Ministry of Health clinical practice guidelines: Management of Rhinosinusitis and Allergic Rhinitis

The Ministry of Health publishes national clinical practice guidelines to provide doctors and patients in Singapore with evidence-based guidance on managing important medical conditions. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the Ministry of Health clinical practice guidelines on Management of Rhinosinusitis and Allergic Rhinitis, for the information of readers of the Singapore Medical Journal. Chapters, page and figure numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=24046). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

CT Based Lymphatic Mapping and Localization – A New Method To Detect Sentinel Lymph Node in Breast Cancer Patients

Background: Sentinel lymph node biopsy in breast cancer patients has not been extensively accepted in mainland China. The main reason is that radioisotope tracer is not available in many hospitals. The objective of this study is to explore CT based lymphatic mapping and localization. The accuracy will be evaluated comparing SLN found by CT with those found by isotope and blue dye.Methods: 18 breast cancer patients who diagnosed by core needle biopsy or excisional biopsy underwent CT scan to locate the SLN before SLNB at the same day of surgery. When CT examination performed, those patients were in supine position, with the arms stretched upward but bent at the elbow with the hands at the side of the cranium which similar to the surgical position. After local anesthesia, 2mL of iopamidol was injected subcutaneously to the peritumoral and peri-areolar areas followed by gentle massage for about 1 minute. Contiguous 2-mm-thick CT images that included the breast and axilla were obtained prior to administration of the contrast agent. After 3D CT reconstruction, the SLN was identified as the most inferiorly visible nodule in the axilla connected to the lymphatic vessel on the CT imaging monitor. A professional intervention doctor punctured the defined lymph node guided by the CT monitor using the Breast Lesion Localization Needles (interv). The needle would stay in the patient's axilla until the surgery. All the lymph nodes including the CT defined one and which marked by methylene blue dye or 99mTc-sulfur colloid tracers were removed, which then would be tested by touch imprint cytology for the intraoperative diagnosis. Patients who had positive SLN would receive axillary dissection. We evaluated the new method by comparing lymph nodes defined by CT and traditional ways.Results: In this study, the success rate of SLNB was 100% (18/18). 15 of 18 patients (83.3%) showed the direct connection of SLN and lymphatic vessels draining from the injection sites on CT monitor successfully. 13 of 15 patients' SLN localization corresponded well with SLN identified by the traditional SLN mapping. Of the 40 SLNs in 15 patients, 7 SLNs in 3 patients were positive and received the ALND. These 7 SLNs were all clearly visualized on CT monitor. Among 15 SLNs (in 15 patients) punctured by needles, 13 SLNs had the highest radioactivity by DGP-guided probe and 12 are blue dye–stained. All of the 15 SLNs had radioactivity or blue stained. None of these 18 patients showed any adverse events during or after CT examination and surgery. With the assistant of CT location, the mean time of SLNB had been shortened from 20 mins to 16 mins.Conclusion: Comparing with usual tracing method, CT guided axillary SLN mapping and localization showed good specificity and gave concordant results in locating sentinel lymph nodes. These results suggest that CT guided localization would be a valuable tool for identify sentinel lymph nodes in breast cancer patients.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1035.

Clinical Applications and Acute Hepatotoxicity of Intravenous Amiodarone

This cross-sectional, retrospective study was designed to evaluate the current clinical applications and acute hepatotoxicity of intravenous amiodarone administration at a hospital in China. Clinical data were collected from 1214 patients receiving intravenous amiodarone treatment between October 2003 and September 2005. Baseline patient characteristics, drug indications, administration records and acute hepatotoxicity associated with the drug were examined. Amiodarone was used primarily in arrhythmic patients with obvious cardiac dysfunction. Atrial fibrillation and ventricular arrhythmia were the two most commonly treated dysfunctions. Incorrect indications and administration methods were also noted. Hepatotoxicity occurred in 12.6% of the patients, but was mild in most cases. Males showed a higher incidence of hepatotoxicity than females. The use of amiodarone was considered to be reasonable and standardized, but there was still considerable room for improvement, particularly in the standardization of administration guidelines. Intravenous amiodarone can cause hepatotoxicity and hepatic function tests should be performed soon after giving amiodarone intravenously.

