Successful surgery for epilepsy due to early brain lesions despite generalized EEG findings

OBJECTIVE

To understand the role of epilepsy surgery in children with generalized or bilateral findings on preoperative scalp EEG.

METHODS

From our pediatric epilepsy surgery series, we identified 50 patients in whom 30 to 100% of preoperative epileptiform discharges (ictal, interictal, or both) were generalized or contralateral to the side of surgery.

RESULTS

All patients had severe refractory epilepsy and an epileptogenic lesion on brain MRI. Ninety percent of the lesions were congenital, perinatal, or acquired during infancy, predominantly malformations of cortical development (44%) or cystic encephalomalacia (40%). Age at surgery was 0.2 to 24 (median 7.7) years. Surgeries were hemispherectomy (64%) or lobar or multilobar resection. At last follow-up (median 24.0 months), 72% of patients were seizure-free, 16% had marked improvement with only brief episodes of staring or tonic stiffening, and 12% were not improved. The rate of seizure-free outcome was not significantly associated with age at seizure onset or surgery, presence of hemiparesis or focal clinical features during seizures, type of lesion, or surgery type. Postoperative seizure-free rate did not differ from that in a comparison group of similar patients who matched the study group except for their high percentage (70 to 100%) of ipsilateral ictal and interictal epileptiform discharges on preoperative EEG.

CONCLUSIONS

Epilepsy surgery may be successful for selected children and adolescents with a congenital or early-acquired brain lesion, despite abundant generalized or bilateral epileptiform discharges on EEG. The diffuse EEG expression may be due to an interaction between the early lesion and the developing brain.

Tubercular and chronic pyogenic osteomyelitis of cranio-facial bones: a retrospective analysis

AIM

To analyse current trends in our population with respect to the presentation, diagnosis and management of tubercular and chronic pyogenic osteomyelitis of the cranio-facial bones.

DESIGN

Retrospective study.

SETTING

Tertiary healthcare centre.

PATIENTS AND METHODS

The study population comprised 14 patients with tubercular and chronic pyogenic osteomyelitis who were managed in the otorhinolaryngology department between May 2002 and December 2005.

RESULTS

Odontogenic infections, sinus infections and aural infections were the most commonly identified aetiological factors. Most of the patients presented with swelling, pain and discharging sinus. The diagnosis was established on the basis of clinical evaluation, radiological investigations and histopathological analysis, with six cases diagnosed with tubercular osteomyelitis and eight cases with chronic pyogenic osteomyelitis. All the patients were initially commenced on oral antibiotics, which were continued for two weeks in all cases with chronic pyogenic osteomyelitis. All the patients with pyogenic osteomyelitis underwent surgical management, with one patient requiring repeated surgical interventions. All the patients with tubercular osteomyelitis received anti-tubercular chemotherapy, with complete cure.

CONCLUSIONS

Osteomyelitis of the cranio-facial bones is an uncommon entity which requires a high index of clinical suspicion along with radiological and histopathological investigations in order to establish the diagnosis. Tubercular osteomyelitis is clinically and radiologically indistinguishable from pyogenic osteomyelitis, and the two conditions can be differentiated only on the basis of histopathological evaluation of involved tissue.

Posterior sympathetic ophthalmia: a single centre long-term study of 40 patients from North India

OBJECTIVE

To report 'posterior sympathetic ophthalmia' in North Indian population as an early manifestation of sympathetic ophthalmia.

METHODS

Forty consecutive patients with a diagnosis of sympathetic ophthalmia seen between 1989 and 2004 at our centre were studied for their clinical presentation and disease course. All received systemic corticosteroids and 12 patients, in addition, also received immunosuppressive agents.

