Weathering the COVID-19 storm: Lessons from hematologic cytokine syndromes

A subset of patients with severe COVID-19 develop profound inflammation and multi-organ dysfunction consistent with a "Cytokine Storm Syndrome" (CSS). In this review we compare the clinical features, diagnosis, and pathogenesis of COVID-CSS with other hematological CSS, namely secondary hemophagocytic lymphohistiocytosis (sHLH), idiopathic multicentric Castleman disease (iMCD), and CAR-T cell therapy associated Cytokine Release Syndrome (CRS). Novel therapeutics targeting cytokines or inhibiting cell signaling pathways have now become the mainstay of treatment in these CSS. We review the evidence for cytokine blockade and attenuation in these known CSS as well as the emerging literature and clinical trials pertaining to COVID-CSS. Established markers of inflammation as well as cytokine levels are compared and contrasted between these four entities in order to establish a foundation for future diagnostic criteria of COVID-CSS.

How might controlled fusion fit into the emerging low-carbon energy system of the mid-twenty-first century?

We examine the characteristics that fusion-based generation technologies will need to have if they are to compete in the emerging low-carbon energy system of the mid-twenty-first century. It is likely that the majority of future electric energy demand will be provided by the lowest marginal cost energy technology-which in many regions will be stochastically varying renewable solar and wind electric generation coupled to systems that provide up to a few days of energy storage. Firm low-carbon or zero-carbon resources based on gas-fired turbines with carbon capture, advanced fission reactors, hydroelectric and perhaps engineered geothermal systems will then be used to provide the balance of load in a highly dynamic system operating in competitive markets governed by merit-order pricing mechanisms that select the lowest-cost supplies to meet demand. These firm sources will have overnight capital costs in the range of a few $/Watt, be capable of cycling down to a fraction of their maximum power output, operate profitably at low utilization fraction, and have a suitable unit size of order 100 MW_e. If controlled fusion using either magnetic confinement or inertial confinement approaches is to have any chance of providing a material contribution to future electrical energy needs, it must demonstrate these key qualities and at the same time prove robust safety characteristics that avoid the perceived dread risk that plagues nuclear fission power, avoid the generation of long-lived radioactive waste and demonstrate highly reliable operations. This article is part of a discussion meeting issue 'Prospects for high gain inertial fusion energy (part 1)'.

A Meta-Analysis of Case Fatality Rates of Recurrent Venous Thromboembolism and Major Bleeding in Patients with Cancer

BACKGROUND

 Knowing the case fatality rates of recurrent venous thromboembolism (VTE) and major bleeding is important for weighing the relative risks and benefits of anticoagulation and deciding on the duration of anticoagulant therapy, but these rates are uncertain in patients with cancer-associated thrombosis.

METHODS

 We performed a systematic review and a meta-analysis to determine the incidence of recurrent VTE and major bleeding and their respective case fatality rates in patients with cancer-associated VTE.

RESULTS

 Our analysis included 29 studies (15 prospective cohort studies and 14 randomized controlled trials) from 1980 to January 2019. Data from 8,000 cancer patients with 4,786 patient-years of follow-up were summarized. Rates of recurrent VTE and fatal recurrent VTE were 23.7 (95% confidence interval [CI]: 20.1-27.8) and 1.9 (95% CI: 0.8-4.0) per 100 patient-years of follow-up, respectively, with a case fatality rate of 14.8% (95% CI: 6.6-30.1%). The rates of major bleeding and fatal major bleeding events were 13.1 (95% CI: 10.3-16.7) and 0.8 (95% CI: 0.3-2.1) per 100 patient-years of follow-up, respectively, with a case fatality rate of 8.9% (95% CI: 3.5-21.1%). While the estimates of case fatality vary by anticoagulation regimen and study design, the differences between them were not statistically significant.

CONCLUSION

 In cancer patients receiving anticoagulation, the case fatality rate of recurrent VTE is higher than the case fatality rate of major bleeding. These findings may help to inform decisions regarding the management of anticoagulation in patients with active cancer and VTE.

The effect of therapeutic drug monitoring of beta-lactam and fluoroquinolones on clinical outcome in critically ill patients: the DOLPHIN trial protocol of a multi-centre randomised controlled trial

BACKGROUND

Critically ill patients undergo extensive physiological alterations that will have impact on antibiotic pharmacokinetics. Up to 60% of intensive care unit (ICU) patients meet the pharmacodynamic targets of beta-lactam antibiotics, with only 30% in fluoroquinolones. Not reaching these targets might increase the chance of therapeutic failure, resulting in increased mortality and morbidity, and antibiotic resistance. The DOLPHIN trial was designed to demonstrate the added value of therapeutic drug monitoring (TDM) of beta-lactam and fluoroquinolones in critically ill patients in the ICU.

