Intrathecal baclofen in the treatment of painful, disabling spasms in Friedreich's ataxia.

We report on the case of a patient suffering from Friedreich's ataxia (FA) with very painful and disabling spasms that were improved markedly by intrathecal baclofen infusion. To our knowledge, this is the first report of an intrathecal baclofen-delivering pump implantation in an FA patient.     

Six-hour trimethoprim-sulfamethoxazole–graded challenge in HIV-infected patients

Background: Hypersensitivity reactions to trimethoprim-sulfamethoxazole (TMP-SMX) are very common in HIV-infected patients, leading to drug discontinuation. However, it is the drug of choice as prophylaxis for Pneumocystis carinii pneumonia. Objectives: We sought to determine the safety and long-term efficacy of a 6-hour TMP-SMX–graded challenge in a group of hypersensitive HIV-infected patients. Methods: Forty-four consecutive HIV-infected patients with documented TMP-SMX hypersensitivity were seen in our outpatient allergy department. They ingested 12 doses of increasing amounts of TMP-SMX at half-hour intervals. Thereafter, they took 80/400 mg TMP-SMX daily and were advised to “treat through” every nonbullous cutaneous adverse reaction. Results: All 44 patients tolerated the procedure without any adverse reactions during the day of challenge. Eleven of the 44 patients experienced mild hypersensitivity reactions on days 1 to 2 (8 patients) and 8 to 10 (3 patients), consisting mainly on a 1-day pruritic maculopapular eruption. Two patients stopped TMP-SMX at day 1, and 2 stopped it at days 10 and 15, giving an overall success rate at 1 month of 91% (40 of 44). Two were successfully rechallenged late. After a median follow-up of 10 months, 42 patients were taking TMP-SMX without any adverse reaction, giving an overall success rate of 95%. Conclusions: A 6-hour graded challenge with cautious “treating through” of mild reactions enables more patients to take TMP-SMX and is safe and effective. (J Allergy Clin Immunol 1998;102:1033-6.)     

Pruritus after intrathecal baclofen withdrawal: A retrospective study

OBJECTIVES: To determine the frequency of pruritus after intrathecal baclofen (ITB) withdrawal and to study the pathophysiology of this symptom. DESIGN: Retrospective cohort study. SETTING: Rehabilitation department of a general hospital. PARTICIPANTS: Patients (N=102) implanted with an ITB pump who had been followed up since 1988. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Incidence of pruritus after withdrawal. We studied the relation between pruritus and daily dose, concentration and mode of infusion of baclofen, and cause of the central nervous system lesion inducing spasticity. RESULTS: Pruritus was observed in 10 of 23 cases of ITB withdrawal. It never occurred during the first 3 months after pump implantation. It seems likely that the segmental spinal action of baclofen is responsible for pruritus. There was no statistically significant difference between patients with ITB deprivation who did and did not experience pruritus in their daily infused dosage or in concentration and mode of infusion. Surprisingly, no pruritus was observed in patients with multiple sclerosis. CONCLUSIONS: Pruritus is a frequent symptom after ITB withdrawal. Its occurrence is probably subsequent to chronic blocking of the liberation of substance P by baclofen at the spinal level. This symptom is a good clinical predictor of baclofen withdrawal, in contrast to an isolated increase of spasticity that may be due to drug tolerance or irritant factors. Pruritus requires investigation of a possible dysfunction of the infusion system.     

Acute graft pyelonephritis: a potential cause of acute rejection in renal transplant

Acute graft pyelonephritis is a common complication in renal transplant recipients. The consequences of this complication on kidney allograft survival remain controversial. Bacterial infection is likely to activate the immune system, potentially leading to acute or chronic rejection. Here, we report for the first time two documented cases of acute rejection occurring shortly after acute graft pyelonephritis, suggesting that pyelonephritis can initiate acute rejection. The immunologic process leading to the alloimmune response is discussed. These reports suggest that acute rejection should be questioned in case of atypical graft outcome in the context of acute graft pyelonephritis.     