RESULTS

There were 28 male and 12 female patients with a median age of 29.4 years. In 22 of the 40 sympathizing eyes, the only presenting sign was the fundus lesions without any associated anterior segment inflammation. Only four eyes showed classically described granulomatous anterior uveitis at presentation. The fundus lesions predominately included exudative retinal detachment (29 eyes), yellowish-white mid-peripheral lesions (10 eyes), optic disc oedema (15 eyes), vasculitis (three eyes), and peripapillary choroidal neovascular membrane (two eyes). Over a median follow-up of 5.2 years, recurrences were seen in 12 of 40 (30%) eyes and were mainly in the anterior segment. Over a median follow-up of 5.2 years, a final visual acuity of 20/40 or better could be achieved in 29/36 (80.5%) eyes.

CONCLUSION

In the early stage, sympathetic ophthalmia may present only in the posterior segment without any associated anterior segment inflammation and carries a good visual prognosis. Anterior segment inflammation, however, maybe seen during recurrences.

Ocular adnexal lymphoma subtyped according to the REAL classification: A 12-year experience from a single institution

18541

Background: The Revised European and American Lymphoma (REAL) classification (1994) provided a useful and practical tool to define lymphomas. The aim is to report our experience with this unusual malignancy diagnosed since the REAL classification was implemented. Methods: Retrospective review was performed on patients (pts) with ocular adnexal lymphoma between 1994 and 2006. Medical records, diagnostic imaging procedures, and pathology reports, including immunophenotyping studies, were reviewed. Histologic definition of lymphoma was based on the REAL Classification. Results: 10 pts were identified. All but one were females. Median age at diagnosis was 69 years (54–84). Primary sites included conjunctiva (5), orbital soft tissue (3), and eyelid (2). No lacrimal gland location was found. Ann Arbor stage at diagnosis was IE in most cases (7). One patient (pt) had stage IIE (conjunctival and maxillary sinus) and 2 pts had simultaneous bone marrow involvement (stage IV). 6 pts had marginal zone B-cell subtype, and the remaining 4 pts had small lymphocytic B-cell lymphoma. Radiation as single treatment modality was given to all 7 pts with stage IE, and all those achieved a complete remission (CR). CR was also achieved using chemotherapy with cyclophosphamide (C), vincristine (V), doxorubicin, prednisone (P), and rituximab followed by radiation in the pt with stage IIE. Of the 2 pts with stage IV, 1 achieved a CR with rituximab-based chemotherapy, and 1 never achieved a CR despite chemotherapy (chlorambucil, CVP). With a median follow-up of 23 months (9–70), the 9 pts that achieved a CR after initial treatment remain alive and disease-free. The only pt that did not achieve a CR lost follow-up at 18 months. Conclusions: In our patient population, radiation alone appears to be an effective treatment modality for stage IE. Achieving a CR seems to be a crucial factor for long-term control of the disease.

No significant financial relationships to disclose.

Gestational trophoblastic disease: Experience at a tertiary care center from a developing country

16041

Background: We retrospectively analyzed case records of patients diagnosed to have Gestational Trophoblastic Disease (GTD) to determine clinical characteristics, risk groups, treatment outcome, and reproductive function post treatment. Methods: Between Jan 1991 to Dec 2005, 102 patients (mean age: 28.2 years, range 19–50) were diagnosed to have GTD. 35 patients were nulliparous and 8 had prior molar pregnancy. Vaginal bleeding was the most common presenting symptom (77.5%). The antecedent pregnancy was vesicular mole in 50%, abortion - 34.3%, ectopic pregnancy - 4% and term pregnancy in 11.8% patients. The mean value of B hCG was 1225386 mIU/ml. The histopathology (n=85) was complete mole in 30, partial mole - 28, invasive mole- 9, PSTT -1 and choriocarcinoma in 17 patients. 68(66.7%) patients had non-metastatic disease. Sites of metastasis were - lung (38.2%), vagina (11%), brain (8.8%), liver (6.9%) and kidney, Urinary bladder and peritoneum in one patient each. According to modified WHO risk scoring - 78(76.5% had low risk and 24 (23.5%) were high risk. Results: Eighty-seven (85.3%) patients received chemotherapy using methotrexate with leucovorin (n=63), EMA/CO (n=19) and BEP (n=5). 77/87 (89.5%) achieved complete remission (CR) ; the response rate was higher in non-metastatic GTD (p<0.05). Two of 7(28.6%) patients with liver and 5/9 (55,6%) of brain metastasis achieved CR. Two patients had grade III oral mucositis and diarrhoea with methotrexate. One patient died of Methotrexate hypersensitivity. 19 patients received second line chemotherapy using EMA/CO (n=11), EMA/EP (n=2), BEP (n=1), actinomycin-D (n=1) and MAC (methotrexate, actinomycin D and Cyclophosphamide) n=1; 14 patients achieved CR. At a mean follow up of 180 months, 5-year survival for patients with low risk is 100% and that of high risk is 95%. Eight patients had recurrent disease including recurrent molar pregnancy in four. 16 patients had 24 successful deliveries after completion of treatment and 10 of them were primiparae. No fetal abnormalities were found. We did not observe second malignancy or other therapy related sequele. Conclusions: Present study confirms excellent outcome for patients with gestational trophoblastic disease. The potential for childbearing is well maintained.