Isolation and characterization of actinomycetes from healthy goat faeces

AIMS

To isolate and characterize actinomycetes with probiotic activities from healthy goat faeces.

METHODS AND RESULTS

Faecal actinomycetes were isolated by dilution methods and identified by 16S rRNA gene sequence analysis. The hydrolytic enzyme activities were analysed by clear zone formation. The antimicrobial activities and resistance to heavy metals were tested by growth inhibition methods. The isolates belong to a small group of actinobacterial genera, including Streptomyces, Nocardiopsis and Oerskovia. The Oerskovia was the most widely distributed genus among the cultures. The proportion of streptomycete-like strains producing amylase or protease is significantly higher than those of other actinomycetes (P < 0.05). Compared with streptomycete-like strains, a higher proportion of (alpha- or beta-) galactase-producing other actinomycetes was found in goat faeces. More than 50% of streptomycete-like strains showed activities against test fungi. Streptomycetes could tolerate 0.25 mmol l(-1) Cr(2)O(7)(2-), 2 mmol l(-1) Ni(2+); however, other actinomycetes are liable to 40 mmol l(-1) Fe(3+) and 0.25 mmol l(-1) Cr(2)O(7)(2-) and resistant to 5 mmol l(-1) Ni(2+) and 2 mmol l(-1) Cu(2+).

CONCLUSIONS

The different physiological characteristics of the actinomycetes suggested that the cooperation in the actinomycetes might be involved in their association with goat.

SIGNIFICANCE AND IMPACT OF THE STUDY

Probiotic mixtures based on faecal actinomycetes showed potentials in animal production.

Evaluating risk of hospitalization with G-CSF use in real-world oncology practice

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Background: Limited published data exist on how granulocyte colony-stimulating factor (G-CSF) treatment patterns affect risk of neutropenia-related hospitalizations. This study examines prophylactic vs. delayed use of G-CSF and compares the effectiveness of prophylaxis with filgrastim (FIL) vs. pegfilgrastim (PEG). Methods: A retrospective analysis of administrative claims from U.S. commercial health plans identified adult patients with non-Hodgkin's lymphoma, breast, or lung cancer, treated with chemotherapy between July 2004 and January 2008. For these patients, the first course of chemotherapy and each unique cycle with use of G-CSF (FIL or PEG) was identified and designated ‘prophylaxis’ if used within the first 5 days of each cycle, or ‘delayed', if after day 5. The risk of neutropenia-related hospitalization was then evaluated on a cycle basis. A generalized estimating equation (GEE) was used to adjust for baseline demographics and clinical characteristics. Results: Among 5,571 patient-cycles identified: 87.4% were prophylactic and 12.6% were delayed G-CSF. PEG use was primarily prophylactic (93.6%) in contrast to use of FIL which was delayed in 62.5% of patient-cycles. The rate of neutropenic hospitalization was 1.2% for prophylaxis (n=59) and 3.7% for delayed G-CSF (n=26) (P < 0.001). Among prophylactic patient-cycles, the neutropenic hospitalization rate was lower with PEG than FIL (1.1% (n=51) vs. 3.5% (n=8), p = 0.001). Multivariate analyses using GEE model showed consistent trends (Table). Conclusions: Prophylactic G-CSF use was associated with lower neutropenic hospitalization risk than delayed use. Among prophylactic use in real-world oncology practice, PEG was associated with about a two-thirds lower risk of neutropenic hospitalization compared with FIL.