METHODS

A multi-centre, randomised controlled trial (RCT) was designed to assess the efficacy and cost-effectiveness of model-based TDM of beta-lactam and fluoroquinolones. Four hundred fifty patients will be included within 24 months after start of inclusion. Eligible patients will be randomly allocated to either study group: the intervention group (active TDM) or the control group (non-TDM). In the intervention group dose adjustment of the study antibiotics (cefotaxime, ceftazidime, ceftriaxone, cefuroxime, amoxicillin, amoxicillin with clavulanic acid, flucloxacillin, piperacillin with tazobactam, meropenem, and ciprofloxacin) on day 1, 3, and 5 is performed based upon TDM with a Bayesian model. The primary outcome will be ICU length of stay. Other outcomes amongst all survival, disease severity, safety, quality of life after ICU discharge, and cost effectiveness will be included.

DISCUSSION

No trial has investigated the effect of early TDM of beta-lactam and fluoroquinolones on clinical outcome in critically ill patients. The findings from the DOLPHIN trial will possibly lead to new insights in clinical management of critically ill patients receiving antibiotics. In short, to TDM or not to TDM?

TRIAL REGISTRATION

EudraCT number: 2017-004677-14. Sponsor protocol name: DOLPHIN. Registered 6 March 2018 . Protocol Version 6, Protocol date: 27 November 2019.

The Revised Sonographic NASCET Index: A New Hemodynamic Parameter for the Assessment of Internal Carotid Artery Stenosis

PURPOSE

A previously described Doppler parameter, the sonographic NASCET index (SNI), was derived to be more directly analogous to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) methodology for assessing carotid artery stenosis. However, this index does not account for complex changes affecting the Doppler waveform. We propose a revised SNI (rSNI) in an effort to improve predicting carotid stenosis.

MATERIALS AND METHODS

25 carotid bifurcations with stenoses ranging from 40 - 92 % were analyzed. For each vessel, the rSNI and original SNI were calculated. The peak systolic velocity (PSV), rSNI, and original SNI were correlated with angiography using linear regression analysis and relative accuracies were compared at two thresholds.

RESULTS

A correlation between rSNI and angiography was found to be significantly better than that between PSV or internal carotid artery-common carotid artery (ICA-CCA) peak velocity ratio and angiography (r² = 0.47 vs. 0.22; r² = 0.47 vs. 0.16). The accuracy of PSV in predicting high-grade stenosis was 68% and 72%, compared with 80% and 88% for rSNI, at each of two thresholds. The original SNI better correlated with angiography compared to the rSNI (r² = 0.55 vs. 0.47), but with slightly lower accuracy in predicting high-grade stenosis (76% vs. 80%).

CONCLUSION

The revised SNI correlates more closely with angiographic stenosis than either the PSV or the ICA-CCA ratio, and is more accurate in predicting high-grade stenosis. However, it is overall comparable to the original SNI, suggesting that the previously unaccounted for effects over the remainder of the cardiac cycle do not significantly improve the ability to sonographically predict significant stenosis.

Are physicians performing neonatal circumcisions well-trained?

INTRODUCTION

Notwithstanding the recommendations from the Canadian Pediatric Association and the American Academy of Pediatrics on the indications for neonatal circumcision, this procedure is still common in North America and throughout the world. Our purpose is not to argue whether this procedure should be done, but rather to examine who is doing it, their training, how it is performed and how can we prevent unsatisfactory results and complications. The objective is to identify what fields of knowledge require improvement and then design a teaching module to improve the outcomes of neonatal circumcision.

METHODS

A 19-question cross-sectional survey, including a visual identification item, was submitted to 87 physicians who perform neonatal circumcisions in Southwestern Ontario, Canada. To improve our response rate, study subjects were contacted in a variety of ways, including mail and fax and telephone. Once the survey was completed, we produced a surgical technique training video on using the Gomco clamp and the Plastibell techiques. A knowledge dissemination workshop was held with survey participants to discuss contraindications and the use of anesthesia and management of complications of neonatal circumcision and to evaluate the surgical technique training video. A 6-month follow-up questionnaire was completed to determine the impact of the teaching course on participants' daily practice.