No significant financial relationships to disclose.

Impact of screening on presentation and survival of colorectal cancer

1535

Background: There is an increasing emphasis and utilization of colorectal cancer (CRC) screening. We evaluated the effect of screening on CRC presentation and outcome. Methods: We reviewed all the invasive CRC cases diagnosed between Jan 1995-Dec 2005 at the Cincinnati Veteran’s Affairs hospital. Individual case records were reviewed and the data collected including patient demographics, treatment, outcome, mode of presentation as well as whether CRC was detected as a result of screening. Results: Altogether 288 patients were diagnosed with CRC during the study period. The median age at presentation was 69.3 years and 18.8% were African-Americans. Early stage CRC was diagnosed in 63.4% cases (stage 1: 32.7%, stage 2: 30.8%) and 33.3% were diagnosed at advanced stage (stage 3: 18.1% and stage 4: 15.3%). Seventy seven (26.7%) CRCs were asymptomatic at presentation and were diagnosed as a result of screening. Predominant screening modalities included fecal occult blood testing (46.8%) and flexible sigmoidoscopy (22.1%). The proportion of screen- detected cases increased from 19% in 1995–1999 to 32% in 2000–05 (p = 0.047). Demographics, including age and race, as well as the site of CRC were similar to symptomatic cases. Screen-detected cancers presented early, with 77.9% presenting at early stage (stage 1: 55.8%, stage 2: 22.1%), compared to 51.5% (stage 1: 21.0%, stage 2: 30.5%) of symptomatic cancers (p <0.01). Only 1.3% of screen-detected CRC was found to be metastatic as compared to 21.0% of the symptomatic cases. The screen-detected cancers had significant survival advantage compared to symptomatic cases; with median survival being 81 months vs. 43 months in the latter (p =0.018). A proportional hazard regression analysis indicated that this improvement in survival was related to the fact that screening resulted in earlier stage at diagnosis. Only 20.3% of screen-detected CRC received adjuvant chemotherapy compared to 41.4% of symptomatic cases (p=0.002). Conclusions: An increasing proportion of CRC is being diagnosed as a result of screening. These cancers present at an earlier stage and are associated with a significantly improved survival. However, most CRC still presents symptomatically and more effective population screening is needed.

No significant financial relationships to disclose.

Peripheral and central H1 histamine receptor occupancy by levocetirizine, a non-sedating antihistamine; a time course study in the guinea pig

BACKGROUND AND PURPOSE

The H(1) receptor occupancy (H1RO) in brain is an indicator of central side effects of antihistamines. Here, we determined the kinetics of central and peripheral H1RO by levocetirizine in relation to its brain and plasma concentration, and investigated the role of the blood-brain barrier in any delay in brain H1RO.

EXPERIMENTAL APPROACH

Concentration-time profiles in plasma and brain were obtained after 0.1 and 1 mg kg(-1) oral doses of levocetirizine in guinea pigs. H1RO in brain was measured ex vivo using [3H]-mepyramine and, in the periphery, by measuring the degree of inhibition of histamine-induced contractions of isolated guinea pig ileum.

