[Does ECT raise the risk of a recurrent stroke?]

BACKGROUND

As the guidelines and evidence for the use of electroconvulsive therapy (ECT) in patients with a recent or past history of stroke are unclear, ECT tends to be avoided in this population.

AIM

To give a systematic review the literature on the risk and incidence of cerebrovascular accidents after ECT in these patients.

METHOD

A systematic literature search was performed according to the PRISMA guidelines in PubMed and in the Cochrane Library. Publications in which ECT was applied in patients with a history of stroke were included by using specific MeSH terms.

RESULTS

The following 19 articles met the criteria for review: 1 wide-scale prospective study, 1 small-scale prospective study with a control group, 3 small-scale retrospective studies, and 14 case reports. In the vast longitudinal Danish study, ECT was not associated with an elevated risk of recurrent stroke. Similarly, none of the other studies found the risk to be raised.

CONCLUSION

Despite the limited number of prospective studies and the methodological discrepancies in the reports, ECT does not seem to be associated with an elevated risk of recurrent stroke. This review supports the safe use of ECT in patients with a recent or past history of stroke, if prior neurologic and cardiovascular assessments are being performed, as well as monitoring during the treatment.

Position statement: The need for EU legislation to require disclosure and labelling of the composition of medical devices

BACKGROUND

In recent years, skin reactions secondary to the use of medical devices (MD), such as allergic contact dermatitis have increasingly been observed (e.g. to continuous blood sugar monitoring systems, insulin pumps, wound dressings, medical gloves, etc.): this is regarded as a developing epidemic. Lack of labelling of the composition of MD, as well as frequent lack of cooperation of manufacturers to disclose this relevant information, even when contacted by the clinician for the individual case of an established adverse reaction, significantly impede patient care.

OBJECTIVES

To advocate for full ingredient labelling in the implementation of EU regulation for MD.

METHODS

This position paper reviews the scientific literature, the current regulatory framework adopted for MD to date, and the likely impact, including some costs data in case of the absence of such labelling.

RESULTS

Efforts made by several scientific teams, who are trying to identify the culprit of such adverse effects, either via asking for cooperation from companies, or using costly chemical analyses of MD, can only partly, and with considerable delay, compensate for the absence of meaningful information on the composition of MD; hence, patient management is compromised. Indeed, without knowing the chemical substances present, physicians are unable to inform patients about which substances they should avoid, and which alternative MD may be suitable/tolerated.

CONCLUSION

There is an urgent need for full and accurate labelling of the chemical composition of MD in contact with the human body.

The epidemic of methylisothiazolinone contact allergy in Europe: follow-up on changing exposures

BACKGROUND

Methylisothiazolinone (MI) has caused an unprecedented epidemic of contact allergy in Europe and elsewhere. Subsequently, regulatory action has been taken, at least in Europe, aiming at reducing risk of MI sensitization.

OBJECTIVE

To follow-up on the prevalence of contact allergy to MI in consecutively patch tested patients and assess the spectrum of products containing MI or methylchloroisothiazolinone (MCI)/MI in patients positive to MI which elicited current allergic contact dermatitis.

METHODS

A cross-sectional survey was performed in 2016 and 2017, including all adult patients patch tested with the baseline series (including MI 0.2% aq.) between 1 May and 31 October at 14 centres in 11 European countries. Patients with positive reactions (+ to +++) to MI were further examined regarding history, clinical characteristics and eliciting products, which were categorized into 34 types and 4 classes (leave-on, rinse-off, household, occupational). The results were compared with the reference year 2015.

RESULTS

A total of 317 patients, n = 202 of 4278 tested in 2016 (4.72%) and n = 115 of 3879 tested in 2017 (2.96%), had positive reactions to MI; the previous result from 2015 was 5.97% (P < 0.0001). The share of currently relevant contact allergy among all positive reactions declined significantly as well (P = 0.0032). Concerning product classes, a relative decline of leave-on and a relative increase of rinse-off and household products was noted.

CONCLUSION

The prevalence of MI contact allergy decreased by 50% from 2015 to 2017. As a consequence of regulation, the share of cosmetics products (leave-on in particular) eliciting allergic contact dermatitis is decreasing. The chosen method of analysing causative products in sensitized patients has proven useful to monitor effects of intervention.