[Table: see text]

[Table: see text]

Study on external Chinese herbal medicine LC07 treating capecitabine-induced hand-foot syndrome in metastatic breast cancer

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Background: With the capecitabine being increasingly used in the treatment of metastatic breast cancer (MBC), the common side effect of capecitabine, hand-foot syndrome (HFS) has become a main problem which can distress both physicians and patients. Severe HFS such as severe pain can have a negative impact on quality of life (QOL) of these patients and cause reduced dosage or even stopping chemotherapy. No effective treatment for HFS can be available at present. Over the years we have used LC07, a kind of external agents from Chinese herbs (Herba Geranii, etc.), to treat capecitabine-induced HFS. In this study, the efficacy and safety of LC07 were evaluated in patients with MBC and HSF. Methods: Eligible patients includes patients with MBC, who had HFS (NCI-CTC grade ≥1) after receiving single capecitabine chemotherapy (1,250 mg/m2, PO, twice daily, cycled days 1–14, every 21 days). LC07 granules 10g was dissolved in 1,000mL of warm water (keep 34°C-37°C in a footbath), the patients soaked their feet and hands in this lotion for 20 minutes, twice daily for 7 days. An independent researcher assessed symptoms before and after treatment. Evaluation criteria, CR as symptom disappearing completely, PR as NCI-CTC grade for HFS decreasing by more than 1 level after treatment, the total response rate as CR+PR. The QOL of these patients were also evaluated before and after treatment using a FACT-B questionnaire (Version 4.0-Chinese). Results: 42 patients (pts) have been enrolled in this study. All of them are Asian and female. Media age 51.5 yrs (25–72). Grade 1 for HFS was seen in 8 pts, G2 in 19 pts, and G3 in 15 pts. The total response rate was 83.3% (35/42), CR 38.1% (16/42), PR 45.2% (19/42). The average time from therapy to pain relief was 1.8±0.8 days, the skin lesion of HFS including dermatitis, peeling, ulceration have been improved after treatment. The QOL scores before and after treatment were 77.24±25.69 and 109.17±20.53, respectively (p < 0.01). No side effects such as skin allergies related to LC07 was found in this study. Conclusions: In the treatment of capecitabine-induced HFS, the external Chinese medicine LC07 is fast effective for relieving pain, and it has the features of easy use and no skin allergies. Thus LC07 can improve the QOL of patients with MBC and HFS.

No significant financial relationships to disclose.

Pulsed arterial spin-labeled MR imaging evaluation of tuberous sclerosis

BACKGROUND AND PURPOSE

Tuberous sclerosis presents with characteristic cortical hamartomas and subependymal nodules associated with seizures. The purpose of this study was to use pulsed arterial spin-labeling (PASL) to quantify the perfusion of the cortical hamartomas and correlate the perfusion values with seizure frequency.

MATERIALS AND METHODS

A retrospective search yielded 16 MR imaging examinations including conventional MR imaging and PASL perfusion performed in 13 patients (age range, 7 months to 23 years) with a history of tuberous sclerosis. The mean perfusion of each cortical hamartoma greater than 5 mm in size localized with conventional MR imaging sequences was obtained with use of manually drawn regions of interest. Cortical hamartomas were classified as normal, hyperperfused, or hypoperfused on the basis of the mean and SD of the unaffected cortex. Correlation was made between perfusion imaging, conventional imaging, and clinical history.

RESULTS

Of the 245 cortical hamartomas, 227 (92.7%) were hypoperfused, 10 (4.1%) were hyperperfused, and 8 (3.3%) were unchanged relative to the mean gray matter. One patient had a subependymal giant cell astrocytoma with a mean perfusion of 93.5 mL/100 g tissue/min. There was a statistically significant positive correlation between seizure frequency and the number of hyperperfused cortical tubers (r = 0.51; n = 16; P = .04), with higher seizure frequency associated with a greater number of hyperperfused cortical tubers. There was no significant correlation, however, between seizure frequency and the overall number of cortical tubers (r = 0.20; n = 16; P = .47).

CONCLUSIONS

The PASL technique can assess and quantify the perfusion characteristics of a cortical hamartoma. Most lesions are hypoperfused; however, both normally perfused and hyperperfused lesions occur. The presence of hyperperfused cortical tubers was associated with increased seizure frequency.