RESULTS

In total, we received 54 responses (62% response rate). From these, 46 (85%) were family doctors and pediatricians, while the remaining 8 (15%) were pediatric general surgeons and urologists. The circumcisions were carried out with the Gomco clamp 35 (63%) and the Plastibell 21 (37%). No respondent admitted to learning the procedure through a structured training course. Of the non-surgeons, 19 (43%) learned to perform a circumcision from a non-surgeon colleague. A little over a third of the participants (17, 31%) were happy to perform a circumcision in a child born with a concealed penis, where circumcision is contraindicated. With respect to the early complications post-circumcision, 8 (100%) surgeons versus 29 (63%) non-surgeons felt comfortable dealing with bleeding (p = 0.046). In total, 7 (88%) surgeons versus 16 (35%) non-surgeons were comfortable dealing with urinary retention (p = 0.01). Also, 8 (100%) surgeons versus 24 (52%) non-surgeons were comfortable dealing with a wound dehiscence (p = 0.02). Moreover, 6 (75%) surgeons and 5 (10%) non-surgeons were comfortable managing meatal stenosis (p < 0.01). Five (63%) surgeons versus 15 (33%) non-surgeons were confident in dealing with a trapped penis post-circumcision (p = 0.24).

CONCLUSIONS

Our survey findings indicate that most physicians performing neonatal circumcisions in our community have received informal and unstructured training. This lack of formal instruction may explain the complications and unsatisfactory results witnessed in our pediatric urology practice. Many practitioners are not aware of the contraindications to neonatal circumcision and most non-surgeons perform the procedure without being able to handle common post-surgical complications. Based on our survey findings, we planned and carried out a formal training course to address these issues.

Emerging novel therapies in the treatment of castrate-resistant prostate cancer

The treatment options for patients with castration-resistant prostatecancer (CRPC), until very recently, only included docetaxel.In the past 10 months, newly Federal Drug Administration (FDA)approved agents in the United States have shown survival benefitfor patients with CRPC. This review takes a closer look atthese newer agents: sipuleucel-T (immune therapy) and cabazitaxel(cytotoxic therapy). We also review the evidence supportingthe FDA’s approval of denosumab (bone-targeted therapy)as a treatment option for men with CRPC and bony metastases.Newer agents currently being investigated in phase III clinical trialsfor their potential role in metastatic CRPC are also reviewed.These agents include abiraterone (hormonal therapy), TAK-700(hormonal therapy), MDV3100 (hormonal therapy), ipilimumab(immune therapy), zibotentan (endothelin-A receptor antagonist)and dasatinib (tyrosine kinase inhibitor). As ongoing studies usingall the aforementioned agents continue to evolve, our understandingof how and where these agents fit into the treatment paradigmfor patients with CRPC will become clearer.

Quality of life of children and adolescents with type 1 diabetes in Kuwait

OBJECTIVES

To evaluate the health-related quality of life (HRQoL) of children and adolescents with type 1 diabetes (T1DM) in Kuwait using the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scale and PedsQL 3.0 Diabetes Module, and to identify the risk factors associated with unsatisfactory QoL and their effects on metabolic control.

SUBJECTS AND METHODS

A total of 436 patients (2-18 years) with T1DM (>6 months) and 389 healthy controls, with the parents of both groups, completed the Arabic Generic Core Scale. Those with T1DM also completed the Arabic Diabetes Module.

RESULTS

The mean total score of the PedsQL Diabetes Module was 70.2 ± 9.8 reported by children and 59.9 ± 11.1 reported by parents (higher scores indicate better QoL). Young age and long duration of diabetes were associated with poor QoL (p < 0.001). Boys had better total scores than girls in most age groups (70.3 ± 9.3 vs. 52.3 ± 7.2, p < 0.001); however, girls did better than boys regarding treatment barriers and adherence (71.3 ± 7.8 vs. 68.1 ± 6.2, p < 0.005). Higher HbA1c values were associated with lower QoL scores (31.1 ± 5.1 at HbA1c of 15% vs. 82.5 ± 6.1 at HbA1c of 6%, p < 0.0001).

CONCLUSION

HRQoL of children and adolescents with T1DM was consistently poorer than controls. Parents consistently reported poorer QoL scores than their children. We recommend that more support should be provided for the care of children with diabetes in Kuwait.

Buried penis: An unrecognized risk factor in the development of invasive penile cancer

One of the documented benefits of neonatal circumcision is protection against invasive penile cancer. To date there have been a handful of published cases of invasive penile cancer in men circumcised as neonates. We report a case of a 73-year-old man, with a history of neonatal circumcision with no evidence of previous human papillomavirus exposure, who developed a buried penis secondary to obesity. He was diagnosed with Grade 2, pT3N0 squamous cell carcinoma of the penis. This report suggests that buried penis may pose a risk factor for the development of penile cancer despite the protective effects of neonatal circumcision. Thus periodic examination of a buried penis is warranted even in patients with no risk factors for penile cancer. A review of the literature is provided.

