A decision analysis approach to the treatment of patients with suspected pulmonary emboli and an intermediate probability lung scan

There remains no clear consensus as to the appropriate further investigation and management of the patient suspected of pulmonary embolism (PE) who has an intermediate lung scan. Clinical assessment is documented as unreliable, yet many of these patients are unlikely to be treated or to have further tests despite a 36% chance of having PE. Using Medical Decision Analysis, four management strategies for such patients have been examined in terms of mortality and morbidity up to 6 mo post-presentation. The strategies were: (1) treat all patients; (2) treat no patients; (3) perform pulmonary angiography; and (4) perform contrast venography. In the last two strategies, the patients with positive examinations are treated; those with negative examinations are not treated. An extensive literature review was performed to provide probability estimates of chance events and outcomes. If all patients are treated, there is 96.8% chance of survival, with an 85.8% chance of survival with no major complications. If no patients are treated, survival is 89.3% and complication-free survival is 89.3%. Angiography and venography results were 96.7%, 93.1% and 94.6% and 89.6%, respectively. We conclude that in patients suspected of PE who have intermediate lung scan results, the optimal strategy is pulmonary angiography since this results in the highest survival with the lowest complications.     

Differential expression of hZnT-4 in human prostate tissues

BACKGROUND: Altered zinc levels in prostate benign prostatic hyperplasia (BPH) and carcinoma is well documented. It is not known whether loss of zinc, necessary to restrain aggressive growth, results from loss of a single specific or multiple zinc transporters. METHODS: Human prostate tissues from patients who underwent radical prostatectomy were screened by RT-PCR analysis for five zinc transporters. Relative cDNA expression was determined in normal, BPH, and tumor specimens and four prostate epithelial cell lines. RESULTS: Surgical specimens were obtained from patients with assigned Gleason scores ranging from 5 to 9. Relative expression of hZIP-1 and hZnT-1 were prominent in most samples with relatively lesser degree of expression of hZIP-2 and no detectable expression of hZnT-3. Expression of hZnT-4 was decreased in BPH and tumor samples compared to normal tissue. CONCLUSIONS: These data suggest that zinc homeostasis in normal prostate tissues results from an interplay of multiple transporters and decreased hZnT-4 expression is associated with prostate tissue abnormalities independent of total cellular zinc content.     

Classical pathway complement destruction is not responsible for the loss of human erythrocytes during porcine liver perfusion

BACKGROUND: Porcine livers perfused with human blood destroy 85% of human erythrocytes (red blood cells [RBC]) during prolonged extracorporeal perfusion, raising the possibility of a complement-mediated graft-versus-host effect. METHODS: Isolated porcine livers were perfused with fresh human blood. Plasma samples were analyzed for complement production by reverse CH50 analysis and porcine immunoglobulin class and specificity by enzyme-linked immunosorbent assay (ELISA) and flow cytometry. Anti-CD59 and anti-decay accelerating factor (DAF) monoclonal antibody were used to investigate whether human complement regulatory proteins inhibit porcine complement. RESULTS: After 64 hr of perfusion of porcine livers with human blood, mean complement activity in the perfusate was 95% of the starting value and increasing, whereas perfusion in the absence of a liver showed a falling complement activity of 28.7%. ELISA demonstrated porcine immunoglobulin (Ig) G and IgM in the xenoperfused human plasma. Whereas in a previous study flow cytometry demonstrated porcine antibodies specific for antigens on human T lymphocytes, in this study, anti-human RBC antibodies were not found. Xenoperfused human plasma did not lyse fresh human RBC. Human complement was consistently more efficient at lysing porcine RBC than was porcine complement at lysing human RBC, and human plasma inhibited the ability of porcine plasma to lyse human RBC, raising the possibility of cross-species complement regulation. Complement regulatory proteins on human RBC were blocked using mouse monoclonal anti-human CD59 and DAF. Blocking CD59, but not DAF, augmented lysis of human RBC by porcine complement. CONCLUSIONS: Human CD59 inhibits porcine complement. The production of porcine complement from xenoperfused porcine livers is unlikely to result in clinically significant injury mediated through the classical pathway of complement activation.     