KEY RESULTS

The concentration-time profile of levocetirizine indicated lower levels (partition coefficient, K(p)=0.06-0.08), higher t(max) (2-4 h vs 1-1.5 h) and longer terminal half-life (4-5.6 h vs 2.1-2.8 h) in brain than plasma. The H1RO at 0.1 and 1 mg kg(-1) were 75% and 97%, respectively, at 1 hr in the periphery and, in the brain, were <20% and 28-67% respectively, at all time points studied. Brain H1RO vs plasma concentrations profile showed a delay, but not when compared to brain concentrations.

CONCLUSIONS AND IMPLICATIONS

This study demonstrates an effective peripheral antihistamine effect of levocetirizine without central adverse effects at the dose close to human therapeutic dose. The slow increase in H1RO in the brain with time was caused by slow blood-brain barrier transport of levocetirizine. This demonstrates the importance of measuring time course of brain H1RO in relation to brain concentrations of drugs.

Comparison of HTK and hypertonic citrate to intraarterial cooling in human non-heart-beating kidney donors

Intraarterial cooling (IAC) of non-heart-beating donors (NHBD) for renal donation requires a cheap, low-viscosity solution. HTK contains a high hydrogen ion buffer level that theoretically should reduce the observable acidosis associated with ongoing anaerobic metabolism. A retrospective comparison of all retrieved NHBD kidneys as well as of viability on the Organ Recovery Systems Lifeporter machine perfusion circuit was performed with respect to the preservation solution HTK or Marshall's HOC. Forty-two NHBD kidneys (19 HTK and 23 HOC) were machine perfused between February 2004 and May 2005. Most of the HTK kidneys were obtained from uncontrolled donors (12 vs 5; Fisher exact test, P = .01). As a consequence, the glutathione-s-transferase viability assay (411 vs 292 IU/L, P = .12) and the lactate concentrations (2.33 vs 1.94 mmol/L, P = .13) were higher among the HTK cohort. There was evidence of greater buffering capacity in HTK, since the lactate:hydrogen ion ratios were consistently lower during the first 2 perfusion hours (1 hour P = .03, 2 hour P = .02). A linear regression analysis confirmed that this was related to the IAC solution (ANCOVA, P < .001). All controlled donor kidneys passed viability testing and were transplanted. In contrast, 83% (10/12) of the uncontrolled donor kidneys preserved with HTK passed the viability test and were transplanted, compared with only 20% (1/5) of the HOC-treated comparators (Fisher exact test, P = .03). It may be concluded that the postulated advantages of improved pH buffering with HTK appear to have clinical relevance.

Cerebrovascular reactivity during hypothermia and rewarming

BACKGROUND

Experimental evidence from a murine model of traumatic brain injury (TBI) suggests that hypothermia followed by fast rewarming may damage cerebral microcirculation. The effects of hypothermia and subsequent rewarming on cerebral vasoreactivity in human TBI are unknown.

METHODS

This is a retrospective analysis of data acquired during a prospective, observational neuromonitoring and imaging data collection project. Brain temperature, intracranial pressure (ICP), and cerebrovascular pressure reactivity index (PRx) were continuously monitored.

RESULTS

Twenty-four TBI patients with refractory intracranial hypertension were cooled from 36.0 (0.9) to 34.2 (0.5) degrees C [mean (sd), P < 0.0001] in 3.9 (3.7) h. Induction of hypothermia [average duration 40 (45) h] significantly reduced ICP from 23.1 (3.6) to 18.3 (4.8) mm Hg (P < 0.05). Hypothermia did not impair cerebral vasoreactivity as average PRx changed non-significantly from 0.00 (0.21) to -0.01 (0.21). Slow rewarming up to 37.0 degrees C [rate of rewarming, 0.2 (0.2) degrees C h(-1)] did not increase ICP [18.6 (6.2) mm Hg] or PRx [0.06 (0.18)]. However, in 17 (70.1%) out of 24 patients, rewarming exceeded the brain temperature threshold of 37 degrees C. In these patients, the average brain temperature was allowed to increase to 37.8 (0.3) degrees C (P < 0.0001), ICP remained stable at 18.3 (8.0) mm Hg (P = 0.74), but average PRx increased to 0.32 (0.24) (P < 0.0001), indicating significant derangement in cerebrovascular reactivity. After rewarming, PRx correlated independently with brain temperature (R = 0.53; P < 0.05) and brain tissue O2 (R = 0.66; P < 0.01).