Intramedullary angioma with bilateral arm hypothermia

Spinal cavernous malformations are collections of abnormal blood vessels in the spinal cord. They are rare and frequently accompany cranial cavernous angiomas. They exhibit clinical features representing the region of the spine affected by the cavernous malformation. We present a 12-year-old boy with bilateral hypothermia predominantly in the left arm and motor weakness of the upper extremities, and lesser involvement of the lower extremities The case had normal cranial magnetic resonance imaging, but MRI of cervical region revealed an intramedullary cavernous haemangioma confirmed with histopathological examination. The lesion was totally excised and hypothermia completely improved within 2 weeks after operation. We suggested that hypothermia in the extremities may be added as a rare finding to the list of the clinical features in cervical myelopathy.

Hypercapnia-induced cerebral hyperperfusion: an underrecognized clinical entity

BACKGROUND AND PURPOSE

The incidence of cerebral hyperperfusion and hypoperfusion, respectively, resulting from hypercapnia and hypocapnia in hospitalized patients is unknown but is likely underrecognized by radiologists and clinicians without routine performance of quantitative perfusion imaging. Our purpose was to report the clinical and perfusion imaging findings in a series of patients confirmed to have hypercapnic cerebral hyperperfusion and hypocapnic hypoperfusion.

MATERIALS AND METHODS

Conventional cerebral MR imaging examination was supplemented with arterial spin-labeled (ASL) MR perfusion imaging in 45 patients during a 16-month period at a single institution. Patients presented with an indication of altered mental status, metastasis, or suspected stroke. Images were reviewed and correlated with arterial blood gas (ABG) analysis and clinical history.

RESULTS

Patients ranged in age from 1.5 to 85 years. No significant acute findings were identified on conventional MR imaging. Patients with hypercapnia showed global hyperperfusion on ASL cerebral blood flow (CBF) maps, respiratory acidosis on ABG, and diffuse air-space abnormalities on same-day chest radiographs. Regression analysis revealed a significant positive linear relationship between cerebral perfusion and the partial pressure of carbon dioxide (pCO(2); beta, 4.02; t, 11.03; P < .0005), such that rates of cerebral perfusion changed by 4.0 mL/100 g/min for each 1-mm Hg change in pCO(2).

CONCLUSIONS

With the inception of ASL as a routine perfusion imaging technique, hypercapnic-associated cerebral hyperperfusion will be recognized more frequently and may provide an alternative cause of unexplained neuropsychiatric symptoms in hospitalized patients. In a similar fashion, hypocapnia may account for a subset of patients with normal MR imaging examinations with poor ASL perfusion signal.

Migraine associated cerebral hyperperfusion with arterial spin-labeled MR imaging

We present a case series demonstrating abnormal regional cerebral hyperperfusion associated with migraine headache using arterial spin-labeling (ASL). In 3 of 11 patients, regional cortical hyperperfusion was demonstrated during a headache episode that corresponded to previous aura symptoms.

Arterial spin-labeling in routine clinical practice, part 3: hyperperfusion patterns

Arterial spin-labeled (ASL) perfusion imaging can be implemented successfully into a routine clinical neuroimaging protocol and can accurately demonstrate alterations in brain perfusion. We have observed patterns of focal, regional, and global hyperperfusion in a wide variety of disease processes. The causes of hyperperfusion at clinical ASL have not been previously characterized. Focal lesions such as brain tumors and vascular malformations with increased perfusion can be well depicted by ASL. More global causes of hyperperfusion, including postanoxia vasodilation and hypercapnia, may go undetected on conventional MR images, whereas the regional hyperperfusion, which may occur in reversible encephalopathies and luxury perfusion, has been consistently illustrated on ASL cerebral blood flow maps at our institution.

A novel gene-samfR involved in early stage of Streptomyces ansochromogenes differentiation

A 4.6 kb DNA fragment was cloned from the DNA library of Streptomyces ansochromogenes using a partial DNA fragment located in the downstream of promoter-P(TH4) as probe. The experiments revealed that this DNA fragment consists of saw D gene and a 1.4 kb Pvu II fragment which can accelerate mycelium formation o fS. ansochromogenes. The nucleotide sequence of 1.4 kb DNA fragment was determined and analysed; the result indicated that the fragment contains one complete open reading frame (ORF) which encodes a protein with 213 amino acids, and this gene was designated as samfR. The deduced protein has 36% amino acid identities and 52% amino acid similarities in comparison with that encoded by hppR gene, which is involved in the regulation of catabolism for 3-(3-hydroxyphenyl) propionate (3HPP) in Rhodococcus globerulus. The function of samfR gene was studied using strategy of gene disruption, and the resulting samfR mutant failed to form aerial hyphae and spores, its development and differentiation stopped at the stage of substrate mycelium in contrast with wild type strain. The results showed that the samfR gene is closely related to S. ansochromogenes differentiation.

