Patients with acute pulmonary embolism should have an echocardiogram to guide treatment decisions

A 62-year-old man with a past medical history notable for hypertension, osteoarthritis, and calf deep vein thrombosis at age 55 following a total hip arthroplasty presents to the emergency department with acute-onset dyspnea and right-sided pleuritic chest pains. His medications consist of a calcium channel blocker and a COX-2 inhibitor. Pretest clinical suspicion for pulmonary embolism (PE) is high. Ventilation and perfusion lung scintigraphy are interpreted as being high-probability for PE. The nurse asks if a stat transthoracic echocardiogram should be ordered.     

Prolonged severe 5-fluorouracil-associated neurotoxicity in a patient with dihydropyrimidine dehydrogenase deficiency

5-Fluorouracil (5-FU) is an analogue of pyrimidine nucleosides that is widely used in the treatment of head and neck, breast, ovarian, and colon cancer. Stomatitis, diarrhea, dermatitis, and myelosuppression are the main toxicities of 5-FU. A less frequent side effect that is becoming more recognized is neurologic toxicity. Dihydropyrimidine dehydrogenase (DPD) is the rate-limiting enzyme in the catabolism of 5-FU. DPD deficiency follows an autosomal recessive pattern of inheritance, and its prevalence is estimated to be 3%. Cancer patients who are receiving 5-FU treatment and are DPD deficient can develop severe side effects. The neurologic toxicity can vary from being mild to severe and prolonged. We describe the side effects of 5-FU in a colon cancer patient who suffered severe mucositis, desquamating dermatitis, prolonged myelosuppression, and neurologic toxicity that required admission to the intensive care unit. The patient remained hospitalized for 3 months. Recovery from the side effects was complete 4 months after the last 5-FU treatment. Subsequent testing revealed that this patient has an extremely low level of DPD activity (0.015 nmol/min/mg protein; mean, 0.189 nmol/min/mg protein). Because neurologic toxicity is becoming more recognized and DPD affects the catabolism of 5-FU, we discuss management issues and the use of new DPD inhibitors. We also discuss whether screening for DPD deficiency is warranted to identify patients at risk for severe toxicities from 5-FU treatment.     

Clofazimin in the treatment of scleroma

Scleroma is a chronic progressive granulomatous disease predominantly affecting the mucous membrane of the upper respiratory tract, endemic in temperate and tropical zone countries including Egypt. Many patients in early stages respond to medical treatment while others do not. In these patients an antileprotic agent Clofazimin (Lamprene) was tried in 76 patients and the therapeutic results are very promising, especially for the early stages of the disease.     

A robust sliding mode controller with internal model for closed-loop artificial pancreas

The study presents a robust closed-loop sliding mode controller with internal model for blood glucose control in type-1 diabetes. Type-1 diabetic patients depend on external insulin delivery to keep their blood glucose within near-normal ranges. Closed-loop artificial pancreas is developed to help avoid dangerous, potentially life-threatening hypoglycemia, as well as to prevent complication-inducing hyperglycemia. The proposed controller is designed using a combination of sliding mode and internal model control techniques. To enhance postprandial performance, a feedforward controller is added to inject insulin bolus. Simulation studies have been performed to test the controller, which revealed that the proposed control strategy is able to control the blood glucose well within the safe limits in the presence of meals and measurements errors. The controller shows acceptable robustness against changes in insulin sensitivity, model–patient mismatch, and errors in estimating meal’s contents.     

Regional adjuvant irradiation for adenocarcinoma of the cecum

Forty patients with adenocarcinoma of the cecum who underwent right hemicolectomy received regional irradiation for 40-45 Gy/4-5 weeks and weekly 5-Fluorouracil (5-FU). Thirty-four patients received this adjuvant therapy: 12, 10, 5, 4 with Stage B2, B3, C2, C3, respectively, and 3 with abdominal metastasis. Another six patients were similarly treated for palliation because of tumor bed recurrences. Patients were followed for a median of 4 years, 21/31 patients in the adjuvant group with Stage B and C were free of disease with a median survival of 48 months (63% 5-year actuarial disease-free survival). The total local failure rate among the adjuvant group for Stage B and C was 4/31 (13%) with local failure alone occurring in 1 of 4 patients (3%). In the patients treated at our Hospital, there was significant improvement in the 5-year actuarial survival (p = 0.001) for patients with lymph node metastases who received adjuvant irradiation compared to surgery-alone. Acute radiation enteritis occurred in seven out of 40 patients (17.5%) and was severe in 2 (5%). There were no delayed complications. We conclude that adjuvant therapy markedly lowered regional recurrence and seems to improve survival in patients with lymph node metastasis when compared to a group of patients treated by surgery alone in the same institution.     

Direkter Nachweis von Zytomegalievirus in koronaren Atheromen von Patienten mit fortgeschrittener koronarer Herzerkrankung

Zusammenfassung Hintergrund und Ziel: Experimentelle und klinische Studien weisen auf einen möglichen Zusammenhang zwischen dem Zytomegalievirus und der koronaren Herzerkrankung hin. Es war Ziel dieser Studie, mit Hilfe hochsensitiver molekularbiologischer Methoden in seriellen Analysen die Prävalenz von Zytomegalievirusgenom in koronaren Atheromen zu bestimmen sowie eine Assoziation zwischen dem Erregernachweis in koronaren Atheromen, der Läsionsmorphologie und dem klinischen Erscheinungsbild der Patienten herzustellen. Patienten und Methoden: Bei 53 Patienten mit koronarer Herzerkrankung wurde im Rahmen einer aortokoronaren Bypassoperation eine koronare Thrombendatherektomie durchgeführt. Von jedem Atherom wurden zwei Stellen zur molekularbiologischen Analyse verwendet. Ergebnis: Es konnte bei bis zu 30% der untersuchten Patienten mit schwerer koronarer Herzerkrankung Zytomegalievirus-DNA in koronaren Atheromen nachgewiesen werden. Das Verteilungsmuster der Zytomegalievirus in den Läsionen war inhomogen. Schlussfolgerung: Durch den höheren Anteil an Sekundärläsionen sowie den geringeren Kalzifizierungsgrad zytomegalieviruspositiver Atherome wird die Hypothese einer Mitbeteiligung des Zytomegalievirus an Restenosemechanismen unterstützt. Der Einsatz antiviraler Substanzen zur Behandlung der Atherosklerose oder zur Prävention der Restenose ist aufgrund der bestehenden Daten jedoch nicht gerechtfertigt. Abstract Background and Aim: Experimental and clinical data support an infectious cause of atherosclerosis and thereby coronary artery disease. This study was intended to assess the prevalence and possible clinical associations of the presence of cytomegalovirus DNA within coronary samples from patients undergoing coronary artery bypass grafting. Patients and Methods: A coronary thrombendatherectomy was performed in 53 patients with advanced coronary artery disease. Two samples of each atheroma were used for further analysis and pathogen detection. Result: In 30% of patients with advanced coronary artery disease cytomegalovirus DNA was detected in coronary samples as assessed by highly sensitive PCR methods. The occurrence of the virus within the vessels was characterized by an inhomogeneous distribution pattern. Conclusion: Due to an increased proportion of restenotic lesions and a higher degree of calcification in cytomegalovirus-positive lesions, a causative association between the virus presnece and mechanisms of restenosis post angioplasty is further supported. Antiviral pharmacological interventions to prevent restenosis in high-risk patients, however, seem not to be justified by the data currently available.