Isothiazolinone derivatives and allergic contact dermatitis: a review and update

Allergic contact dermatitis (ACD) from isothiazolinones has frequently been described in the literature. Following an epidemic of sensitization to methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) in the 1980s, and more recently to MI, the Scientific Committee on Consumer Safety of the European Commission banned their use in leave-on products, while restricting that in rinse-off cosmetics. Despite a decreasing prevalence of ACD from MCI/MI and MI, cases caused by occupational exposure and non-cosmetic isothiazolinone sources are on the rise. Moreover, sensitization to newer and lesser known isothiazolinones has been reported. This paper reviews the epidemiology of contact allergy to different isothiazolinones, clinical presentation of isothiazolinone-induced ACD, most relevant sensitization sources and potential cross-reactions between isothiazolinone derivatives. It also provides an update on recent legislative measures.

A rare presentation of histologically proven sarcoidosis of the knee: A case report and brief review of the literature

We here report a patient with histologically proven sarcoidosis of the knee, a rare localization of sarcoidosis, which usually presents itself as a pulmonary disease. Case reports of radiological images that suggest osseous sarcoidosis of the appendicular skeleton are not so rare, however few are histologically proven. Since in our patient MRI could not distinguish between sarcoidosis and another (possibly malignant) disease, histological proof was obtained through a CT-guided biopsy. Imaging and treatment guidelines for extrapulmonary sarcoidosis are inexistent, due to lack of randomized trials.

Factors associated with combined hand and foot eczema

BACKGROUND

As for hand eczema, the aetiology of foot eczema is multifactorial and not very well understood. The aim of the present study was to identify factors associated with foot eczema in a cohort of hand eczema patients being classified into different subgroups.

METHODS

Associations between foot and hand eczema were studied in a cross-sectional design in a cohort of hand eczema patients. Consecutive patients were recruited from nine different European Centres during the period October 2011-September 2012. Data on demographic factors, presence of foot eczema, hand eczema duration and severity, and whether the hand eczema was work-related or not were available, as well as patch-test results.

RESULTS

Of a total of 427 hand eczema patients identified, information on foot eczema was available in 419 patients who were included in the present study. A total of 125 patients (29.8%) had concomitant foot and hand eczema. It was found more often in association with hyperkeratotic hand eczema (P = 0.007) and was less often associated with irritant hand eczema (P < 0.001). However, foot eczema was nevertheless found in 18% of patient with irritant hand eczema and in 25% of patients with occupational hand eczema. Combined foot and hand eczema was associated with more severe and long-standing hand eczema (P < 0.001 and P = 0.004, respectively). Contact allergy was found in 51.8% with no difference between patients with combined foot and hand eczema and patients with hand eczema only.

CONCLUSION

Occurrence of combined foot and hand eczema is a common finding and not restricted to endogenous hand eczema.

Implementation of a transfusion bundle reduces inappropriate red blood cell transfusions in intensive care - a before and after study

BACKGROUND

Restrictive red blood cell (RBC) transfusion has been widely described in transfusion guidelines. However, compliance with these guidelines is often poor. Therefore, we developed a care bundle for the transfusion of RBCs in intensive care. We investigated the effect of the application of the transfusion bundle on transfusion practice, hypothesising that the implementation of the transfusion bundle would lead to a reduction of inappropriate RBC transfusions.

STUDY DESIGN AND METHODS

We conducted a before and after study between January and December 2014 in a medical-surgical intensive care unit (ICU) of a university hospital in Amsterdam, the Netherlands. The primary outcome was the percentage of appropriate transfusions, referring to those transfusions that were in accordance to the patients' individual preset haemoglobin threshold.

RESULTS

The mean pre-transfusion haemoglobin level was 7·3 g dL^-1 [standard deviation (SD) = 1·15] during baseline and significantly decreased to 7·1 g dL^-1 (SD = 1·04) after transfusion bundle implementation; 95% confidence interval (CI): 0·009-0·308, P-value = 0·04. The number of inappropriate transfusions significantly decreased from 25% (111/439) during baseline to 15% (42/280) during implementation, a difference of 10%; 95% CI: -0·164 to -0·0416, P-value 0·001. This further decreased to 12% (45/370) in the post-implementation phase. A logistic regression analysis showed that the chance to find an appropriate transfusion is approximately twice as high after transfusion bundle implementation.

