Combination therapy with pulsed methylprednisolone in rheumatoid arthritis.

Pulsed methylprednisolone (PMP) has been shown to produce clinical improvement and reduction in the ESR and acute phase protein concentrations in patients with active rheumatoid arthritis and has been advocated for use either as an alternative to slow-acting antirheumatoid drugs (SAARDs) or in conjunction with SAARDs to accelerate the response to treatment. To test these potential roles for PMP 45 patients with active RA were randomly allocated to treatment with PMP alone, PMP + sulphasalazine (SAS - at a maintenance dose of 2.0 g/day), or PMP + D-penicillamine (DPA - at a maintenance dose of 500 mg/day). In each case three 1 g intravenous infusions were given on alternate days during the first week of the trial. Patients were monitored for 24 weeks by standard clinical and laboratory measurements. All three treatment groups showed significant clinical and laboratory improvements at two weeks. With PMP + DPA and PMP + SAS these improvements were sustained and were not significantly different in these two treatment groups. However, in the 'PMP only' group ESR and CRP rose to pretreatment values by eight weeks. Twelve patients withdrew from the study owing to a relapse of the RA. No serious adverse effects were seen in the 'PMP only' group. Both combination regimens were well tolerated; adverse effects seen were attributable to either DPA or SAS. We conclude that PMP alone is insufficient for treatment of RA but can be used successfully in combination with either DPA or SAS. A comparison between these results obtained from two previous groups of 15 patients treated with DPA alone and SAS alone (using the same study design) shows that PMP accelerated the response to therapy by at least six weeks.     

Antibody seronegative human T-lymphotropic virus type III (HTLV-III)- infected patients with acquired immunodeficiency syndrome or related disorders

The human T-lymphotropic virus type III (HTLV-III) is the primary cause of the acquired immunodeficiency syndrome (AIDS) and related disorders (ARC). Prior studies have reported that nearly all symptomatic patients with AIDS or ARC manifest antibody to HTLV-III. This observation has engendered efforts to screen for HTLV-III, especially prior to blood donation, with assays for antibody to HTLV-III. We report the first two cases, one with AIDS and one with ARC, that are HTLV-III virus positive but antibody negative. Accurate diagnosis of HTLV-III infection in some cases may require direct virus culture or tests for antigen. In addition, lack of HTLV-III antibody may indicate an atypical clinical course of AIDS.     

Rapid transient induction of phenylalanine ammonia-lyase mRNA in elicitor-treated bean cells

DNAs complementary to a size-selected fraction of poly(A)⁺ RNA present in elicitor-treated cells of bean (Phaseolus vulgaris L.) were inserted into pAT153 and used to transform Escherichia coli strain C600. Five clones were identified by hybrid-selected translation and cross-hybridization that contained sequences complementary to mRNA encoding phenylalanine ammonia-lyase (EC 4.3.1.5), which catalyzes the first reaction of phenylpropanoid biosynthesis. The longest insert contained a single open reading frame of 1520 base pairs together with 223 base pairs of 3′ untranslated sequence. RNA blot hybridization showed that elicitor caused a rapid, marked but transient increase in phenylalanine ammonia-lyase mRNA that was closely correlated with changes in translatable mRNA activity in vitro and enzyme synthesis in vivo. Blot hybridization of newly synthesized mRNA purified by organomercurial affinity chromatography following in vivo pulse-labeling with 4-thiouridine indicates that elicitor caused a rapid stimulation of phenylalanine ammonia-lyase mRNA synthesis as an early in the defense response leading to accumulation of phenylpropanoid-derived phytoalexins.     

The process and outcomes of a nurse-led colorectal cancer follow-up clinic

Aim Evidence suggests that follow‐up after colorectal cancer improves survival. Colorectal cancer is so common that patient follow‐up can overwhelm a service, affecting the ability to see new referrals and reassess patients seen previously who have new symptoms. In order to cope with this demand a nurse‐led follow‐up service was started in 2004. We aimed to review the results of a nurse‐led colorectal cancer follow‐up clinic. Method Between 1 December 2004 and 31 January 2011, patients who underwent resection for colorectal cancer were followed up by a nurse specialist according to a protocol determined by the colorectal surgeons in the unit. All patient details were recorded prospectively in a purpose designed database. Results Nine hundred and fifty patients were followed up over 7 years. Some 368 patients were discharged from the follow‐up programme, 474 patients remain actively involved in the programme and 108 patients died. Of the patients discharged from the follow‐up scheme 269 (73%) were discharged to their general practitioner free of disease after 5 years. Of the 108 who patients died, 98 were as a result of colorectal cancer. Twenty patients (2.1%) were identified with local (peri‐anastomotic) disease recurrence and 93 patients (9.8%) were found to have developed distant metastatic disease. Of these, 65 patients (6.8%) were referred for palliative care and 28 (2.9%) had surgery for focal metastatic disease of whom 18 were still alive at the time of this analysis. Conclusion This paper shows that a nurse‐led clinic for colorectal cancer follow‐up can achieve satisfactory results with detection rates of recurrent or metastatic disease comparable to consultant follow‐up. A nurse‐led clinic provides the benefits of follow‐up without overwhelming the consultant colorectal surgical clinic practice.     