P-selectin mediates neutrophil rolling and recruitment in acute pancreatitis

BACKGROUND

The adhesive mechanisms regulating leucocyte-endothelium interactions in the pancreas remain elusive, but selectins may play a role. This study examined the molecular mechanisms mediating leucocyte rolling along the endothelium in the pancreas and the therapeutic potential of targeting the rolling adhesive interaction in acute pancreatitis (AP).

METHODS

Pancreatitis was induced by retrograde infusion of 5 per cent sodium taurocholate into the pancreatic duct, repeated intraperitoneal administration of caerulein (50 µg/kg) or intraperitoneal administration of L-arginine (4 g/kg) in C57BL/6 mice. A control and a monoclonal antibody against P-selectin were administered before and after induction of AP. Serum and tissue were sampled to assess the severity of pancreatitis, and intravital microscopy was used to study leucocyte rolling.

RESULTS

Taurocholate infusion into the pancreatic duct increased the serum level of trypsinogen, trypsinogen activation, pancreatic neutrophil infiltration, macrophage inflammatory protein (MIP) 2 formation and tissue damage. Immunoneutralization of P-selectin decreased the taurocholate-induced increase in serum trypsinogen (median (range) 17·35 (12·20-30·00) versus 1·55 (0·60-15·70) µg/l; P = 0·017), neutrophil accumulation (4·00 (0·75-4·00) versus 0·63 (0-3·25); P = 0·002) and tissue damage, but had no effect on MIP-2 production (14·08 (1·68-33·38) versus 3·70 (0·55-51·80) pg/mg; P = 0·195) or serum trypsinogen activating peptide level (1·10 (0·60-1·60) versus 0·45 (0-1·80) µg/l; P = 0·069). Intravital fluorescence microscopy revealed that anti-P-selectin antibody inhibited leucocyte rolling completely in postcapillary venules of the inflamed pancreas.

CONCLUSION

Inhibition of P-selectin protected against pancreatic tissue injury in experimental pancreatitis. Targeting P-selectin may be an effective strategy to ameliorate inflammation in AP.

Rho-kinase signalling regulates trypsinogen activation and tissue damage in severe acute pancreatitis

BACKGROUND AND PURPOSE

Severe acute pancreatitis (SAP) is characterized by trypsinogen activation, infiltration of leucocytes and tissue necrosis but the intracellular signalling mechanisms regulating organ injury in the pancreas remain elusive. Rho-kinase is a potent regulator of specific cellular processes effecting several pro-inflammatory activities. Herein, we examined the role of Rho-kinase signalling in acute pancreatitis.

EXPERIMENTAL APPROACH

Pancreatitis was induced by infusion of taurocholate into the pancreatic duct in C57BL/6 mice. Animals were treated with a Rho-kinase inhibitor Y-27632 (0.5-5 mg·kg⁻¹) before induction of pancreatitis.

KEY RESULTS

Taurocholate infusion caused a clear-cut increase in blood amylase, pancreatic neutrophil infiltration, acinar cell necrosis and oedema formation in the pancreas. Levels of pancreatic myeloperoxidase (MPO), macrophage inflammatory protein-2 (MIP-2), trypsinogen activation peptide (TAP) and lung MPO were significantly increased, indicating local and systemic disease. Inhibition of Rho-kinase activity dose-dependently protected against pancreatitis. For example, 5 mg·kg⁻¹ Y-27632 reduced acinar cell necrosis, leucocyte infiltration and pancreatic oedema by 90%, 89% and 58%, respectively, as well as tissue levels of MPO by 75% and MIP-2 by 84%. Moreover, Rho-kinase inhibition decreased lung MPO by 75% and blood amylase by 83%. Pancreatitis-induced TAP levels were reduced by 61% in Y-27632-treated mice. Inhibition of Rho-kinase abolished secretagogue-induced activation of trypsinogen in pancreatic acinar cells in vitro.

CONCLUSIONS AND IMPLICATIONS

Our novel data suggest that Rho-kinase signalling plays an important role in acute pancreatitis by regulating trypsinogen activation and subsequent CXC chemokine formation, neutrophil infiltration and tissue injury. Thus, these results indicate that Rho-kinase may constitute a novel target in the management of SAP.

