Clinical value of tumour markers and serum-ascites albumin gradient in the diagnosis of malignancy-related ascites

Abstract To determine the clinical value of tumour markers in the diagnosis of malignancy-related ascites (not including hepatocellular carcinoma), serum and ascitic fluid levels of carcinoembryonic antigen, cancer antigen 125, carbohydrate antigen 19–9, tissue polypeptide antigen and serum-ascites albumin gradient were determined in 66 patients with cirrhotic ascites, 28 patients with hepatocellular carcinoma and ascites, and 29 patients with malignancy-related ascites. Three tumour markers and serum-ascites albumin gradient showed significant difference between patients with malignancy-related ascites and those without: serum carcinoembryonic antigen (26.4 ± 31.5 vs 4.8 ± 4.6 ng/mL, P < 0.01), ascitic fluid carcinoembryonic antigen (118.4 ± 196.5 vs 2.0 ± 1.4 ng/mL, P < 0.01), ascitic fluid carbohydrate antigen 19–9 (12 933 ± 25 496 vs 23 ± 67 U/mL, P < 0.01), and serum-ascites albumin gradient (1.1 ± 0.4 vs 2.0 ± 0.4 g/dL, P < 0.01). At the best cut-off levels chosen from near 95% of the data in those without malignancy-related ascites, the sensitivity, specificity and accuracy to diagnose malignancy-related ascites were, respectively, 65.5%, 93.6%, 87.0% using serum carcinoembryonic antigen 10 ng/mL; 69.0%, 94.7%, 88.6% using ascitic fluid carcinoembryonic antigen 5 ng/mL; 65.5%, 93.6%, 87.0% using ascitic fluid carbohydrate antigen 19–9 50 U/mL; 62.1%, 98.9%, 90.2% using serum-ascites albumin gradient < 1.1 g/dL. Although serum-ascites albumin gradient offered the best diagnostic accuracy and specificity, its sensitivity was not good enough. Our study indicates that serum-ascites albumin gradient and tumour markers are not sensitive parameters in the diagnosis of malignancy-related ascites.     

Immunophenotype of adult and childhood acute promyelocytic leukaemia: correlation with morphology, type of PML gene breakpoint and clinical outcome. A cooperative Italian study on 196 cases

Acute promyelocytic leukaemia (APL), characterized by a specific PML-RARα fusion gene resulting from translocation t(15;17) and by a high response rate to differentiation therapy with all- trans retinoic acid, presents clinical (varying WBC counts, age and treatment outcome), morphological (hypergranular M3 and hypogranular M3V) and molecular (three isoforms of PML breakpoint) heterogeneity.
We correlated leukaemic immunophenotype with these aspects in 196 molecularly confirmed APLs (63 children and 133 adults) in Italy. The bcr3 isoform ( P  = 0.05) and FAB M3V ( P  = 0.05) were more frequent in children. We confirmed in APL an immunophenotype characterized by frequent expression of CD13, CD33 and CD9 and rare expression of HLA-DR, CD10, CD7 and CD11b. However, we recognized CD2 in 28%, CD34 in 23% and CD19 in 11% of cases and demonstrated by double labelling that CD34 and CD2 may be co-expressed. CD2, CD34 and CD19 were significantly intercorrelated, and variably associated to other features: CD2 and CD34 with PML bcr3 ( P  < 0.001 and P  < 0.001, respectively) and with M3V ( P  < 0.001 and P  = 0.002), whereas only CD19 was directly correlated with WBC counts and only CD2 positively influenced CR rate (logistic model) and event-free survival (Cox model). We conclude that immunophenotype plays a role in the determination of the biological and clinical heterogeneity of childhood and adult APL.     

Anti-nociceptive properties of the xanthine oxidase inhibitor allopurinol in mice: role of A1 adenosine receptors

Background and purpose

Allopurinol is a potent inhibitor of the enzyme xanthine oxidase, used primarily in the treatment of hyperuricemia and gout. It is well known that purines exert multiple effects on pain transmission. We hypothesized that the inhibition of xanthine oxidase by allopurinol, thereby reducing purine degradation, could be a valid strategy to enhance purinergic activity. The aim of this study was to investigate the anti-nociceptive profile of allopurinol on chemical and thermal pain models in mice.