Short‐term outcome following elective laparoscopic colorectal cancer resection in octogenarians and nonagenarians

Aim The 30‐day outcome after laparoscopic resection for cancer in patients over the age of 80 years was studied. Method An electronic database was used to identify patients over 80 years who underwent laparoscopic bowel resection between December 2000 and October 2009 at three UK laparoscopic colorectal training units. Patients who required abdominoperineal excision of the rectum were excluded. Results In all, 173 patients (80 men) of median age 84 (80–93) years were identified. American Society of Anesthesiologists (ASA) grades were ASA 1, 14; ASA 2, 87; ASA 3, 68; and ASA 4, 4. Median body mass index was 26 (14–45) kg/m². Thirteen (7.5%) patients were converted to open surgery. The major causes for conversion were bleeding and adhesions. Thirty‐three major complications occurred in 21 (12%) patients. Ten (5.8%) required readmission after discharge for complications giving a total of 17.8% of patients with complications. The median hospital stay was 5 (1–37) days. Three (1.7%) patients died within 30 days of surgery. Conclusion This study confirms that laparoscopic large bowel resection is safe and beneficial in a population over 80 years. It has low morbidity and mortality and a shortened hospital stay. Octogenarians should not be denied major laparoscopic bowel surgery based on age alone.     

Reconstruction with Vertical Rectus Abdominus Myocutaneous flap in advanced pelvic malignancy

Pelvic extenuative surgery produces good long term outcomes in advanced pelvic malignancies. We evaluate the use and clinical outcomes of the Vertical Rectus Abdominus Myocutaenous (VRAM) flap as a reconstruction technique in a heterogenic cohort of patients with advanced colorectal cancer in whom neo-adjuvant chemo-radiotherapy had been performed pre-operatively. Analysis of patients having VRAM flaps for pelvic reconstruction in a tertiary referral centre from 2001 to 2010 was conducted. 37 patients (23 female, 14 male) underwent pelvic extenuative surgery of which 22 (60%) had recurrent pelvic disease. All surgical and medical complications were analysed. Major flap complications were defined as 'requiring return to the operating theatre at any stage' and these occurred in 6 (16%) patients. There were 7 (19%) minor flap complications defined as 'requiring conservative non surgical treatment' The total global re-intervention rate of patients requiring return to theatre for re-operation as a result of their exenteration and reconstruction was 6 (16%). We highlight the merits and versatility of the VRAM flap in advanced pelvic malignancy in obtaining stable and supple reconstructive cover and the relative low morbidity in this difficult group confirms out strong support for immediate VRAM reconstruction in pelvic exenterative procedures.     

The incidence of cement extrusion from the acetabulum in total hip arthroplasty

Acetabular cement extrusion (CE) is a common finding after total hip arthroplasty, but the incidence is unclear from the literature, and there is no accepted way of measuring it. We report a retrospective observational study of 100 patients (25 consecutive patients from each of 4 consultants, 112 hips) to determine the site and incidence of CE on postoperative radiographs, and to measure its area and the maximum distance of the extruded cement from the edge of the cement mantle. We found that 50 of 112 (44.6%) hips showed evidence of CE, with a 15.2% incidence of CE > 200 mm(2).     

Prospective, Randomized, Multi-Center Trial of Antibody Induction Therapy in Simultaneous Pancreas-Kidney Transplantation

A randomized, multicenter, prospective study was conducted at 18 pancreas transplant centers in the United States to determine the role of induction therapy in simultaneous pancreas-kidney (SPK) transplantation. One hundred and 74 recipients were enrolled: 87 recipients each in the induction and noninduction treatment arms. Maintenance immunosuppression consisted of tacrolimus, mycophenolate mofetil, and corticosteroids. There were no statistically significant differences between treatment groups for patient, kidney, and pancreas graft survival at 1-year. The 1-year cumulative incidence of any treated biopsy-confirmed or presumptive rejection episodes (kidney or pancreas) in the induction and noninduction treatment arms was 24.6% and 31.2% (p = 0.28), respectively. The 1-year cumulative incidence of biopsy-confirmed, treated, acute kidney allograft rejection in the induction and noninduction treatment arms was 13.1% and 23.0% (p = 0.08), respectively. Biopsy-confirmed kidney allograft rejection occurred later post-transplant and appeared to be less severe among recipients that received induction therapy. The highest rate of Cytomegalovirus (CMV) viremia/syndrome was observed in the subgroup of recipients who received T-cell depleting antibody induction and received organs from CMV serologically positive donors. Decisions regarding the routine use of induction therapy in SPK transplantation must take into consideration its differential effects on risk of rejection and infection.