Emerging novel therapies in the treatment of castrate-resistant prostate cancer

The treatment options for patients with castration-resistant prostate cancer (CRPC), until very recently, only included docetaxel. In the past 10 months, newly Federal Drug Administration (FDA) approved agents in the United States have shown survival benefit for patients with CRPC. This review takes a closer look at these newer agents: sipuleucel-T (immune therapy) and cabazi-taxel (cytotoxic therapy). We also review the evidence supporting the FDA's approval of denosumab (bone-targeted therapy) as a treatment option for men with CRPC and bony metastases. Newer agents currently being investigated in phase III clinical trials for their potential role in metastatic CRPC are also reviewed. These agents include abiraterone (hormonal therapy), TAK-700 (hormonal therapy), MDV3100 (hormonal therapy), ipilimumab (immune therapy), zibotentan (endothelin-A receptor antagonist) and dasatinib (tyrosine kinase inhibitor). As ongoing studies using all the aforementioned agents continue to evolve, our understanding of how and where these agents fit into the treatment paradigm for patients with CRPC will become clearer.

Role of platelets in experimental acute pancreatitis

BACKGROUND

Platelets not only control thrombosis and haemostasis but may also regulate inflammatory processes. Acute pancreatitis (AP) is characterized by changes in both coagulation and proinflammatory activities. The role of platelets in AP is not yet known.

METHODS

AP was induced in C57BL/6 mice by repeated caerulein administration (50 µg/kg intraperitoneally). Mice received a platelet-depleting or control antibody before caerulein challenge. Neutrophil infiltration, myeloperoxidase (MPO) and macrophage inflammatory protein (MIP) 2 levels, acinar cell necrosis and haemorrhage in the pancreas, as well as serum amylase activity, were determined 24 h after caerulein injection. In an alternative model of pancreatitis, L-arginine (4 g/kg intraperitoneally) was given twice with an interval of 1 h and tissue samples were taken after 72 h [Correction added after online publication 29 September 2010: in the preceding sentence, 4 mg/kg was corrected to 4 g/kg].

RESULTS

Caerulein administration increased acinar cell necrosis, neutrophil infiltration, focal haemorrhage and serum amylase levels. Platelet depletion reduced acinar cell necrosis, haemorrhage and serum amylase levels in AP. Depletion of platelets decreased caerulein-induced MPO levels and neutrophil recruitment in the pancreas. Platelet depletion abolished caerulein-induced MIP-2 generation in the pancreas and circulation. The effects of platelet depletion on necrosis, neutrophils and MPO levels were confirmed in L-arginine-induced pancreatitis.

CONCLUSION

Platelets play a crucial role in AP by regulating neutrophil infiltration, most likely mediated by MIP-2 production in the pancreas.

Effect of midazolam, dexamethasone and their combination on the prevention of nausea and vomiting following strabismus repair in children

BACKGROUND

Postoperative nausea and vomiting is a common complication following strabismus surgery. This randomized and double-blind study was designed to evaluate the efficacy of midazolam alone or in combination with dexamethasone in reducing the incidence of postoperative nausea and vomiting in children undergoing strabismus repair.

METHODS

One hundred ASA I children, aged 4-12 yr, scheduled to undergo elective strabismus surgery, were enrolled. No premedication was given. Anaesthesia was induced with sevoflurane, nitrous oxide and oxygen. After induction, fentanyl 2 microg kg-1 and cisatracurium 0.1 mg kg-1 were administered and an endotracheal tube was inserted. After induction of anaesthesia and before start of surgery, patients were randomly allocated into one of four groups of 25 children each to receive placebo, midazolam 50 microg kg-1, dexamethasone 0.5 mg kg-1 or a combination of midazolam 50 microg kg-1 and dexamethasone 0.5 mg kg-1. Episodes of nausea, and retching and vomiting were recorded during the first 24 h after surgery.

RESULTS

The incidence of postoperative nausea was 48%, 32%, 12% and 0% with placebo, dexamethasone, midazolam and the midazolam-dexamethasone combination, respectively. The incidence of vomiting was 52% and 32% with placebo and dexamethasone, respectively; no child vomited with midazolam alone, or with the midazolam-dexamethasone combination.

CONCLUSION

Prophylactic midazolam with or without dexamethasone reduces the incidence of PONV in children undergoing strabismus repair.