CONCLUSIONS

Introduction of a transfusion bundle results in a significant reduction of the number of inappropriate RBC transfusions in the medical-surgical ICU. Our results show that the introduction of a transfusion care bundle helps to improve compliance with transfusion guidelines in daily practice.

How successful is TESE-ICSI in couples with non-obstructive azoospermia?

STUDY QUESTION

What are the chances of a couple with infertility due to non-obstructive azoospermia (NOA) having their genetically own child by testicular sperm extraction combined with ICSI (TESE-ICSI)?

SUMMARY ANSWER

Candidate TESE-ICSI patients with NOA should be counselled that, when followed-up longitudinally, only a minority (13.4%) of men embarking for TESE eventually become a biological father.

WHAT IS KNOWN ALREADY

Data available in the literature are only fragmentary because they report either on sperm retrieval rates after TESE or on the outcome of ICSI once testicular spermatozoa has been obtained, mostly in a selected subpopulation. Unfortunately, reliable data to counsel men with NOA on their chance to become a biological father are still lacking.

STUDY DESIGN, SIZE, DURATION

This is a retrospective cohort study performed in the Centre for Reproductive Medicine, University Hospital of Brussel, approved by the institutional review board of the hospital.

PARTICIPANTS/MATERIALS, SETTING AND METHODS

We identified all patients with NOA, based on histology, who had their first testicular biopsy between 1994 and 2009. Patients were followed longitudinally during consecutive ICSI cycles with testicular sperm. The primary outcome measure was live birth delivery. The cumulative live birth delivery rate was calculated, based only on ICSI cycles with testicular sperm (fresh and/or frozen) available for injection. When patients delivered after transfer of supernumerary frozen embryos, this delivery was tallied up to the (unsuccessful) original fresh ICSI cycle. The sperm retrieval rate and pregnancy rate were secondary outcome measures.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the 714 men with NOA, 40.5% had successful sperm retrieval at their first TESE. In total, 261 couples had 444 ICSI cycles and 48 frozen embryo transfer cycles, leading to 129 pregnancies and 96 live birth deliveries. Crude and expected cumulative delivery rates after six ICSI cycles were 37 and 78%.

LIMITATIONS AND REASON FOR CAUTION

A retrospective cohort study design was the only way to study the cumulative delivery rate after TESE-ICSI in couples with NOA. Intrinsic limitations are related to the observational study design.

WIDER IMPLICATION OF THE FINDING

TESE-ICSI is a breakthrough in the treatment of infertility due to NOA, with almost 4 out of 10 (37%) couples having ICSI obtaining a delivery. However, unselected candidate NOA patients should be counselled, before undergoing TESE, that only one out of seven men (13.4%) eventually father their genetically own child.

STUDY FUNDING AND COMPETING INTERESTS

None declared.

Developing 3D SEM in a broad biological context

When electron microscopy (EM) was introduced in the 1930s it gave scientists their first look into the nanoworld of cells. Over the last 80 years EM has vastly increased our understanding of the complex cellular structures that underlie the diverse functions that cells need to maintain life. One drawback that has been difficult to overcome was the inherent lack of volume information, mainly due to the limit on the thickness of sections that could be viewed in a transmission electron microscope (TEM). For many years scientists struggled to achieve three-dimensional (3D) EM using serial section reconstructions, TEM tomography, and scanning EM (SEM) techniques such as freeze-fracture. Although each technique yielded some special information, they required a significant amount of time and specialist expertise to obtain even a very small 3D EM dataset. Almost 20 years ago scientists began to exploit SEMs to image blocks of embedded tissues and perform serial sectioning of these tissues inside the SEM chamber. Using first focused ion beams (FIB) and subsequently robotic ultramicrotomes (serial block-face, SBF-SEM) microscopists were able to collect large volumes of 3D EM information at resolutions that could address many important biological questions, and do so in an efficient manner. We present here some examples of 3D EM taken from the many diverse specimens that have been imaged in our core facility. We propose that the next major step forward will be to efficiently correlate functional information obtained using light microscopy (LM) with 3D EM datasets to more completely investigate the important links between cell structures and their functions.

Jasmonate signalling: a copycat of auxin signalling?

