[Dry cough in a 17 year old patient]

We present a case of mediastinal ganglioneuroma observed in a 17-year-old girl. Imaging suggested the diagnosis that was confirmed histologically on a peroperative specimen. Mediastinal ganglioneuroma is a highly uncommon tumor with characteristic imaging features that is quite difficult to resect.

[Initial management of community-acquired pneumonia]

There continue to be major controversies in the management of community-acquires pneumonia, concerning either investigations, decision to hospitalize and antibiotic therapy. All authors agree that a chest radiography must be obtained in all cases, and two sets of blood cultures for hopitalized patients but there is there controversies about other microbiological tests. Decision to hospitalize must be based on clinical judgement but can be helped by Fine's predictive rule. Initial therapy is almost always empiric, antibiotic selection being primarily based on disease severity.

Erythromycin for chlamydiasis in pregnant women. Assessing adherence to a standard multiday, multidose course

OBJECTIVE

To assess patient adherence among pregnant women infected with Chlamydia trachomatis given a self-administered, 10-day course of erythromycin prescribed as 500-mg tablets to be taken four times a day for the full 10-day period of treatment.

STUDY DESIGN

Study participants (n = 30) were given the standard, 10-day supply of 500-mg tablets of erythromycin and instructed to take one tablet four times daily for 10 days. Patients were blinded to the fact that the Medication Event Monitoring System was being used and that their adherence to this course of drug therapy was being monitored.

RESULTS

A 100% cure rate was achieved. The average percentage of therapeutic coverage actually achieved by the study participants declined with the length of erythromycin therapy. Further, as the duration of treatment increased, the longest interval between two successive doses of erythromycin also increased.

CONCLUSION

This study demonstrated the importance of assessing both the quantitative and temporal aspects of self-administered oral medication when assessing patient adherence. Moreover, since the length of the course of antibiotic therapy was shown to affect patient adherence, coupled with the 100% cure rate we observed, future research geared toward maximizing adherence while minimizing duration of treatment seems warranted.

[Hepatic hemangioma]

OBJECTIVE: To describe a case of a congenital hepatic hemangioma treated with surgery. METHODS: We report the case of a 6-day-old boy who presented a giant hepatic hemangioma, and describe its evolution. RESULTS: The child developed hemodynamic instability secondary to consumption coagulopathy and respiratory failure. The image studies were inconclusive. He was submitted to surgery with complete resection of the tumor. Pathology confirmed it was hemangioma. The child was discharged after 15 days and is well, without symptoms. CONCLUSIONS: Hepatic hemangiomas should be treated conservatively, with surgery reserved for intractable cardiac failure and/or refractory consumptive coagulopaty.

[Liver transplantation from living related donors]

OBJECTIVES: To present the experience with the first 12 living related liver transplants performed at Hospital Sírio-Libanês in São Paulo. METHODS: The donors were the fathers (6) and the mothers (6) with age ranging from 30 to 48 years. All candidates for donation were submitted to a full informed consent form, clinical and radiological evaluation and had blood withdrawn for autotransfusion. Recipient age ranged from 7 months to 10 years whereas recipient weight varied from 6.3 to 34 kg. Six patients were considered as high risk due to complications of advanced liver disease and were submitted to urgent transplantation. RESULTS: Mean donor hospital stay was 10 days with no mortality. Technical complications were observed in 4 recipients. Seven patients presented at least one episode of bacterial, viral or fungal infection. One or more biopsy proven rejection episodes were disclosed in 7 patients. Overall recipient survival was 67%, being 83% for elective cases and 50% for urgent cases. Long term follow up ranged from 8 to 25 months. Seven out of 8 survivors present excellent quality of life and normal liver function. The other patient is currently under reduced immunosuppression due to Epstein-Barr virus infection.CONCLUSIONS: These results demonstrate the safety and viability of living related liver transplantation which, in face of the current donor scarcity, should be considered as a valid option for the treatment of children with end stage liver disease.

Ovarian carcinoma: value of CT in predicting success of debulking surgery

OBJECTIVE

Initial therapy for metastatic epithelial ovarian adenocarcinoma involves aggressive surgery to remove as much tumor as possible. However, this procedure is not beneficial for patients unless tumor implants can be reduced to less than 2 cm in diameter. This study was performed to determine whether CT can be used to predict the success of debulking surgery and thereby spare some patients from an unnecessary operation.