U.S. medical students choice of careers and its future impact on health care manpower

During the last 10-15 years, the health care system of this country has faced major challenges, among them, spiraling increases of health care costs, physician manpower maldistribution, excessive production of subspecialists, shortages of primary care physicians (family practice, general internal medicine, and general pediatrics), and lack of access to health care, predominantly among the poor and disadvantaged populations. As a way of shedding light on some of these challenges, the authors conducted a study among junior medical students from the University of Texas Medical School at Houston which focused on some of the factors that might influence medical students' choice of careers. In this article, the authors review the most salient findings for some of the problems that currently plague the health care system of this nation. Certainly, the outcome of this study has important educational and health service delivery implications not only in the United States but abroad as well, particularly among developing nations.

The clinical spectrum of Clostridium sordellii bacteraemia: two case reports and a review of the literature

Clostridium sordellii is rarely associated with disease in humans. Since its first report in 1922 only a few cases of bacteraemia have been reported. This report describes two cases of C sordellii bacteraemia; the oldest and youngest patients reported to date. The first, is a previously well 81 year old woman presented with perianal infection, which was later complicated by thrombosis of the aorta, and the second is a 12 year old boy with epilepsy who presented with an ear infection. These cases are also highlighted to demonstrate the wide spectrum of presentation of sordellii bacteraemia.

Interferon-alpha in chronic hepatitis C infection in dialysis patients

This study assesses the efficacy and adverse effects of interferon-alpha (IFN-alpha) administered at a dosage of 3 million units three times weekly for 1 year in 17 hemodialysis patients with hepatitic C virus (HCV)-associated chronic hepatitis (biopsy proven). The patients were prospectively followed up for a period of 18 months. Liver biopsy was repeated after 6 months of treatment in 13 patients. Patients were classified according to the histological activity index. Biochemical and virological responses were evaluated at the end (end-of-treatment response) and 6 months after completion of therapy (sustained response). HCV RNA became negative in 76% of the patients after 12 weeks of treatment, in 88% after 12 months of treatment, and in 71% of the patients 6 months after completion of therapy. HCV genotype 4 was found in 60% of our population. Alanine aminotransferase (ALT) levels were initially increased in only 6 patients and normalized in 4 of these patients after 12 weeks of therapy, with end-of-treatment and sustained biochemical responses of 83% and 67%, respectively. Of 13 patients who underwent liver biopsies after 6 months of therapy, 11 patients (85%) showed histological improvement. One patient could not tolerate therapy because of marked lethargy and myalgia; the other patients had minor side effects that did not require discontinuation of treatment. Two patients received a cadaveric renal transplant after 1 year of IFN treatment, and they continued to maintain biochemical and virological responses after a follow-up of 17 and 28 months, respectively.

Benign recurrent intrahepatic cholestasis in a Saudi child

We report a case of benign recurrent intrahepatic cholestasis (BRIC) in an 11-year-old Saudi girl who developed three episodes of pruritus and jaundice at the ages of 4, 8, and 9 years. These episodes were almost stereotypic and lasted 5-8 weeks. Although she had elevated liver enzymes and serum bile acids in her blood during the attacks, they returned to normal between attacks. Thorough investigation excluded other causes of liver disease and her recurrent attacks were shortened by cholestyramine therapy. A diagnosis of BRIC should be kept in mind in patients with cholestasis.

Women's advancement in medicine and academia: barriers and future perspectives

Although women made early advancements in the field of medicine during the second half of the 19th century, they were not able to make relevant strides in both medicine and academia until the 1960s. Despite women's recent advancements, obstacles and barriers to their hope of achieving fairness and equality in their professional and academic careers still exist. These practices include professional discrimination, blatant sexism, lack of appropriate mentors, and unfair faculty promotion processes. In this article, we address the most common problems affecting women physicians' advancement in academic medicine. We also focus on the role of mentorship as a relevant and beneficial factor for progress in their medical and academic careers. Finally, we provide a perspective designed to resolve most of the barriers confronting women physicians in their quest for advancement in academic medicine.