CONCLUSIONS

After moderate hypothermia, rewarming exceeding the 37 degrees C threshold is associated with a significant increase in average PRx, indicating temperature-dependent hyperaemic derangement of cerebrovascular reactivity.

Outcome of alveolar hemorrhage in hematopoietic stem cell transplant recipients

Alveolar hemorrhage (AH) is a frequent, serious complication of hematopoietic stem cell transplantation (HSCT). To study the incidence of AH, its clinical course and outcomes in HSCT patients, a retrospective review of the records of all adult patients who underwent bronchoscopy between January 1, 2002 and December 31, 2004 was carried out and those who underwent bronchoscopy after HSCT identified. A total of 223 patients underwent bronchoscopy after HSCT for diffuse pulmonary infiltrates with respiratory compromise. Eighty-seven (39%) patients had AH. Of these, 53 had AH without any identified organism while 34 had an organism along with hemorrhage on bronchoalveolar lavage (BAL). Six-month survival rate of patients with AH was 38% (95% confidence interval: 27-48%). In 95 of the 223 patients, an organism was isolated from BAL. These patients had poor outcomes compared to patients in whom no organism was identified. Patients with both AH and an organism had the worst prognosis. Mortality of patients with AH is improving and long-term survival of patients with AH is feasible. Isolation of a microbial organism in BAL is a strong predictor of poor outcome.

Correlation between microaneurysm closure rate and reduction in macular thickness following laser photocoagulation of diabetic macular edema

AIM

To correlate the microaneurysmal closure rate measured on fundus fluorescein angiography (FFA) with reduction in macular thickness observed on optical coherence tomography (OCT) following laser photocoagulation of diabetic macular edema.

MATERIALS AND METHODS

A prospective observational case series. Fifty patients (50 eyes) of type II diabetes mellitus with clinically significant macular oedema (CSME) underwent focal/grid laser photocoagulation. OCT and FFA were performed at baseline and at 2 and 12 weeks following laser photocoagulation to measure the change in macular thickness and the number of leaking microaneurysms respectively. Statistical analysis was performed using paired-ttest and Pearson's correlation test.

RESULTS

A significant reduction in macular thickness was seen at both 2 (P=0.02) and 12 weeks (P<0.0001), most remarkably in the central 1 mm quadrant. However, microaneurysm closure was only 0.67% at 2 weeks, which increased to 89.6% by 12 weeks. The change in retinal thickness correlated significantly with the decrease in the number of leaking microaneurysms at 12 weeks (r=0.597, P<0.0001), but not at 2 weeks (r=-0.228, P=0.112). On OCT, the final reduction in retinal thickness achieved at 12 weeks from baseline correlated significantly with the initial decrease in retinal thickness at 2 weeks (r=0.66, P<0.0001). However, on FFA, the final closure rate of leaking microaneurysms at 12 weeks from baseline did not correlate with the initial closure rate at 2 weeks (r=-0.039, P=0.413).

CONCLUSION

Following laser photocoagulation for CSME, an OCT at 2 weeks is more informative and better correlates with the final outcome than an FFA at 2 weeks.