Experimental approach

Mice received an intraperitoneal (i.p.) injection of vehicle (Tween 10%) or allopurinol (10–400 mg kg⁻¹). Anti-nociceptive effects were measured with intraplantar capsaicin, intraplantar glutamate, tail-flick or hot-plate tests.

Key results

Allopurinol presented dose-dependent anti-nociceptive effects in all models. The opioid antagonist naloxone did not affect these anti-nociceptive effects. The non-selective adenosine-receptor antagonist caffeine and the selective A₁ adenosine-receptor antagonist, DPCPX, but not the selective A_2A adenosine-receptor antagonist, {"type":"entrez-protein","attrs":{"text":"SCH58261","term_id":"1052882304","term_text":"SCH58261"}}SCH58261, completely prevented allopurinol-induced anti-nociception. No obvious motor deficits were produced by allopurinol, at doses up to 200 mg kg⁻¹. Allopurinol also caused an increase in cerebrospinal fluid levels of purines, including the nucleosides adenosine and guanosine, and decreased cerebrospinal fluid concentration of uric acid.

Conclusions and implications

Allopurinol-induced anti-nociception may be related to adenosine accumulation. Allopurinol is an old and extensively used compound and seems to be well tolerated with no obvious central nervous system toxic effects at high doses. This drug may be useful to treat pain syndromes in humans.     

Comparison of Cooled-Tip Versus 4-mm-Tip Catheter in the Efficacy of Acute Ablative Tissue Injury During Circumferential Pulmonary Vein Isolation

Introduction: Although several studies have reported the benefits of cooled-tip ablation for circumferential pulmonary veins isolation (CPVI), the acute change of substrate property and acute PV reconnection have not been well demonstrated. The aim of this study was to compare the cooled-tip with regular 4-mm-tip catheter in acute substrate change after CPVI and long-term efficacy.
Methods and Results: One hundred and fifty-six patients (115 males, age 53 ± 12 years) who underwent CPVI for treatment of atrial fibrillation (AF) were included. Group A consisted of 52 patients with cooled-tip ablation, and group B consisted of 104 patients with 4-mm-tip catheter ablation. The bipolar voltage of circumferential lesions was obtained using a 3-dimensional (3D) mapping system (NavX) before and after CPVI. The electrical reconnections of 4 PVs were evaluated 30 minutes after CPVI using a circular catheter. Cooled-tip catheter caused more reduction of the electrical voltage in PV antrum, lower incidence of acute PV reconnection, inducibility of AF, and gap-related atrial tachyarrhythmia (AT). Less number of left atrial (LA) ablation line and ablation applications and less procedure time were found in cooled-tip group compared to 4-mm-tip group. No significant difference in the incidence of pain sensation and complication was observed between the 2 groups. At a 14-month follow-up, the recurrence rate in the cooled-tip group was lower than in the 4-mm group (13.5% vs 33.7%, P = 0.009).
Conclusion: Cooled-tip catheter has a superior long-term outcome than the 4-mm-tip catheter in CPVI, which may be associated with the efficacy of transmural block and electrical isolation in PV antrum.     

Efficacy of Additional Ablation of Complex Fractionated Atrial Electrograms for Catheter Ablation of Nonparoxysmal Atrial Fibrillation

Background: The efficacy of ablation of complex fractionated atrial electrograms (CFEs) in the single ablation procedure for nonparoxysmal atrial fibrillation (AF) patients is not well demonstrated. The aim of this study was to compare the ablation strategies of pulmonary vein isolation (PVI) plus linear ablation with and without additional ablation of CFEs in these patients.
Methods: Consecutive 60 patients (49 ± 11 years old, 50 male, 10 female) with nonparoxysmal AF underwent catheter ablation guided by a NavX mapping system. A stepwise approach included a circumferential PVI and left atrial (LA) linear ablation followed by either the additional ablation of continuous CFEs in the LA/coronary sinus (the first 30 patients) or not (the second 30 patients), detected by an automatic algorithm.
Results: There was no difference in the baseline characteristics between the two groups. Complete PVI eliminated some continuous CFEs and altered the distribution of CFEs. Following PVI and linear ablation, the remaining continuous CFEs were identified in 7.9 ± 10% mapping sites of the LA and CS, and were ablated successfully with a procedural AF termination rate of 53%. With a follow-up of 19 ± 11 months, a Kaplan–Meier analysis showed that the patients with additional ablation of the CFEs had a higher rate of sinus rhythm maintenance. Multivariate analysis showed the single procedure success could be predicted by the procedural AF termination and the additional ablation of continuous CFEs in the LA/CS.
Conclusions: Ablation of continuous CFEs after PVI and LA linear ablation had a better long-term efficacy based on the results of single-ablation procedure.     