Follow-up of HIV western blot indeterminate results

Indeterminate results obtained with the Western blot (WB) confirmatory test on HIV enzyme immunoassay (EIA)-positive samples, constituted 15.6% (444/2849) over a 2.5-year period at the referral laboratory for the Western region at the King Fahd General Hospital, Jeddah. Two hundred and fourteen WB-indeterminate samples were followed up by repeat WB testing of subsequent samples from the same patients over a 3-12 month period. One hundred and forty-two samples (66.4%) gave negative results. Sixty-five samples (30%) remained indeterminate. Only seven samples (3.3%) not initially meeting WHO criteria for positivity turned clear-cut positive, with high EIA readings on follow-up. It was discovered initally that a significant proportion of indeterminates was due to low-grade cross-contamination between samples as a result of aerosol backflow during aspiration in the washing procedure. This was eliminated by rinsing the lines between samples, separating samples with high EIA from those with low EIA, and rerunning indeterminate samples. A reduction of indeterminates from 21% to 8.5% subsequently followed. After this improvement, most of the samples that remained indeterminate had low EIA readings, and few bands of mainly anti-gag (p55, p24 or p18) or anti-pol (p51) antibodies, while the few turning positive all had anti-gp160, in addition to anti-p24 or p55. Interestingly, over the last year and a half of the study, 1.4% of the total samples (21/1506) had repeatedly high EIA readings but were negative by WB. In addition, 16 samples (1.1%) were positive for HIV-2. A separate computer-based system for the storage of data was very helpful in ascertaining proper follow-up of indeterminate WB results.

Hypodermoclysis as a means of rehydration

This article discusses the use of hypodermoclysis, a method of fluid replacement that is little practised by today's physicians and nurses, although it was widely used in the early 1950s. The article reviews the literature on the use of hypodermoclysis as a safe and convenient method of fluid administration, and spotlights some concerns surrounding the use of hypodermoclysis.

Liver transplantation at king fahad national guard hospital riyadh, kingdom of saudi arabia

Liver disease is a major medical problem in the Kingdom of Saudi Arabia and is mostly due to viral hepatitis. Liver transplantation is the only option for patients with end-stage liver disease offering good long-term survival. The first liver transplant at the King Fahad National Guard Hospital was performed in February 1994 and since then, 40 liver transplants have been performed on 37 patients. Immunosuppression consisted of prednisone combined with cyclosporin (Neoral) or FK 506. Maintenance immunosuppression was with the use of cyclosporin or FK 506 as monotherapy. All, but one patient, survived the surgical procedure; there were no cases of primary non-function; acute cellular rejection occurred in 12 patients all of whom responded to steroids. Pneumonia and biliary sepsis occurred in 12 patients each. A total of 10 patients died, with sepsis being the leading cause of death. The overall graft survival was 73%. Donor shortage continues to be a major limiting factor.

Aluminum monitoring for chronic renal failure patients in kuwait

The importance of monitoring serum aluminum (Al) level in patients undergoing long-term hemodialysis (HD) is well known. This study on 94 HD patients from Mubarak Hospital, Kuwait revealed that serum Al level was significantly higher in HD patients on aluminum hydroxide therapy (n = 57) than those not on this treatment (n = 37) (p = 100 ug/L. Analysis of water and dialysis fluid showed Al levels just above the permissible limit, on certain occasions, suggesting the need for regular monitoring of these substances for Al contamination. Patients on HD for longer than five years and those above the age of 50 years had higher serum Al levels. The most important single factor causing elevated serum Al levels in the study patients was aluminum hydroxide therapy, administered orally as a phosphate binder.

Diagnosis and management of heart failure. Canadian Cardiovascular Society

Many of the recommendations presented in this consensus report are summarized in Figure 2. All patients with known or suspected heart failure should undergo a detailed history and physical examination. Other causes for the symptoms and/or clinical signs indicative of heart failure should be excluded. Routine biochemical tests, as well as a standard chest x-ray and ECG, should be performed on all patients with heart failure. Precipitating or aggravating causes of heart failure should be eliminated. Patients with potentially surgically correctable lesions, such as constrictive pericarditis, valvular disease or left ventricular aneurysm, should be referred for cardiological evaluation and the appropriate surgery. Patients with ischemic induced heart failure should be assessed for possible revascularization by either angioplasty or bypass surgery. Pending clinical findings and the degree of systolic or diastolic dysfunction present, determined by noninvasive tests, the panel made recommendations concerning the choice of various therapeutic agents. These clinical guidelines have been developed for practising physicians who manage patients with heart failure. The process by which consensus recommendations were developed by the Canadian Cardiovascular Society was based on the principle that guidelines have the best chance of succeeding if they are developed by those who will be using them. Strategies that ensure physicians are aware of the current guidelines, and that their implementation leads to measurable improvement in the diagnosis and management of patients with heart failure must be developed. Consensus reports represent an ongoing process which is subject to revision when further conclusive evidence is obtained by ongoing and future clinical trials.

Acute renal failure occurring in scleroderma treated with cyclosporin A: a report of three cases

Cyclosporin A, which is a nephrotoxic agent, has been a mainstay antirejection drug in heart, kidney and lung transplant programmes for about 10 yr. Renal transplant physicians have become adept in balancing its powerful immunosuppressive effects with its undoubted potential nephrotoxicity. Here we report three of eight systemic sclerosis (SSc) patients treated with cyclosporin A who developed acute renal failure. Consideration is given to the evidence of benefit from this agent in SSc and to the management of acute hypertensive renal failure in this disease.