MATERIALS AND METHODS

Preoperative CT scans of 28 women who underwent primary surgery for ovarian carcinoma were retrospectively reviewed (18 patients had extrapelvic [stage III or IV] disease at surgery). Five regions were analyzed for evidence and extent of metastatic disease (omentum, liver, small bowel mesentery, paraaortic nodes, and diaphragm), and a score of 0-2 (see below) was assigned to each. These scores were added together for a total score of 0-10, which was compared with the surgical results. Receiver operating characteristic curve analysis was used to assess the ability of the scoring system to predict which patients would benefit from tumor debulking. Patient age, serum CA-125 level, and amount of ascites were also examined.

RESULTS

On a 10-point preoperative CT scoring system, a score of 3 or higher identified patients whose tumors were not successfully debulked with a sensitivity of 58% (7/12) and a specificity of 100% (16/16). The area under the receiver operating characteristic curve for this system was 0.94. The use of additional parameters, such as extent of ascites, serum CA-125 level, or age, did not improve accuracy.

CONCLUSION

Our results show that CT can be used to predict the success of primary debulking surgery in women with metastatic ovarian carcinoma. A significant number of patients in whom the surgery will have no benefit can be identified.

Analysis of the population structure of Mycobacterium tuberculosis in Ethiopia, Tunisia, and The Netherlands: usefulness of DNA typing for global tuberculosis epidemiology

The genetic heterogeneity among Mycobacterium tuberculosis isolates from 501 patients in Ethiopia, Tunisia, and the Netherlands was compared by analysis of DNA polymorphism driven by insertion element IS6110. The percentage of isolates displaying two or more identical patterns differed greatly in the three countries: It was highest among Tunisian isolates and lowest in Dutch isolates. In contrast to isolates from Dutch subjects infected with M. tuberculosis, the majority of strains from Ethiopia and Tunisia were from a few families of genetically highly related strains. Furthermore, little overlap was observed among isolates from the three countries, indicating strict isolation of the bacterial reservoirs in the countries. A few strains from the Netherlands matched strains from Ethiopia and Tunisia. Those strains were invariably isolated from refugees, immigrants, or persons who visited Ethiopia or Tunisia.

The familial ovarian cancer registry: progress report

BACKGROUND

Ovarian cancer can be cured if detected early enough, but usually has already metastasized when diagnosed. A family history of ovarian cancer is still the strongest known risk factor.

OBJECTIVE

To identify women at risk for ovarian cancer and design a program of surveillance.

METHODS

Prospective registry of women with a family history of ovarian cancer.

RESULT

From April 1991 to July 1993, 137 women (119 families), mean age 43, registered with the Familial Ovarian Cancer Registry. The 119 pedigrees revealed 171 cases of ovarian cancer. Only one family is undocumented by pathology. Forty of 137 registrants have more than one relative with ovarian cancer. Six percent of pelvic examinations were abnormal for potential adnexal disease. In 4% of registrants, initial CA125 concentrations were abnormal. Ultrasound examinations were abnormal in ovarian size (5%), in morphology (3%), and by resistive indices (4%). Four ultrasounds were repeated earlier than routine. Using "standard" fees, the total cost to diagnose the one case of ovarian cancer discovered was $68,848.

CONCLUSIONS

This approach still cannot be considered cost-effective. We are continuing to search for genetic and molecular markers of disease in women at greatest risk and in their affected relatives.

Phenotypic identification of T lymphocytes subset in recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is characterized by recurring ulcers in the oral mucosa as abnormality of the immune response, autoimmune or abnormal immunological reaction to antigens of oral bacteria. This study was conducted on 25 patients 15 suffering RAS of the minor form and 10 of the major form and 15 student as control. The T lymphocytes were determined by the monoclonal antibodies (OKT) using the indirect immunofluorescent technique of Hoffman percentage of cells having surface fluorescence was calculated and the monoclonal antibody coated cells visualized and enumerated. It was concluded from this study that the two clinical entities of RAS may be of the same immunopathologic etiology but the difference lies in the T cell subpopulation and the ratio of T helper to T suppressor T4/T8.