An algorithm for the treatment of pain in advanced cancer

An algorithm is presented that has been developed over the past three years to provide pain relief in advanced cancer. The hospital records of 92 patients were reviewed to evaluate the validity of the algorithm. The algorithm is as follows: the 24 hour oral consumption of opioids was converted to sustained release morphine. If ineffective usually over 360 mg daily the total 24 hour oral dose was divided by 6 to convert to I.V. If this was ineffective, usually over 10 mg/hr of morphine, the intravenous dose was divided by 10 and infused epidurally. Local anesthetic was added for plexus involvement. After four days, the patient was weaned from local anesthetic solution. If sharp pain or pain to movement persisted, 6% phenol in 1 to 2 ml aliquots was injected every 8-12 hours to a total of 5-8 ml. While the conversion from intravenous to epidural morphine was 10:1 that from epidural to intravenous was only 1:3. Intravenous dose converts directly to the subcutaneous. The conversion from intravenous to oral is 1:3. There view showed that the dosages at which the conversions were made varied considerably. The reasons for the wide variation are presented. In summary the algorithm is a good practical guide for treatment of cancer pain.     

Potential problem with fluorescence polarization immunoassay cross-reactivity to vancomycin degradation product CDP-1: its detection in sera of renally impaired patients

During the development of a homogeneous immunoassay for the antibiotic vancomycin, we observed in certain patient samples a quantitation difference between the enzyme multiplied immunoassay technique (EMIT) method and the comparison method, fluorescence polarization immunoassay (FPIA). This prompted us to evaluate the integrity of vancomycin in samples from renally impaired patients. Since it has been reported in the scientific literature that vancomycin degrades into an antibiotically inactive crystalline degradation product (CDP-1) in vitro, we developed high-performance liquid chromatography (HPLC) and liquid chromatography/mass spectrometry (LC/MS) methods to determine whether CDP-1 is present in patient sera. HPLC and LC/MS analysis on samples from renally impaired patients positively identified CDP-1 in fresh samples. Next, we tested the cross-reactivity of three currently available vancomycin immunoassays, radioimmunoassay (RIA) FPIA, and EMIT, to CDP-1 prepared in our laboratory. Our data suggest that CDP-1 is recognized by FPIA and RIA, both polyclonal antibody-based methods, but not by EMIT, which uses a monoclonal antibody.     

Risk factors for placental abruption in a socio-economically disadvantaged region.

OBJECTIVE: This study was undertaken in order to determine the risk factors for pregnancies complicated by placental abruption in a socio-economically disadvantaged region in metropolitan Adelaide. METHODS: This was a retrospective case-control study including all singleton pregnancies resulting in placental abruption between 2001 and 2005. RESULTS: The overall incidence of placental abruption was 1.0%; the overall perinatal mortality among the births with abruption was 13%. Univariate analyses showed the following significant risk factors for placental abruption: preterm pre-labor rupture of the membranes (PRE-PROM; odds ratio (OR) 4.79, 95% confidence interval (CI) 1.52-15.08), non-compliance with antenatal care (OR 2.93, 95% CI 1.06-8.90), severe intrauterine growth restriction (IUGR), and elevated homocysteine levels (OR 45.55, 95% CI 7.05-458.93). Severe IUGR was significantly more common in the abruption group compared with the control group (p = 0.032). In the multivariate analysis, PRE-PROM remained a significant independent risk factor for placental abruption. Marijuana use, domestic violence, and mental health problems were more common (borderline significance) in the abruption group. Smoking and preeclampsia were not found to be associated with placental abruption in this study. CONCLUSIONS: In this high-risk population, PRE-PROM and elevated homocysteine levels appear to represent the major risk factors for placental abruption.     

Acute post-streptococcal glomerulonephritis followed shortly by acute rheumatic fever

A 16 year old girl with post-streptococcal glomerulonephritis developed acute rheumatic fever 19 days afterwards. Previous publications on concurrent post-streptococcal glomerulonephritis and acute rheumatic fever are reviewed.     

High-dose VP-16 with intermediate-dose cytosine arabinoside in the treatment of relapsed acute nonlymphocytic leukemia

Summary In a study of 11 adult patients with acute nonlymphocytic leukemia (ANLL), infusion therapy with high-dose VP-16 and intermediate-dose cytosine arabinoside was administered. Response was assessed with reference to bone marrow aspirations performed on days 1; 12, 13, or 14; and 21 of treatment. All 7 of the patients with ANLL in relapse achieved marrow hypoplasia, and 3 of them achieved complete response. LFTs were elevated in most patients but no evidence of hepatocellular necrosis was observed. It is concluded that the value of VP-16 in ANLL may have been underestimated in the past because of inadequate dosing.Abbreviations ANLL acute nonlymphocytic leukemia - CGL chronic granulocytic leukemia - DNR daunorubicin - VNC vincristine - ID Ara-C, intermediate-dose Ara-C (500 mg/m² for 12 doses) - HD Ara-C, high-dose Ara-C (3 g/m² for 12 doses) - SGGT serum glutamic transaminase - LDH lactic dehydrogenase - SGOT serum glutamic oxaloacetic transaminase     

Cerebral amyloid angiopathy and spontaneous intracerebral haemorrhage. Report of a sporadic case in a young Chinese.

A 49-year-old Chinese male with spontaneous intracerebral haemorrhage due to cerebral amyloid angiopathy is presented. This is the first case reported in the Chinese population, and the youngest patient described without a family history or associated mental disorder.     

Thoracoscopic excision of mediastinal parathyroid adenomas: a report of two cases and review of the literature

Background:Most abnormal parathyroid glands can be removed through a standard cervical incision; even those in the superior mediastinum. Those located in certain areas of the mediastinum, for example posteriorly or in the aortopulmonic window, historically have required excision through a median sternotomy or thoracotomy. Angioablation is a nonsurgical alternative to management of these lesions.Study Design:We present two case reports of mediastinal parathyroid adenomas that were excised thoracoscopically, and review the literature regarding the management of mediastinal parathyroid adenomas.Results:Both patients who underwent precise localization and thoracoscopic excision of their mediastinal parathyroid adenomas had resolution of their hypercalcemia with minimal associated morbidity and shortened recovery periods.Conclusions:We suggest that thoracoscopic excision of mediastinal parathyroid adenomas is the better means of controlling hypercalcemia secondary to parathyroid adenoma in those patients considered for either median sternotomy, thoracotomy or angiographic ablation where the exact location of the lesion can be established preoperatively.