Plant hormones regulate almost all aspects of plant growth and development. The past decade has provided breakthrough discoveries in phytohormone sensing and signal transduction, and highlighted the striking mechanistic similarities between the auxin and jasmonate (JA) signalling pathways. Perception of auxin and JA involves the formation of co-receptor complexes in which hormone-specific E3-ubiquitin ligases of the SKP1-Cullin-F-box protein (SCF) type interact with specific repressor proteins. Across the plant kingdom, the Aux/IAA and the JASMONATE-ZIM DOMAIN (JAZ) proteins correspond to the auxin- and JA-specific repressors, respectively. In the absence of the hormones, these repressors form a complex with transcription factors (TFs) specific for both pathways. They also recruit several proteins, among which the general co-repressor TOPLESS, and thereby prevent the TFs from activating gene expression. The hormone-mediated interaction between the SCF and the repressors targets the latter for 26S proteasome-mediated degradation, which, in turn, releases the TFs to allow modulating hormone-dependent gene expression. In this review, we describe the similarities and differences in the auxin and JA signalling cascades with respect to the protein families and the protein domains involved in the formation of the pathway-specific complexes.

[Lack of compliance to topical corticosteroid therapy: possible cause and solutions]

Adherence to therapy is low for topical therapy used in dermatological disorders. particularly in chronic diseases like atopic dermatitis and psoriasis. One of the reasons is that patients do not trust their therapy and fear side effects, particularly with topical corticosteroids. In order to make patients more confident, it is it important to provide correct and detailed information about the prescribed products and the amount to apply, to involve them in the implementation of therapy and to harmonize the information given by various care providers (physicians, nurses, pharmacists). The message needs to be clear and consistent between caregivers and not lead to unjustified worries. Poor adherence may result in the use of stronger preparations or switch to systemic treatment, which eventually will result in more severe side effects.

Systemic contact dermatitis to corticosteroids

BACKGROUND

Although unexpected and paradoxical, allergic hypersensitivity to corticosteroids is a common finding, delayed-type reactions being much more frequently encountered than the immediate-type ones. Although the skin is the main sensitization and elicitation route, other routes, amongst them systemic administration of corticosteroids may exceptionally be involved.

OBJECTIVE

To determine the frequency, clinical presentation and cross-reactivity patterns for allergic reactions following systemic administration of corticosteroids amongst patients with identified and investigated 'contact allergy' to corticosteroids.

METHODS

We reviewed clinical data, patch test results and sensitization sources in patients who reacted positively to corticosteroids tested in the K.U. Leuven Dermatology department during an 18-year period.

RESULTS

Sixteen subjects (out of 315 with CS delayed-type hypersensitivity) presented with allergic manifestations due to systemic administration of corticosteroids. Most patients reacted to molecules from the three groups of the recently reappraised classification.

CONCLUSION

The reactions observed seem to be in most cases 'systemic contact dermatitis' due to oral or parenteral re-exposure of sensitized individuals with the respective corticosteroids previously applied topically. Moreover, most patients seem to be able to react to any corticosteroid molecules and therefore need a systematic individualized evaluation of their sensitization/tolerance profile.

Spectroscopic Investigation of Lithium Intercalation in Thin Films of Anatase Titanium Dioxide

Thin films of anatase TiO2 have been deposited on tin-doped indium oxide (ITO) and Sb-doped tin oxide using electron beam evaporation. Subsequently these samples have been mounted into an electrochemical cell. Assuming a composition of LixTiO2 with x being 0.5 or 1, voltammetric measurements show that all lithium is present within the first 15 or 7.5 nm of the TiO2 film, respectively. Stepped potential experiments in combination with optical transmission measurements show that de-intercalation is much faster than intercalation. Differential absorption spectra as a function of intercalation potential suggest that the observed dark coloring of intercalated anatase can be attributed to electron traps at Li+ sites. This contradicts assumptions made in literature that the coloring mechanism of anatase is based on intervalence charge transfer from Ti4+ to Ti3+.

New insights about delayed allergic hypersensitivity to corticosteroids

Corticosteroids are among the most commonly used drugs, both topically and systemically. Although unexpected and paradoxical, allergic hypersensitivity to corticosteroids is a common finding, delayed-type reactions being much more frequently encountered than the immediate-type ones. With regard to cross-reactions between corticosteroids, based on patch-test results and molecular modelling, we were recently able to simplify the previous classification into 3 different groups, i.e., Group 1: the non-methylated, most often non-halogenated molecules (Group A, D2 and budesonide), which produce most of the allergic reactions; Group 2: the halogenated molecules with a C16/C17 cis ketal/diol structure (acetonide Group B); and Group 3: the halogenated and C16-methylated molecules (Group C and D1) that only rarely produce allergy.