The Disparities in the Electrogram Voltage Measurement During Atrial Fibrillation and Sinus Rhythm

Unipolar Electrogram Voltage in Patients with Atrial Fibrillation . Introduction: The peak electrogram voltage is a typical metric applied at each site for voltage mapping. However, the peak amplitude depends on the direction and complexity of the wavefront propagation. The root‐mean‐square (RMS) measure of the amplitude is a temporal integral that represents the steady‐state value. The objective of this study was to investigate the disparities between the electrogram voltage during SR and AF by using 2 recording modalities: the conventional peak voltage and an RMS measurement. Methods and Results: This study enrolled 20 patients (age = 59 ± 13) with paroxysmal AF undergoing catheter ablation guided by Ensite array. The unipolar electrogram voltage during SR and AF (7 seconds in duration) was obtained from the same sites, and labeled by the 3‐dimensional (3D) geometry. Overall 1,200 electrograms were analyzed from equally distributed mapping sites in the left atrium. A point‐by‐point comparison of the unipolar peak negative voltage (PNV) showed less agreement (Bland and Altman test: 10.4% outside 2 standard deviations, and intraclass correlation coefficient [ICC]= 0.64). The RMS voltage demonstrated agreement between SR and AF for all sites (BA test: 5.9% of the sites, and the ICC = 0.81). The probability of predicting a low‐voltage during AF using the voltage during SR was significantly lower when using the PNV measurement compared to that when using the RMS voltage (15% vs 61%, P < 0.05). Conclusion: The peak electrogram unipolar voltage during AF did not represent the voltage during SR. The RMS amplitude may be an alternative metric for voltage mapping to characterize the myocardial substrate. (J Cardiovasc Electrophysiol, Vol. 21, pp. 393–398, April 2010)     

Anesthetic‐specific electroencephalographic patterns during emergence from sevoflurane and isoflurane in infants and children

Background: Devices that monitor the depth of anesthesia are increasingly used to titrate sedation and avoid awareness during anesthesia. Many of these monitors are based upon electroencephalography (EEG) collected from large adult reference populations and not pediatric populations (Anesthesiology, 86, 1997, 836; Journal of Anaesthesia, 92, 2004, 393; Anesthesiology, 99, 2003, 34). We hypothesized that EEG patterns in children would be different from those previously reported in adults and that they would show anesthetic‐specific characteristics. Methods: This prospective observational study was approved by the Institutional Review Board, and informed written consent was obtained. Patients were randomized to receive maintenance anesthesia with isoflurane or sevoflurane. EEG data collection included at least 10 min at steady‐state maintenance anesthesia. The EEG was recorded continuously through emergence until after extubation. A mixed model procedure was performed on global and regional power by pooled data analysis and by analyzing each anesthetic group separately. Statistical significance was defined as P < 0.05. Results: Thirty‐seven children completed the study (ages 22 days–3.6 years). Isoflurane and sevoflurane had different effects on global and regional EEG power during emergence from anesthesia, and frontal predominance patterns were significantly different between these two anesthetic agents. Conclusions: The principal finding of the present study was that there are anesthetic‐specific and concentration‐dependent EEG effects in children. Depth‐of‐anesthesia monitors that utilize algorithms based on the EEGs of adult reference populations therefore may not be appropriate for use in children.     

多发性膀胱平滑肌瘤误诊为子宫内膜异位症1例并文献复习

目的提高对膀胱平滑肌瘤的认识,探讨其诊治方法。方法分析1例误诊为子宫内膜异位症的多发性膀胱平滑肌瘤患者的临床资料,并在文献复习的基础上对两种疾病的发病情况、临床表现、诊断及治疗方法进行讨论。结果患者经手术治愈,随访18个月,未见复发。结论膀胱颈部平滑肌瘤与子宫内膜异位症均可导致膀胱刺激症状和慢性盆腔痛,诊断主要依靠影像学检查,而剖宫产术导致的膀胱与宫颈粘连可造成诊断上的困难。两病治疗均首选手术,预后良好。