New insights into the effects of the protein moiety of oxidized LDL (oxLDL)

Oxidative stress has been implicated in the cardiovascular complications in chronic renal failure patients. Lipoprotein oxidation is involved in the genesis of atherosclerosis. Both the lipid and the protein moieties of low-density lipoproteins (LDL) are subject to oxidation. We have shown that oxidation of LDL by hypochlorous acid (HOCl) in vitro, reflecting increased myeloperoxidase (MPO) activity in vivo, leads mainly to modifications of apolipoproteins, such that the latter in turn induce high rates of apoptosis in a human monocytic cell line via a caspase-dependent pathway. These in vitro oxidative changes of LDL protein moiety, if shown to occur to a significant extent in uremic patients in vivo, may represent an important pathway in the pathogenesis of atherogenesis.     

Open heart surgery: one-year self-assessment of quality of life and functional outcome

BACKGROUND: The aim of this prospective study, based on the completion of the short form health survey questionnaire (SF36) before and 1-year after open heart surgery, was threefold: to evaluate the changes in quality of life (QOL) after open heart surgery, to determine the factors influencing QOL, and to assess the relation between preoperative QOL and 1-year cardiac functional status. METHODS: Logistic regression was used to determine factors that influence patients' QOL scores and their 1-year cardiac functional status. Different groups were constituted in terms of 1-year cardiac functional status by means of an arborescent classification. RESULTS: Comparison of preoperative and postoperative mean scores in the 293 patients included in the study revealed an improvement in all but three dimensions of the SF36 scale. Quality of life improved after operation in an average of 50% of patients. The most frequently found independent predictors of impairment after surgery were NYHA functional class III or IV and angina class III or IV. At 1 year, 64% of patients had satisfactory cardiac functional status. Independent predictive factors of 1-year cardiac functional status were: physical functioning, pain, general health problems, and coronary artery bypass graft. The arborescent classification indicated that the probability of having a "satisfactory" 1-year cardiac functional status was greater than 75% for patients with at least one preoperative QOL dimension above 75 on the scale. CONCLUSIONS: Preoperative QOL determined by the SF36 is predictive of 1-year cardiac functional status. Coronary artery bypass patients do not recover as well as patients having undergone heart valve surgery.     

Management of the second episode of spontaneous pneumothorax: a decision analysis

BACKGROUND: Optimal management for patients presenting a second episode of spontaneous pneumothorax remains controversial. The aim of this study was to compare two possible treatment strategies, video-assisted thoracic surgery (VATS) and conservative management, in order to assess which of the two was better adapted for the treatment of the second episode of spontaneous pneumothorax. METHODS: The authors propose a decision analytic model including a cost-effectiveness study to compare two clinical strategies: VATS (reference strategy) and conservative management (alternative strategy). Data were obtained from a Medline search for English language articles and cost estimates were derived from the financial and public health departments of our hospital. The model was analyzed to determine the baseline strategy leading to the highest expected effectiveness and the lowest expected cost. RESULTS: Conservative management offered a slight advantage in expected effectiveness value (99.99 vs 99.93 for VATS). VATS produced the lowest expected cost (4347 vs 7536 for conservative management). The incremental cost-effectiveness ratio was 57,750. Within the ranges tested, the sensitivity analysis presented consistent results in terms of effectiveness and advocated conservative management as the best strategy. In terms of cost, with the exception of length of stay, the sensitivity analysis was insensitive in estimating the different probabilities, and favored VATS over conservative management. CONCLUSIONS: In the management of the second episode of spontaneous pneumothorax, VATS offers substantial savings in cost for only a slight decrease in effectiveness, when compared with conservative management.     

Bromocriptine in traumatic brain injury

The authors report the case of a 63-year-old patient with severe traumatic brain injury (TBI) associated with Parkinson's syndrome, whose performances were dramatically improved by bromocriptine therapy, with an improvement of the scores, not only on tests evaluating motor functions but also on tests evaluating the patient's cognitive functions. However, no improvement was observed with levodopa.     

A novel gene from Myxococcus xanthus that facilitates membrane translocation of an extracellular endoglucanase in Escherichia coli?

Expression in Escherichia coli of the Myxococcus xanthus gene celA, which encodes an extracellular endoglucanase, resulted in CelA being distributed between cytoplasm, periplasm and membrane. The presence of an adjacent open reading frame downstream from the full celA gene, or the absence of a putative lipoprotein signal sequence, confined CelA distribution to the periplasm and membrane, or to the cytoplasm and periplasm, respectively.