Factors affecting the sagittal alignment of the lunate

The lunate is described as having a tendency to rotate dorsally as a result of its wedge shape, with the apex towards the dorsum, but maintains an attitude of flexion in most individuals. The present study comprised CT scans of the wrist of 70 healthy volunteers. Sagittal measurements were drawn for the midcarpal and radiocarpal axes, alignment and various shape patterns of the lunate. The midcarpal axis was found to be dorsal, volar and collinear to the radiocarpal axis in 21 (30%), 29 (41%) and 20 (29%) subjects, respectively. The sagittal alignment of the lunate demonstrated significant correlation with measurements of the midcarpal and radiocarpal axes with no correlation with its various shape patterns. It is concluded that the relationship between the midcarpal axis and the radiocarpal axis in terms of dorso-volar displacement has a key role in determining the sagittal alignment of the lunate, while the shape of the lunate may be only a secondary consideration.

A study on multivariable process control using message passing across embedded controllers

Multivariable process control forms an important part of modern day control. While hardwired controllers still constitute the basic component of such control systems, with reducing communication latencies, controllers on the network are being mooted as a viable alternative. These controllers promise a large number of advantages in terms of reduction in wiring and greater flexibility in implementing supervisory control systems. In this paper, a study is presented which shows that UDP (User Datagram Protocol) can actually be used for real-time multivariable process control. Latency reduction algorithms used in high performance message passing systems have been used.

Spectrum of radiological changes in hypertensive children with reversible posterior leucoencephalopathy

We prospectively studied 19 children with severe hypertension to evaluate the spectrum of radiological changes, severity and reversibility of this entity. All of them were subjected to clinical and biochemical evaluation, followed by magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA). Headache was seen in 17 children, 13 had confusion and drowsiness, 12 had nausea and vomiting, 10 patients had visual disturbances, seizure and dyspnoea. Only two had focal neurological deficit (one with right facial palsy and another with right lateral rectus palsy). Of these 19 children, 15 patients had hypertensive retinopathy and four had normal fundi. The positive MRI findings in 17/19 patients were: bilateral leukoencephalopathic changes in occipitoparietal region (9/17), diffuse white/grey matter lesion (3/17) patients, brain stem hyperintensity (2/17) and haemorrhagic lesions (3/17). On MRA, 12/19 patients had attenuation of cerebral arteries of different degree. On follow up, MRI findings resolved in all except three patients. All patients had normal MRA on follow up, except one with persistent minimal attenuation of middle cerebral artery and another had spasm in anterior, middle and posterior cerebral arteries. The intracranial abnormalities in these patients with severe hypertension were reversible in many of the cases after control of blood pressure was achieved. We therefore conclude that severe hypertension may lead to leuoencephalopathy, which had a wide radiological spectrum. A better understanding of this complex syndrome may obviate unnecessary investigations and allow management of associated problems in prompt and appropriate ways.

Mechanisms of edge-localized-mode mitigation by external-magnetic-field perturbations

Particle and energy transport in the tokamak edge transport barrier is analyzed in the presence of magnetic field perturbations from external resonant coils. In recent experiments such coils have been verified as an effective tool for mitigation of the edge-localized modes of type I. The observed reduction of the density in plasmas of low collisionality is explained by the generation of charged particle flows along perturbed field lines. The increase of the electron and ion temperatures in the barrier is interpreted by the reduction of perpendicular neoclassical transport with decreasing density and nonlocality of parallel heat transport. The found modification of the pressure gradient implies the stabilization of ballooning-peeling MHD modes responsible for type I ELMs.

Lack of impact of artesunate on the disposition kinetics of sulfadoxine/pyrimethamine when the two drugs are concomitantly administered

OBJECTIVE

To determine the effect of artesunate (AT) on the disposition kinetics of sulfadoxine/pyrimethamine (SP) in humans.

METHODS

In a randomized cross-over study, 16 healthy volunteers were given a dose of three SP tablets containing 500 mg of sulfadoxine (SDX) and 25 mg of pyrimethamine (PYR) (=SP group), while the second arm received three SP tablets + two AT tablets of 200 mg in total followed by 100 mg AT for the next 4 days (SP+AT group). Blood samples (100 microl) were collected by means of a finger prick and dried on filter paper. The blood spots were wrapped in polythene folders and stored at room temperature until analysis. The samples were assayed using high-performance liquid chromatographic methods.