Structure and function of sawB, a gene involved in differentiation of Streptomyces ansochromogenes

A partial DNA library of Streptomyces ansochromogenes 7100 was constructed by using plasmid pl J702 as vector and white mutant W19 as recipient. About 3 000 clones were obtained, two of which gave rise to the grey phenotype as wild type 7100. The plasmids were isolated from two transformants. The result indicated that the 5.2 kb and 5.8 kb DNA fragments were inserted into plJ702. The resulting recombinant plasmids were designated as pNL-1 and pNL-2 respectively. The 1.25 kb Pstl I -Apa I DNA fragment from pNL-1 was recognized as its complementarity to W19 strain. The nucleotide sequence of the 3.0 kb Pst I DNA fragment including 1.25 kb was determined and analyzed. The result indicated that this DNA fragment contains one complete open reading frame (ORF1) which encodes a protein with 295 amino acid residues, and this gene was designated as sawB. The deduced protein has 81% amino acid identities in comparison with that encoded by whiH in Streptomyces coelicolor. The function of sawB gene was studied by using strategy of gene disruption, and the resulting sawB mutant failed to form spores and produced loosely coiled aerial hyphal. The result showed that sawB is closely related to hyphal coiling and sporulation in S. ansochromogenes, and also indicated that the sawB can complement whiH mutant (C119) to restore the grey phenotype of Streptomyces coelicolor J 1501 (wild type).

Anoxic injury-associated cerebral hyperperfusion identified with arterial spin-labeled MR imaging

BACKGROUND AND PURPOSE

Anoxic brain injury is a devastating result of prolonged hypoxia. The goal of this study was to use arterial spin-labeling (ASL) to characterize the perfusion patterns encountered after anoxic injury to the brain.

MATERIALS AND METHODS

Sixteen patients with a history of anoxic or hypoxic-ischemic injury ranging in age from 1.5 to 78.0 years (mean, 50.3 years) were analyzed with conventional MR imaging and pulsed ASL 1.0-13.0 days (mean, 4.6 days) after anoxic insult. The cerebral perfusion in each case was quantified by using pulsed ASL as part of the standard stroke protocol. Correlation was made among perfusion imaging, conventional imaging, clinical history, laboratory values, and outcome.

RESULTS

Fifteen of the 16 patients showed marked global hyperperfusion, and 1 patient showed unilateral marked hyperperfusion. Mean gray matter (GM) cerebral blood flow (CBF) in these patients was 142.6 mL/100 g of tissue per minute (ranging from 79.9 to 204.4 mL/100 g of tissue per minute). Global GM CBF was significantly higher in anoxic injury subjects, compared with age-matched control groups with and without infarction (F(2,39) = 63.11; P < .001). Three patients had global hyperperfusion sparing areas of acute infarction. Conventional imaging showed characteristic restricted diffusion in the basal ganglia (n = 10) and cortex (n = 13). Most patients examined died (n = 12), with only 4 patients surviving at the 4-month follow-up.

CONCLUSION

Pulsed ASL can dramatically demonstrate and quantify the severity of the cerebral hyperperfusion after a global anoxic injury. The global hyperperfusion probably results from loss of autoregulation of cerebral vascular resistance.

Glandular tularemia: Uncommon presentation of the cause of lymphadenopathy in two children

This report details the clinical and histopathological characteristics and course of glandular tularemia, an uncommon but significant cause of cervical lymphadenopathy in two children. Tularemia should be considered in the differential diagnosis of cases with non-tuberculosis, suppurative cervical lymphadenopathy, particularly in those not responding to penicillin treatment.