Corticosteroid cross-reactivity: clinical and molecular modelling tools

BACKGROUND

Corticosteroids have been classified into following four cross-reacting groups in function of their contact-allergenic properties: A, B, C and D, the last subdivided into D1 and D2. Recent data indicate that C(16)-methylated and nonmethylated molecules need to be distinguished, the latter selectively binding with arginine to form stable cyclic adducts and producing considerably more positive reactions than the former. This study compares molecular modelling and patch-test results to determine cross-reactivity patterns.

METHODS

The patch-test results obtained with 66 corticosteroid molecules in 315 previously sensitized subjects were analysed and correlated with modelling and clustering in function of the electrostatic and steric fields of these molecules.

RESULTS

The classification obtained after in silico hydrolysis of C(21) and C(17) esters was selected with an optimal cut into three clusters: the patients who reacted positively to cluster 2 (halogenated molecules from group B, with C(16)/C(17) cis ketal or diol structure) and cluster 3 (halogenated molecules from groups C and D1, C(16)-methylated) also reacted to cluster 1 (molecules mostly from groups A and D2, without C(16)-methyl substitution or halogenation and budesonide). The reverse, however, was not the case.

CONCLUSION

Two patient profiles with probably different areas of immune recognition are identified as follows: the profile 1 patients were allergic to the frequently positively reacting cluster 1 only, for whom electrostatic fields (molecular charge) seem important; the profile 2 patients reacted to clusters 1 and 2 and/or 3, for whom steric fields (structure) are determinant and who probably presented a global recognition of the corticosteroid skeleton. A modified classification is thus proposed.

The relationship between TXS, DBAT, BAPT and DBTNBT gene expression and taxane production during the development of Taxus baccata plantlets

Taxol and related taxane accumulation in plants is regulated by the expression of genes involved in their biosynthesis. Although the metabolic pathway leading to taxol has been almost completely elucidated, comparatively little is known about the rate-limiting steps and their regulation. In this paper we report on a study of taxane production in Taxus baccata plantlets grown in vitro for 1 year. The relationship between taxane patterns and the expression of genes encoding the enzymes taxadiene synthase (TXS), 10-deacetylbaccatin III-10β-O-acetyltransferase (DBAT), baccatin III 13-O-(3-amino-3-phenylpropanoyl) transferase (BAPT) and 3'-N-debenzoyl-2'-deoxytaxol-N-benzoyltransferase (DBTNBT), involved in early and late steps of the taxane pathway, has been considered. A far higher content was found in the aerial part of the plantlets than in the roots. The most abundant taxane in the aerial parts was 10-deacetylbaccatin III, which increased as the plantlets grew, indicating a low conversion to baccatin III and taxol. In contrast, the levels of 10-deacetylbaccatin III in the roots remained lower than those of taxol. These results correlated with transcript accumulation of the studied genes, since in the aerial parts the expression of DBAT, which codes for the enzyme that converts 10-deacetylbaccatin III into baccatin III, did not increase with the age of plantlets, unlike that of TXS, BAPT and DBTNBT, suggesting that this gene controls a rate-limiting step in the taxane biosynthetic pathway. The lower taxane levels found in the roots also correlated with gene expression, since only the early pathway gene TXS was induced in this organ during the 1-year growth period.

Factors influencing long-term adherence to two previously implemented hospital guidelines

OBJECTIVE AND SETTING

After successful implementation, adherence to hospital guidelines should be sustained. Long-term adherence to two hospital guidelines was audited. The overall aim was to explore factors accounting for their long-term adherence or non-adherence.

DESIGN AND PARTICIPANTS

A fluid balance guideline (FBG) and body temperature guideline (BTG) were developed and implemented in our hospital in 2000. Long-term adherence was determined retrospectively based on data from patient files. Focus groups were launched to explore nurses' perceptions of barriers and facilitators regarding long-term adherence. The predominant themes from the nurses' focus groups were posed to clinicians in questionnaires.

RESULTS

Nurses involved in the FBG (overall adherence 100%) stated that adherence has immediate advantages in terms of safety and a gain in time. Nurses and oncologists acted unanimously which was thought to enhance adherence. On the other hand, opinions differed on the BTG within the nursing teams and medical staff (overall adherence 50%). Although the guideline discourages routine postoperative body temperature measurements, temperature should be measured according to the guideline in a considerable number of cases due to changes in patient characteristics since the year 2000. Therefore, adherence was judged to be rather complex.

