Three-year follow-up of hydroxyurea treatment in severely ill children with sickle cell disease. The French Study Group on Sickle Cell Disease

PURPOSE

To observe the safety and efficacy of hydroxyurea (HU), a drug that stimulates fetal hemoglobin (Hb F) production, in previously severely ill children with sickle cell disease.

PATIENTS AND METHODS

HU was given in an uncontrolled study to 35 children with sickle cell disease, aged from 3 to 20 years, suffering from frequent painful crises. Mean duration of treatment was 32 months (range: 12-59 months).

RESULTS

HU induced an increase in Hb F levels in all children out one; this increase was maximal after 9 months of treatment, was largely sustained thereafter, and was related to HU dose and inversely to patients' age. We also noted an apparent reduction in crisis, which occurred principally after 3 months of therapy and did not seem strictly correlated with the rise in Hb F level. No serious hematopoietic complication was observed. Growth curves and sexual development were not modified.

CONCLUSION

Our data support the efficacy of HU in reducing painful events in children with sickle cell disease. Short- and middle-term tolerances are good. Thus, we think that HU can be given to children affected by frequent and severe painful crises. We recommend, however, very cautious use of this drug, because its long-term effects in children are still unknown.

Gallstone recurrence after successful lithotripsy

We report the recurrence rate of gallstone within 5 years after successful lithotripsy. One hundred and fifty consecutive patients (solitary stones, 102 patients; multiple stones, 48 patients) were followed up for a median of 42 months (range 6-72) after stone clearance and cessation of bile acid therapy. No patient received any therapy to prevent recurrence. Thirty-seven patients developed recurrent gallstones. Probabilities of recurrence were (mean +/- SD) 6.6% +/- 2%, 15.7% +/- 3%, 22.8% +/- 3.6%, 29.7% +/- 4.5%, 32.2% +/- 5% at 1, 2, 3, 4 and 5 years, respectively. The recurrence rate was lower in patients who had solitary stones than in patients with multiple stones (26.1% versus 47% at 5 years, respectively; p<0.009 - log rank test). Only five patients developed recurrent symptoms or stone complication (14%). We conclude that the recurrence rate after successful lithotripsy is lower than expected from dissolution studies, due to a low recurrence rate in patients who had solitary stones.

Extracorporeal lithotripsy associated with laparoscopic cholecystectomy: results of 60 patients

Gallbladder extracorporeal lithotripsy was performed on 60 patients before laparoscopic cholecystectomy. Of the 44 cases with solitary stones (range, 17-45 mm; mean +/- SEM, 26.9 +/- 0.1 mm), satisfactory fragmentation was obtained in 77.2%. Of the 16 cases with multiple stones (range, 11-25 mm; mean +/- SEM, 14.9 +/- 0.7 mm), satisfactory fragmentation was obtained in 18.75%. Minimal adverse effects were observed both clinically and macroscopically during surgery. Upon histologic investigation, only two small gallbladder lesions could be attributed to extracorporeal lithotripsy. No changes in blood chemistry tests were recorded. When carried out with high performance equipment, extracorporeal lithotripsy appears to be an interesting procedure that permits an appreciable reduction in the number of parietal wall incisions that need to be widened, therefore simplifying laparoscopic cholecystectomy when dealing with large stones.

Low early gallstone recurrence rate after successful extracorporeal lithotripsy in patients with solitary stones

Piezoelectric lithotripsy with the EDAP LT-01 machine combined with adjuvant bile acid therapy results in complete clearance of radiolucent gallstones in selected patients. We assessed stone recurrence rate in 84 patients with complete clearance of stone fragments and followed up at least 12 months after cessation of bile acid therapy (mean 17 months, range 12-33). Fifty-four patients had a solitary stone and 30 multiple stones. Bile acid therapy was continued for 3 months after complete fragment stones clearance which was ascertained by two consecutive ultrasound examinations. Stone recurrence was assessed by ultrasonography at 6 and 12 months, and then at least once a year. Gallstone recurrence occurred in 5 patients (6%) between 9 and 12 months with no further recurrence up to 33 months. The rate of recurrence at one year was 3.7% in patients with a solitary stone and 10% in patients with multiple stones. Only one patient with stone recurrence had recurrent biliary pain. We concluded that early gallstone recurrence rate after successful lithotripsy seems to be low in patients with solitary stones.

