Pneumocystis carinii pneumonia in HIV negative patients with primary brain tumors

Background: Pneumocystis carinii pneumonia (PCP) is an opportunistic infection with rather adverse outcomes. An unexpected increase in cases of PCP was noted in the brain tumor population at the Johns Hopkins Hospital (JHH) in 2000. This prompted the present review of the clinical features and risk factors for PCP in the human immunodeficiency virus (HIV) negative brain tumor population. Methods: The study was located at the JHH. A retrospective review of medical records was done to identify patients with discharge diagnosis of PCP from 1980 to 2001. Patients who were HIV positive were excluded. A detailed analysis was done of patients with brain tumors. Results: From 1980 to 2001, 468 cases of PCP were identified, diagnosed histologically or clinically, of which 110 were patients with an underlying malignancy. Of the 110 cases 15 were seen in the brain tumor population. Of these, 6 patients were seen in 2000 and one in early 2001. Three of these had primary central nervous system (CNS) lymphoma (PCNSL) on high dose methotrexate. Eight of the fifteen episodes (53.3%) were fatal despite institution of antibiotics and supportive therapy. Conclusion: The incidence and mortality due to Pneumocystis carinii among the brain tumor population is increasing. While corticosteroids are known immunosupressants, prescribing patterns for these medications has not changed lately. However, high dose methotrexate is now being used in PCNSL and could be a complicating factor. Since effective prophylaxis exists, it should be considered in patients with brain tumors receiving high dose steroids, high dose methotrexate or with lymphopenia.     

The modified Palmer lateral approach for calcaneal fractures: wound healing and postoperative computed tomographic evaluation of fracture reduction

In 32 consecutive intra-articular calcaneal fractures (28 patients, 4 bilateral), open treatment was done using the modified Palmer lateral approach and the reduction was assessed with postoperative radiography and computed tomography (CT) (coronal and axial images, 1-2 days after surgery). Retrospective analysis of the available radiographs and CT scans was done in 27 fractures (25 patients, 2 bilateral) to assess accuracy of reduction achieved; in five fractures the studies were not available. Sanders classification was type I in 2 (7%), type II in 20 (74%), and type III in 5 (19%) fractures; the calcaneocuboid joint was involved in 9 (33%) fractures. Reduction included elevation of the depressed lateral side of the posterior facet, reduction of the neck (anterior third of calcaneus) to the body (middle third of calcaneus), realignment of the posterior tuberosity, and reduction of lateral wall blowout; internal fixation was done with cannulated screws. Mean (+/-SD) values of the following displacement parameters were significantly improved after surgery: B?hler's angle, posterior facet angle, lateral posterior facet articular depression, heel width (coronal CT), and calcaneal height. There was no significant difference between preoperative and postoperative values of mean angle of Gissane, posterior tuberosity position, and body width and length on axial CT. One (3%) of the 32 fractures was associated with preoperative (traumatic) full-thickness skin necrosis at the sinus tarsi that required free muscle flap coverage. One (3%) postoperative wound healing complication occurred, consisting of wound dehiscence and drainage at the central portion of the surgical wound in a smoker, which resolved with dressing changes and antibiotics. In conclusion, the modified Palmer lateral approach enabled open reduction of major features of calcaneal fractures with less soft-tissue risk than more extensile approaches.     

Carcinoma urinary bladder presenting as acute abdomen

Bladder perforation presenting as acute peritonitis is a rare and dramatic event in the course of carcinoma urinary bladder. We present one such case and discuss the presentation, management and brief follow-up.     

Binding of Imipramine,Dosulepin, and Opipramol to Liposomes for Overdose Treatment

Polymer shielded liposomes were investigated as detoxifying agents for the weak bases imipramine and dosulepin and the diprotic drug opipramol. In vitro binding measurements in the presence of human serum samples revealed that the liposomes reduced the free drug concentration of the weak bases (corrected for protein binding) by 88–93%. The reduction for opipramol was around 76%. The results demonstrate that polymer shielded liposomes composed of anionic lipids are widely useful for drug overdose treatment. Polyethylene glycol chain lengths of 2000 and 5000 for the polymer coatings were also explored, and chain length showed no evidence of affecting drug uptake by liposomes. Liposomes compete favorably with other binding targets for drugs, and pharmacokinetic considerations suggest that liposomes could reduce toxicity by transporting drugs from fast-equilibrating organs such as the heart to slow-equilibrating organs such as the fat, muscle, and skin. © 2009 Wiley-Liss, Inc. and the American Pharmacists Association J Pharm Sci 98:3718–3729, 2009     

Hepatic Artery Resection for Bismuth Type III and IV Hilar Cholangiocarcinoma: Is Reconstruction Always Required?

Objective

The objective of the study is to examine the feasibility of hepatic artery resection (HAR) without subsequent reconstruction (RCS) in specified patients of Bismuth type III and IV hilar cholangiocarcinoma.

Methods

We retrospectively reviewed 63 patients who underwent hepatic artery resection for Bismuth type III and IV hilar cholangiocarcinoma. These patients were subsequently enrolled into two groups based on whether the artery reconstruction was conducted. Postoperative morbidity and mortality, and long-term survival outcome were compared between the two groups.

Results

There were 29 patients in HAR group and 34 patients in the HAR + RCS group. Patients with hepatic artery reconstruction tended to have longer operative time (545.6?±?143.1 min vs. 656.3?±?192.8 min; P?=?0.013) and smaller tumor size (3.0?±?1.1 cm vs. 2.5?±?0.9 cm; P?=?0.036). The R0 resection margin was comparable between the HAR group and HAR?+?RCS group (86.2 vs. 85.3%; P?>?0.05). Twelve patients (41.4%) with 24 complications in HAR group and 13 patients (38.2%) with 25 complications in HAR?+?RCS group were recorded (P?=?0.799). The postoperative hepatic failure rate (13.8 vs. 5.9%) and postoperative mortality rate (3.4% vs. 2.9%) were also comparable between the two groups. In the HAR group, the overall 1-, 3-, and 5-year survival rates were 72, 41, and 19%, respectively; while in the HAR?+?RCS group, the overall 1-, 3-, and 5-year survival rates were 79, 45, and 25%, respectively (P?=?0.928).

Conclusions

Hepatic artery resection without reconstruction is also a safe and feasible surgical procedure for highly selected cases of Bismuth type III and IV hilar cholangiocarcinoma.