Mesenchymal stem cell transplantation to promote bone healing

An overall decline in the availability of osteogenic precursor cells and growth factors in the bone marrow microenvironment have been associated with impaired bone formation and osteopenia in humans. The objective of the current study was to determine if transplantation of mesenchymal stromal cells (MSC) from a healthy, young donor mouse into an osteopenic recipient mouse could enhance osseointegration of a femoral implant. MSC harvested from normal young adult mice differentiated into bone forming osteoblasts when cultured on implant grade titanium surfaces ex vivo and promoted bone formation around titanium-coated rods implanted in the femoral canal of osteopenic recipient mice. Micro computed tomographic imaging and histological analyses showed more, better quality, bone in the femur that received the MSC transplant compared with the contra-lateral control femur that received carrier alone. These results provide pre-clinical evidence that MSC transplantation promotes peri-implant bone regeneration and suggest the approach could be used in a clinical setting to enhance bone regeneration and healing in patients with poor quality bone.     

Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis

BACKGROUND: Necrotizing fasciitis (NF) is an uncommon but serious infection of fascia and skin associated with considerable morbidity and mortality. One modality proposed for improving the outcome of this condition is hyperbaric oxygen (HBO) therapy. This is a form of medical treatment that involves intermittent inhalation of 100% oxygen under pressures exceeding the atmosphere. The aim of this article is to review current practice and evidence for the use of HBO as adjunctive therapy in the management of NF. METHODS: A survey of published English literature through searches of Medline and PubMed was carried out using the following key words: "necrotizing fasciitis," "Fournier's gangrene," "necrotizing soft tissue infections," "hyperbaric oxygen therapy," "and hyperbaric oxygen chambers." RESULTS: The results of studies on the use of HBO therapy in NF are inconsistent. Some studies have demonstrated that HBO can improve patient survival and decrease the number of debridements required to achieve wound control, whereas others have failed to show any beneficial effect. CONCLUSIONS: Encouraging results have been achieved with the addition of HBO therapy to standard treatment regimes, thus justifying further research in this field. More robust evidence by way of a prospective randomized trial is necessary before widespread and routine use of HBO in the management of NF can be recommended.     

The Effectiveness of Eye Movement Desensitization and Reprocessing Therapy to Treat Symptoms Following Trauma in Timor Leste

The effectiveness of eye movement desensitization and reprocessing (EMDR) therapy for treating trauma symptoms was examined in a postwar/conflict, developing nation, Timor Leste. Participants were 21 Timorese adults with symptoms of posttraumatic stress disorder (PTSD), assessed as those who scored ≥2 on the Harvard Trauma Questionnaire (HTQ). Participants were treated with EMDR therapy. Depression and anxiety symptoms were assessed using the Hopkins Symptom Checklist. Symptom changes post‐EMDR treatment were compared to a stabilization control intervention period in which participants served as their own waitlist control. Sessions were 60–90 mins. The average number of sessions was 4.15 (SD = 2.06). Despite difficulties providing treatment cross‐culturally (i.e., language barriers), EMDR therapy was followed by significant and large reductions in trauma symptoms (Cohen's d = 2.48), depression (d = 2.09), and anxiety (d = 1.77). At posttreatment, 20 (95.2%) participants scored below the HTQ PTSD cutoff of 2. Reliable reductions in trauma symptoms were reported by 18 participants (85.7%) posttreatment and 16 (76.2%) at 3‐month follow‐up. Symptoms did not improve during the control period. Findings support the use of EMDR therapy for treatment of adults with PTSD in a cross‐cultural, postwar/conflict setting, and suggest that structured trauma treatments can be applied in Timor Leste.     

Avid thallium-201 uptake in hepatic carcinoid metastases

While radiolabelled somatostatin analogues sensitively detect extrahepatic carcinoid tumour, intrahepatic metastases are frequently not visualised due to somatostatin accumulation in normal hepatic tissues. We report a case of avid thallium-201 uptake in multiple hepatic carcinoid metastases using single-photon emission tomography (SPET) and compare this to a SPET technetium-99m sulphur colloid scan in the same patient. The ^99mTc sulphur colloid images demonstrate multiple focal defects at the site of known metastases in the hepatic right lobe (confirmed on both CT and surgery). However, there is avid uptake of thallium in the metastases on comparative SPET slices. ²⁰¹Tl may be a useful agent for the detection and localisation of carcinoid tumour and in particular of intrahepatic carcinoid metastases. Correspondence to: R.J. Quinn     

Rare case of metastatic prostate adenocarcinoma to the pituitary

We report a rare case of metastatic prostate adenocarcinoma to the pituitary gland. The patient had lung and bone metastases when he presented with bitemporal hemianopsia. He was also receiving total androgen blockade at that time. Magnetic resonance imaging showed an intrasellar mass, and biopsy confirmed metastatic prostate cancer. Radiotherapy, in the form of intensity-modulated radiotherapy, was delivered to the intrasellar mass. The patient responded well to radiotherapy. The mechanisms of spread to the pituitary gland and treatment options, including intensity-modulated radiotherapy, are discussed.