Treatment of gallstones with piezoelectric lithotripsy and oral bile acids. A multicenter study

The efficacy of the combination of piezoelectric lithotripsy and oral bile acids in the treatment of gallbladder stones was assessed. Three hundred and sixty-three patients with symptomatic radiolucent gallstones in functioning gallbladder were treated in five medical centers using the same protocol with the EDAP LT 01 lithotripter. No anesthesia, analgesia or sedation was used. After one session of lithotripsy, fragmentation was observed in 89% of the patients, and satisfactory fragmentation (fragments less than or equal to 5 mm) in 29%. The satisfactory fragmentation rate was higher in patients with solitary stones less than or equal to 20 mm than in patients with solitary stones 21-35 mm or multiple stones (p less than 0.001). After multiple sessions (mean 1.6 session/patient, range 1-5) the overall rate of satisfactory fragmentation was 50%. After 12 months on oral bile acid therapy, complete clearance of the gallbladder was observed in 69% of patients with solitary stones less than or equal to 20 mm, 25% of patients with solitary stones 21-35 mm and 37% of patients with multiple stones. No complication was observed during the lithotripsy. During follow-up under bile acid therapy, there were five complications (1.4%): four patients had acute cholecystitis and one had mild, self-limited pancreatitis. We conclude that piezoelectric lithotripsy with the EDAP lithotripter is a safe and effective treatment which can be performed in outpatients. Satisfactory fragmentation and rapid disappearance of stones are obtained mainly in patients with solitary stones less than or equal to 20 mm.

TNF alpha enhancement of NK and LAK cell functions induced by high-dose IL-2 in human peripheral blood mononuclear cells from patients pretreated with alpha IFN + IL-2

In this study we analyzed the induction of NK and LAK cell functions by TNF alpha, alone or combined with IL-2, in 4 days in vitro culture of PBMC from patients treated with alpha IFN + IL-2. Although the MN cell recovery after 4 days culture was very similar with TNF alpha alone or with IL-2 alone, TNF alpha did not maintain nor induce LAK or NK activities of in vivo preactivated PBMC. When compared to preculture values, TNF alpha alone induced a preferential outgrowth of CD4+ T cells together with a decrease of CD8+ T cells, NK cells and IL-2R (p55)-expressing cells. The combination of TNF alpha (100 ng) and high dose IL-2 (9,000 IUg/ml) did not improve the MN cell recovery after 4 days culture; but increased IL-2-induced NK activities in PBMC from 6/7 patients, and IL-2-induced LAK activities in 4/7 patients. However, these variations were not significant. The combination of TNF alpha and lower doses of IL-2, ranging from 150 IU/ml to 30 IU/ml, did not modify MN cell recovery in culture nor IL-2-induced NK and LAK cell activities. When compared to paired samples cultured with IL-2 alone, the combination of TNF alpha with all doses of IL-2 did not modify the distribution of T and NK cells, but increased the expression of CD8 on NK cells. Furthermore, the combination of TNF alpha and IL-2 increased the expression of IL-2R (p55) on PBMC but the expression of this receptor was restricted to CD4+ T cells and did not appear on NK cells.

Functional and phenotypic modifications induced by IL-4, as single agent or in combination with IL-2, on PBMC preactivated in vivo by alpha-interferon + interleukin-2 therapy