RESULTS

The peak concentration C(max)), time required to attain peak concentration (T(max)), half-life (t ((1/2))) and area under the plasma concentration-time curve (AUC) were determined. The C(max) of SDX were 92.9 and 98.9 microg/ml for the SP and SP+AT arms, respectively; for PYR, these were 0.86 and 0.79 microg/ml, respectively. The T(max) of SDX were 10 and 8 h for the SP and SP+AT arms, respectively; for PYR, these were 4.0 and 3.0 h, respectively. The AUC(0-288) of SDX were 15,840 and 18,876 microg/ml h for the SP and SP+AT arms, respectively; for PYR, they were 124 and 112 microg/ml h, respectively. The t ((1/2)) of values for SDX were 165 and 180 h for the SP and SP+AT arms, respectively; for PYR, these were 158 and 177 h, respectively. There was no statistically significant difference between the C(max), T(max), AUC(0-288) and t ((1/2)) between the two arms (p > 0.05).

CONCLUSION

Taking AT concomitantly with SP does not have any impact in the disposition of SP.

Visual loss in the setting of allergic fungal sinusitis: pathophysiology and outcome

Objective:

To hypothesise the probable pathophysiological mechanism responsible for visual loss in allergic fungal sinusitis, other than direct compression.

Design:

Retrospective, non-randomised case series. Out of 274 cases of allergic fungal sinusitis, four cases with sudden visual loss were enrolled into the study. The fourth case had visual loss on the contralateral side to bony erosion of the lateral wall of the sphenoid sinus.

Interventions:

All four cases were evaluated with fungal smear, immunoglobulin (Ig) E titres, visual evoked potentials, non-contrast computed tomography and magnetic resonance imaging of the paranasal sinuses, and fundus examination. They then underwent endoscopic sinus debridement followed by intravenous methylprednisolone.

Outcome measures:

Improvement in vision.

Results:

All four cases experienced an improvement in vision: full recovery in three cases and partial improvement in one case.

Conclusion:

In view of the operative, radiological and laboratory findings for case four, with the suggestion of a hyperimmune response to fungal antigens (in the form of raised IgE titre and positive fungal serology), we suggest that a local immunological reaction to fungal antigens might be responsible for the observed visual loss in cases of allergic fungal sinusitis, in addition to mechanical compression of the optic nerve.

Hematological and molecular response evaluation of CML patients on imatinib

BACKGROUND

The BCR-ABL tyrosine kinase is a well-validated therapeutic target in Chronic Myeloid Leukemia (CML). Imatinib mesylate (formerly STI-571), a tyrosine kinase inhibitor is highly effective at the hematological, cytogenetic and molecular level in CML.

AIMS

To evaluate hematological and molecular response in CML patients on Imatinib and also the side effects of the therapy if any.

METHODS AND MATERIALS

Sixteen patients were diagnosed as having chronic phase CML at Kasturba Medical College Hospital, Attavar, Mangalore during the period of two years from January 2004 to January 2006 and were given Imatinib at 400 mg/day orally. They were followed closely over a period of 1 year using the following parameters: (1) monthly clinical examination, (2) monthly peripheral blood smear examination, (3) real time reverse transcriptase quantitative polymerase chain reaction (RT Q-PCR) for BCR-ABL at the end of every 6 months. The findings were evaluated after one year for hematological and molecular response achieved.

RESULTS

Fifteen (93.75%) patients achieved complete hematological response within three months of therapy. Six (37.5%) patients achieved complete molecular response(CMR) within six months of therapy as measured by real time RT Q-PCR. None of the patients who did not achieve CMR within first six months of therapy achieved it after one year of therapy. No patient lost the initial response. The median BCR--ABL/ABL value at the end of the six months was 11% and at the end of the one year was 3.38%.

CONCLUSION

Imatinib mesylate is highly effective in the treatment of chronic phase CML and so should be considered as the drug of first choice in CML. Molecular response evaluation after six months can predict the subsequent molecular response and can also be usedas a surrogate monitor of the marrow cytogenetic response to imatinib therapy in CML.