CONCLUSIONS

To secure adherence to hospital guidelines after their successful implementation, guidelines should preferably be comprehensive in terms of being applicable to the majority of the patients in that particular setting and to the most common clinical situations. All healthcare professionals involved should be aware of its immediate benefits for themselves or to their patients.

Tuberculous arthritis of the finger: a forgotten disease

We present a case of a 64-year-old man from Belgian origin with a chronic painful swelling of the third finger. A chronic arthritis from atypical germ was suspected at the third metacarpo-phalangeal joint on the plain radiography, ultrasonography and MR examination. A few months later, he developed thoracic back pain. Plain radiographs, a Technetium-99m bone scan and MR examination of the thoracic spine revealed a spondylodiscitis of the dorsal spine. A tuberculous origin was found on the biopsy of the affected dorsal vertebral bodies D9 and D10 as suspected on the first imaging examinations of the finger. Besides the patient was found to be HIV-positive. This case shows that it is important to think of musculoskeletal tuberculosis particularly in high-risk persons because if left untreated, it can be devastating.

[Alternatives to patch tests]

Patch testing using standard and specific batteries, as well as the ingredients of products brought in by patients, is still the most reliable way of identifying contact allergens. However, under certain conditions, other methods such as the semi-open test and the repeated open application test (ROAT test) may be more appropriate.

Allergic hypersensitivity to topical and systemic corticosteroids: a review

Corticosteroids, which are potent anti-inflammatory and immunomodulator agents used in the treatment of various inflammatory diseases including allergic diseases, can in some cases produce immediate or delayed hypersensitivity reactions. This review summarizes the epidemiological and clinical characteristics of such reactions, including related diagnostic issues. It also presents a detailed analysis of the proposed immunological mechanisms including underlying cross-reactions.

Hand eczema classification: a cross-sectional, multicentre study of the aetiology and morphology of hand eczema

BACKGROUND

Hand eczema is a long-lasting disease with a high prevalence in the background population. The disease has severe, negative effects on quality of life and sometimes on social status. Epidemiological studies have identified risk factors for onset and prognosis, but treatment of the disease is rarely evidence based, and a classification system for different subdiagnoses of hand eczema is not agreed upon. Randomized controlled trials investigating the treatment of hand eczema are called for. For this, as well as for clinical purposes, a generally accepted classification system for hand eczema is needed.

OBJECTIVES

The present study attempts to characterize subdiagnoses of hand eczema with respect to basic demographics, medical history and morphology.

METHODS

Clinical data from 416 patients with hand eczema from 10 European patch test clinics were assessed.

RESULTS

A classification system for hand eczema is proposed.

CONCLUSIONS

It is suggested that this classification be used in clinical work and in clinical trials.

Strongyloides Stercoralis infection associated with repititive bacterial meningitis and SIADH: a case report

Strongyloidiasis is an infection by the intestinal parasite Strongyloides Stercoralis, which usually stays asymptomatic. In some situations a hyperinfection or disseminated disease can occur. We report a case of a 49-year-old Congolese man with a medical history of 5 episodes of bacterial meningitis, who presents himself with a paralytic ileus and a low serum sodium. A Strongyloides hyperinfection with a syndrome of inappropriate secretion of the antidiuretic hormone (SIADH) was diagnosed. After treatment with ivermectine the abdominal symptoms subsided and the serum sodium returned to normal values. In comparison to other case reports our patient had no respiratory or gastrointestinal symptoms during the episodes of bacterial meningitis. Screening for Strongyloides stercoralis is indicated in patients with unexplained SIADH, bacterial meningitis or bacterial septicaemia, who originally come from endemic countries.