Noninvasive identification of left main and triple vessel coronary artery disease: improved accuracy using quantitative analysis of regional myocardial stress distribution and washout of thallium-201

The capabilities of visual and quantitative analysis of stress redistribution thallium-201 scintigrams, exercise electrocardiography and exercise blood pressure response were compared for correct identification of extensive coronary disease, defined as left main or triple vessel coronary artery disease, or both (50% or more luminal diameter coronary narrowing), in 105 consecutive patients with suspected coronary artery disease. Extensive disease was present in 56 patients and the remaining 49 had either less extensive coronary artery disease (n = 34) or normal coronary arteriograms (n = 15). Although exercise blood pressure response, exercise electrocardiography and visual thallium-201 analysis were highly specific (98, 88 and 96%, respectively), they were insensitive for identification of patients with extensive disease (14, 45 and 16%, respectively). Quantitative thallium-201 analysis significantly improved the sensitivity of visual thallium-201 analysis for identification of patients with extensive disease (from 16 to 63%, p less than 0.001) without a significant loss of specificity (96 versus 86%, p = NS). Eighteen (64%) of the 28 patients who were misclassified by visual analysis as having less extensive disease were correctly classified as having extensive disease by virtue of quantitative analysis of regional myocardial thallium-201 washout. When the results of quantitative thallium-201 analysis were combined with those of blood pressure and electrocardiographic response to exercise, the sensitivity and specificity for identification of patients with extensive disease was 86 and 76%, respectively, and the highest overall accuracy (0.82) was obtained.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of cardioinhibitory hypersensitive carotid sinus syncope with permanent cardiac pacing--a seventeen year prospective study

Sudden and unannounced syncope due to increased vagal tone as manifested by hypersensitivity of the carotid sinus mechanism is not uncommon. A 17 year prospective study of 89 patients with cardio-inhibitory (Type 1) hypersensitivity showed that males outnumbered females 4.5:1. The age range at the onset of symptoms was 37 to 88 years with an average of 63 years. Hypersensitivity of the right carotid sinus was 7:1 compared to the left. These patients had unilateral hypersensitivity in 71% and bilateral in 29%. A new classification of Hypersensitive Carotid Sinus Syncope incorporating sinoatrial node (Type 1A) and atriaoventricular node (Type 1B) suppression in the Type 1 syndrome is presented. Many forms of treatment for cardioinhibitory Hypersensitive Carotid Sinus Syncope have been forthcoming but in our hands in these 89 patients over 17 years, there has been no single case of recurrence of syncope after implantation of a permanent VVI electronic cardiac pacemaker. Type 2 (vasodepressor) Hypersensitive Carotid Sinus Syncope is rare, occasionally seen combined with the cardioinhibitory (Type 1) response and it is not helped with cardiac pacing.

Slow regional clearance of myocardial thallium-201 in the absence of perfusion defect: contribution to detection of individual coronary artery stenoses and mechanism for occurrence

As a result of the "spatially relative" nature of perfusion defect analysis of stress-redistribution thallium-201 (201Tl) scintigrams, hypoperfused myocardial segments may not appear as perfusion defects but they may demonstrate a slow washout rate of 201Tl that can be analyzed in a "spatially nonrelative" manner. Quantitative analysis of perfusion defects and slow washout rate of 201Tl was performed on scintigrams from 116 consecutive patients with adequate exercise tests, defined as achievement of 85% or more of age-predicted maximum heart rate or development of angina or ST segment depression. A total of 232 diseased and 116 nondiseased vessels were found in the patients. Additional analysis of slow washout rate significantly (p less than .05) improved sensitivity for detection of disease in the left anterior descending (from 74% to 82%), left circumflex (from 40% to 61%), and right coronary arteries (from 78% to 90%) without significant loss of specificity. This improvement resulted from the additional detection of 32 of 232 (14%) diseased vascular distributions when the isolated slow washout rate of 201Tl was also determined. In nine of these 32, isolated slow washout rate was associated with another region with isolated slow washout rate in the contralateral myocardial segment. Coronary arteriography revealed similar degrees of stenosis in the vessels supplying these segment pairs. In 13 of 32 cases, a perfusion defect and a slow washout rate were found in the contralateral segment.(ABSTRACT TRUNCATED AT 250 WORDS)