The effect of human IL-4, used as a single agent or in combination with low or high dose IL-2, upon LAK-cell proliferation and activation has been tested on PBMC from patients treated with alpha 2-IFN and IL-2. Four days in vitro culture with IL-4 did not induce any LAK-cell activation; IL-4 induced the proliferation of CD3+ CD4+ T-cells, but decreased the percentage of NK cells in culture samples. When combined with high dose IL-2, IL-4 improved the recovery of MN cell without modification of T-cell subsets; however, IL-4 had no major effect on IL-2-induced NK or LAK cell activity. The combination of IL-4 and low dose IL-2 still significantly improved the total MN cell recovery but did not modify the distribution of T and NK lymphocytes; IL-4 inhibited low dose IL-2-induced NK and LAK cell activity, and increased the BL-esterase activity induced by high or low dose IL-2. The combination of IL-4 and IL-2 did not induce any large variation in the percentage of IL-2R (p55) expressing cells. In all tested conditions, IL-2R (p55) was mainly expressed on CD4+ T cells; less than 2% of the cells coexpressed the NK cell marker CD56 and IL-2R (p55). The effect of IL-4 upon IL-2-induced LAK cell expansion is thus very different on PBMC pre-activated in vivo by alpha IFN + IL-2 therapy than on PBMC pre-treated in vitro with IL-2.(ABSTRACT TRUNCATED AT 250 WORDS)

[The secret of the pyramids ... or calcifications in Meckel's diverticulum]

The authors present the case of a 59 year-old patient with numerous stratified stercoliths within a large Meckel's diverticulum. An abdominal X-ray without contrast material, done while the patient was in acute abdominal pain showed a liquid-density mass. The diagnosis was considered because of the presence, within the mass, of a fluid level and several unusual calcifications. Ultrasound ruled out a gall-bladder or urinary origin. Surgical excision of the mass confirmed the diagnosis; the X-ray of the specimen allowed a comparison with the previous abdominal X-rays. The authors review the literature on the subject and suggest a gamut for the differential diagnosis of stratified calcifications of the abdomen.

[Epstein-Barr virus cerebellitis in an 11-year-old girl]

The authors report an eleven year old girl who manifested predominantly an acute cerebellar syndrome secondary to infection by Epstein Barr Virus. This complication is unusual and males are predominantly affected. The diagnostic and common physiopathological hypothesis are discussed.

Colonic perforation during percutaneous nephrolithotomy

Of 250 cases of percutaneous nephrolithotomy perforation of the left colon has been observed in 2 men with mobile kidneys. The clinical signs were rectal hemorrhage with shock in 1 case and passage of gas through the nephrostomy tract in the other case. The perforation was not suspected during the nephrolithotomy. Both patients were treated surgically. In view of the risk of colonic perforation during percutaneous nephrolithotomy, great care should be taken during puncture. This risk is increased in cases with an excessively lateral tract or when the anatomical relationships are modified in subjects with mobile kidneys. Surgical repair is required when the perforation is intraperitoneal or when there is a risk of complications. Simple surveillance is only justified when the perforation is extraperitoneal and when there is no risk of complications.

[Percutaneous ablation of renal calculi]

Percutaneous removal of renal calculi under nephroscopy was attempted in 34 patients. There were 19 pyelic, 9 caliceal, 3 uretero-pyelic and 3 multifocal calculi. The attempt was successful in 30 cases, the stones being removed by immediate lumbotomy in the 4 cases where it failed; 2 caliceal calculi remaining in situ are being followed up. Complete removal was effected in 19 patients. The smaller calculi were directly removed with special forceps, and the larger ones were either fragmented with a lithotriptor or disintegrated by ultrasounds or intracavitary shock waves. The postoperative period was uneventful. Stay in hospital was reduced to 4 days on average and absence from work, to 8 days. Five patients experienced renal colics due to migration of small fragments. One case of haemorrhage was easily controlled. Percutaneous removal of renal calculi is an elegant, though delicate method which seems to be of interest in persistent or recurrent pyelic or caliceal stones, in small or medium size pyelic stones and in mobile and painful caliceal stones. It undoubtedly has its place in the treatment of renal lithiasis.

[A major complication of hysterosalpingography]

The authors report in detail the observation of a patient who presented with urticaria and anaphylactic shock during hysterosalpingography. A review of the literature analyzing different accidents and incidents related to this examination, showed the rarity of such reactions. The authors insist, once more, on the necessity of always having the adequate material and drugs for early intensive treatment. These should be at hand whenever investigation with iodine contrast products are used, whatever the route of administration.