Weekly pegylated interferon alpha-2b vs daily interferon a-2b versus standard regimen of interferon a-2b in the treatment of patients with chronic hepatitis C virus infection

BACKGROUND AND STUDY AIMS

The combination of Pegylated (PEG)interferon alpha-2b and ribavirin is considered to be the standard treatment for naïve chronic hepatitis C patients. Study aims are to evaluate the differences between standard interferon and PEG-interferon by conducting a multi-centre, controlled randomized trial comparing 3 groups. Group A : daily interferon alfa-2b at a dose of 4 MIU + ribavirin, Group B : PEG-interferon alfa-2b at a dose of 100 mcg/week + ribavirin; Group C: interferon alfa-2b at a dose of 3 MIU TIW + ribavirin

PATIENTS AND METHODS

Multicentrer, open label study including naïve chronic Hepatitis C Virus patients randomised in three groups with a ratio of 2:2:1. Group A: daily interferon alpha-2b (4 MIU s.c. for patients > 65 kg or 0.06 MIU/kg < 65 kg) and ribavirin, group B: PEG-interferon alpha-2b (100 microg s.c. weekly for patients > 65 kg or 1.5 microg/kg weekly for patients < 65 kg) and ribavirin and group C (reference arm) : interferon alpha-2b (3MIU s.c. TWI) and ribavirin. The duration of the treatment was 48 weeks for all 3 groups, with a 6 month follow-up period. 336 patients were enrolled in the study and included in the intention-to-treat analysis; 78 never started treatment (35 in group A, 28 in group B and 15 in group C): 101 in group A, 98 in group B and 59 in group C.

RESULTS

Demographic data, PCR results and reasons for early withdrawal have been statistically analysed. At baseline, the 3 groups did not show any statistical difference regarding age, gender, race, genotypes and METAVIR score. At week 24 on treatment, HCV ribonucleic acid RNA was undetectable in 87% in group A, in 79% in group B and in 69% in group C. At the end of treatment, 73% 74% and 58% respectively, had a negative PCR result. At week 24 of follow-up, these results were 71%, 64% and 48%, respectively. When comparing the efficacy of the daily interferon (+ ribavirin) and the PEG-interferon (+ ribavirin) regimen, no statistical difference was found (p = 0.32). In group A, 38% of drop-outs were due to adverse events compared to 37% in group B and 58% in group C. No statistical differences were observed regarding safety.

CONCLUSION

Daily weight based interferon alpha-2b dosing and PEG interferon alpha-2b weighed based dosing once weekly both in combination with Ribavirin offer the same efficacy and safety rates.

Prophylactic gastrostomy placement and early tube feeding may limit loss of weight during chemoradiotherapy for advanced head and neck cancer, a preliminary study

OBJECTIVES

Most patients with advanced head and neck cancer receiving chemoradiotherapy need tube feeding for at least some weeks. For these periods gastrostomy tubes have advantages over nasogastric tubes. Tube feeding may start earlier and thus loss of weight may be limited if the gastrostomy tube already is in place. The objective of this study is to analyse the results of prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement and early tube feeding.

DESIGN

Retrospective chart review.

SETTING

Multidisciplinary head and neck oncology team in a general hospital.

PARTICIPANTS

Fifty consecutive patients with unresectable stage III and IV head and neck cancer treated with concurrent chemoradiotherapy. In all patients prophylactic PEG placement was performed. Tube feeding was initiated if food-intake became insufficient or loss of weight occurred.

MAIN OUTCOME MEASURES

Loss of weight during treatment, complication rate, PEG duration.

RESULTS

The mean loss of weight during treatment for all patients was only 2.8%. One complication of tube placement occurred: a colon perforation, treated successfully by surgery. The median duration of the PEG was 178 days. Three of the 17 patients (18%) with no evidence of disease (NED) still had a PEG at their last follow-up visit. Of the 26 patients who died of their cancer, 13 used the PEG until death.

CONCLUSIONS

Loss of weight was limited after prophylactic gastrostomy placement and early tube feeding. Moreover, the complication rate was low. In 82% of the NED patients the PEG could eventually be removed.

An unusual case of cat-scratch disease of the knee: case report and differential diagnosis

We present a case of a 16-year-old boy with a painful swelling in the popliteal fossa, slight fever, articular and muscle pain of 3 weeks duration. Plain radiography and MR examination were performed in order to characterize the lesion. Additionally to the poorly defined mass, 2 satellite nodules were shown. Subsequent biopsy revealed a granulomatous process and 2 satellite lymphadenopathies highly suggestive of cat-scratch disease. This case shows that the differential diagnosis of a soft tissue mass of the knee should not only include tumoral processes or pseudotumoral lesions, but also granulomas from infectious or non-infectious origin. Knowledge of the patients contact with cats and the detection of skin scratches is usually the clue to the correct diagnosis.