related to daily oral dosing of EM. Of the first 21 patients, one third (n = 7) discontinued therapy within 4 weeks because of protracted nausea and/or thrombotic complications. Dose-limiting toxicities at 118 mg/m(2) paclitaxel were fatigue and hepatotoxicity. Of 13 patients with measurable soft-tissue lesions, 6 had objective partial regressions, and 9 (37.5%) of 24 patients (95% confidence interval 19.1% to 59.1%) with elevated prostate-specific antigen levels had a 50% or greater decline of at least 4 weeks' duration.

CONCLUSIONS

Weekly paclitaxel at doses of 60 to 107 mg/m(2) were feasible in combination with oral EM, but daily oral EM produced unacceptable toxicity. On the basis of these results, a Phase II trial of weekly paclitaxel with the reduced dose and schedule of EM was initiated by the Eastern Cooperative Oncology Group to assess further the benefits and risks of this treatment in men with metastatic HRPC.

[Homonymous lateral hemianopsia revealing cerebral thrombophlebitis. Role of a deficiency of protein S induced by l-asparaginase]

BACKGROUND

Cerebral thrombosis associated with protein S deficiency is very rare and is mainly related to hereditary form of protein S deficiency.

CASE REPORT

A 19-year-old girl with acute lymphoblastic leukemia presented hemianopsy within a few days after the first administration of L-asparaginase. Magnetic resonance of the brain showed a cortical infarct. A marked decrease of the level of protein S was documented. Few days later, the patient was free of symptoms and protein S level was restored to the normal suggesting that the cerebral thrombosis was caused by transient protein S deficiency induced by L-asparaginase administration.

DISCUSSION

Patients with neurological complication caused by L-asparaginase should be tested for protein S and other anticoagulant deficiencies.

[Recurrent coumarin necrosis in type II protein S deficiency]

Coumarin necrosis is a rare but clinical very important complication of therapy with coumarin derivatives. We report a patient with congenital protein S deficiency type II, who developed coumarin necrosis during stabilization of phenprocoumon. Diagnostic problems and therapeutic alternatives are discussed considering the recent literature.

Deep vein thrombosis during enoxaparin prophylactic treatment in a young pregnant woman homozygous for factor V Leiden and heterozygous for the G127-->a mutation in the thrombomodulin gene

Variability of thrombotic disease among individuals homozygous for factor V Leiden has been described. It has been shown that some thrombotic patients carry an additional genetic risk factor such as protein C, protein S, antithrombin deficiency or the G20210A mutation on the prothrombin gene. The occurrence of a deep vein thrombosis during enoxaparin prophylactic treatment in a pregnant woman homozygous for factor V Leiden, without other known prothrombotic genetic factors, led us to investigate her thrombomodulin gene. We found that the patient was heterozygous for the previously described G127-->A mutation, which results in an Ala25-->Thr substitution. Furthermore, for this patient, the allelic combination at the 1418 polymorphic site was C/T, which predicts an Ala455-->Val replacement. Although larger studies are required, this case report suggests that thrombomodulin gene mutations could be an additional genetic risk factor for thrombosis in carriers of the factor V Leiden mutation.

[Case report of acute intoxication from intravenous injection of petroleum]

A 18-year-old patient injected intravenously 2.5 mL of paraffin oil into the right upper limb. It caused a local thrombophlebitis with a slow evolution. A collapsus occurred on the sixth day. The authors obtained a clinical recovery of the limb after heparine and oral anticoagulation.

Comparative safety of teicoplanin and vancomycin

Although modern preparations of vancomycin are associated with a lower incidence of adverse events than the early preparations, a number of clinically significant problems remain. Consequently monitoring of serum concentrations is required. In a meta-analysis of comparative trials adverse events were significantly less likely to occur with teicoplanin (13.9%) than with vancomycin (21.9%) (P = 0.0003). This was particularly significant when nephrotoxicity was considered: 4.8% vs. 10.7%, for teicoplanin and vancomycin, respectively (P = 0.0005). Red man syndrome, which may be due to histamine release, occurs after rapid infusion of vancomycin but is very rare following teicoplanin administration. In USA trials, thrombocytopenia was more commonly seen with teicoplanin administration but this was almost exclusively in patients receiving much larger doses than are now recommended. The lower rate of adverse events supports the choice of teicoplanin over vancomycin in treating infections where the two antibiotics have similar efficacy.

The effects of hormone replacement therapy on thrombin generation, fibrinolysis inhibition, and resistance to activated protein C: prospective cohort study and review of literature

Recent studies have found that hormone replacement therapy (HRT) is associated with a two- to fourfold increased risk of venous thromboembolism, but the thrombogenic mechanism of HRT remains unclear. To investigate whether HRT use induces a procoagulant state, we undertook a prospective cohort study in postmenopausal women to investigate the effects of 3 months of treatment with oral HRT (conjugated equine estrogen 0.625 mg daily and medroxyprogesterone 2.5 mg daily) on markers of thrombin generation (prothrombin fragment 1+2, thrombin-antithrombin complexes), fibrinolytic potential (plasminogen activator inhibitor-1 (PAI-1) activity), and activated protein C (APC) resistance. In addition, we reviewed the literature for studies investigating the effects of HRT on markers of thrombin generation and fibrinolytic potential. In 12 patients who received HRT for a mean of 3.8 months, there was no significant effect of HRT on levels of F1+2, thrombin-antithrombin complexes, or the APC ratio. HRT use had the greatest effect on PAI-1 activity (mean difference = -3.75 UI/mL; 95% confidence interval: - 8.9, 1.1) compared to other coagulation parameters, but this did not attain statistical significance (p = 0.12). In the literature review, the effects of HRT on markers of thrombin generation were inconsistent across studies. There was a consistent pattern of increased fibrinolytic potential with HRT use associated with one marker (PAI-1), but not with another marker (tissue plasminogen activator antigen). We conclude that there is a lack of consistent evidence that the increased risk of venous thromboembolism associated with HRT use is due to a procoagulant state related to increased thrombin generation, decreased fibrinolytic potential, or acquired APC resistance.