Multiple small bowel perforations due to invasive aspergillosis in a patient with acute myeloid leukemia: case report and a systematic review of the literature

Purpose

Invasive aspergillosis (IA) represents a major cause of morbidity and mortality in immunocompromised patients. Involvement of the gastrointestinal tract by Aspergillus is mostly reported as part of a disseminated infection from a primary pulmonary site and only rarely as an isolated organ infection.

Methods

We report a case of small bowel perforation due to IA in a patient with acute leukemia under chemotherapy and pulmonary aspergillosis. We performed a systematic review of the literature as well.

Results

A 43-year-old man with acute myeloid leukemia under chemotherapy developed severe neutropenia and pulmonary aspergillosis due to Aspergillus flavus. He developed melena and hemodynamic failure and a contrast-enhanced ultrasound scan suggested active intestinal bleeding. During emergency laparotomy we found multiple intestinal abscesses, several perforations of intestinal loop and Aspergillus flavus was isolated from the abscesses. Resection of the jejunum was performed. The patient received voriconazole and finally recovered. The patient is now alive and in complete disease remission. From literature review we found 35 intestinal IA previously published in single case reports or small case series as well.

Conclusion

Clinical manifestations of gastrointestinal aspergillosis are nonspecific, such as abdominal pain, and only occasionally it presents as an acute abdomen. Antemortem detection of bowel involvement is rarely achieved and, only in cases of complicated gastrointestinal aspergillosis, the diagnosis is achieved thanks to the findings during surgery. Gastrointestinal aspergillosis should be suspected in patients with severe and prolonged neutropenia with or without pulmonary involvement in order to consider the right therapy and prompt surgery.

     

Hepatocellular carcinomas and primary liver tumors as predictive factors for postoperative mortality after liver resection: a meta-analysis of more than 35,000 hepatic resections

Liver resection is considered the therapeutic gold standard for primary and metastatic liver neoplasms. The reduction of postoperative complications and mortality has resulted in a more aggressive approach to hepatic malignancies. For the most part, results of liver surgery have been published by highly experienced institutions, but the observations of highly specialized units results may not reflect the current status of hepatic surgery, underestimating mortality and complications. The objective of this study is to evaluate morbidity and mortality as a result of liver resection for primary and metastatic lesions, analyzing a large number of studies with a meta-analytic process taking into account the overdispersion of data. An extensive literature search has been conducted, and 148 papers published between January 2000 and April 2008, including a total of 36,629 patients from both high-volume and low volume institutions, were included in the meta-analysis. A beta binomial model was used to provide a robust estimate of the summary event rate by pooling overdispersion binomial data from different studies. Overall morbidity and mortality after liver surgery were 29.32 per cent and 3.15 per cent, respectively. Significantly higher postoperative mortality was observed after liver resection for hepatocellular carcinomas and primary hepatic tumors. The application of a beta binomial model to correct for overdispersion of liver surgery data showed significantly higher postoperative mortality rates in patients with hepatocellular carcinomas or primary hepatic tumors after liver resection.     

Multiresponse biomarker evaluation of interactions between methylmercury and Arochlor 1260 in quail

The single and combined effects of methylmercury and Arochlor 1260 were investigated in experimental quail treated chronically with the two compounds at low and high doses. A series of metabolic and biochemical biomarkers were evaluated together with mercury and PCB accumulation to pinpoint the effects of treatment with one or both chemicals. Methylmercury alone was associated with a decrease in serum cholesterol. Less PCBs were accumulated in tissues when Arochlor 1260 was combined with methylmercury than when the former was administered alone. Liver monooxygenase (MFO) activity was depressed 50% more in the presence of methylmercury than with Arochlor 1260 alone. Single or combined treatment with high doses of the two compounds resulted in similar degrees of DNA damage. This approach was found to provide a good picture of the interaction between environmental contaminants.     

Use of capillary electrophoresis and poly(ethylene oxide) as the coating agent for the determination of substances related to heroin addiction and treatment

The purpose of this study was to identify and quantify morphine, codeine, methadone, and 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine using capillary electrophoresis in urine specimens. Adequate peak separation was achieved using nearly neutral pH phosphate buffer and poly(ethylene oxide) as the coating agent. This dynamic coating of the inner surface of the capillary was obtained by rinsing with a solution containing this compound. The electroosmotic flow and the interactions between analytes and the capillary wall surface were reduced, while resolution and reproducibility were thus improved. Detection limits were appropriate for usual analytical requirements in forensic laboratories.     

Age and comorbidity in acute myocardial infarction: a report from the AMI-Florence Italian registry

A total of 930 cases of ST-segment elevation myocardial infarction were prospectively recorded in the Florence health district. Factors influencing survival or those associated with use of revascularization (percutaneous coronary intervention, 91%) were identified through multivariate analyses (Cox and logistic regression, respectively). The independent protective effect of coronary reperfusion therapy (CRT) was evident at 36 months (39% reduction in the risk of death). After adjusting for all multivariate predictors, CRT use was 63% less likely at age 85 years and older than at under 65 years (p<0.001). Since beyond advancing age, comorbidity appeared to be associated with a reduced chance of CRT, three chronic comorbidity score categories were calculated using information on past medical history. Increased 1-year mortality in patients with higher comorbidity score categories derives, at least in part, from underutilization of CRT. Results confirm that although they might potentially benefit from CRT during ST-segment elevation myocardial infarction, older and frail patients are excluded from CRT, even when eligible.     

Effect of β-Blockers and Other Antihypertensive Drugs On the Risk of Melanoma Recurrence and Death

ObjectiveTo verify preliminary studies on patients with melanoma exposed to β-blockers that suggested a reduced risk of disease recurrence and death.Patients and MethodsData were obtained from all consecutive patients diagnosed as having melanoma between January 1, 1993, and December 31, 2009, at the Department of Dermatology of the University of Florence, Azienda Sanitaria di Firenze. Participants were excluded if at baseline they reported a previous diagnosis of cutaneous malignant melanoma or another malignant disease. We also excluded participants with evidence of visceral, lymph nodal, and in-transit metastasis at the time of the diagnosis.ResultsOf 741 consecutive patients with melanoma, 79 (11%) were prescribed β-blockers (for hypertension in most cases) for 1 or more years (treated) and 662 (89%) were not (untreated). The multivariate Cox model indicated that the treated group had improved overall survival after a median follow-up of 4 years (P=.005). For each year of β-blocker use, the risk of death was reduced by 38%. The presence of hypertension, the use of antihypertensive agents for 1 or more years, or the use of other commonly used medicines were not associated with a better outcome for patients with melanoma.ConclusionThe results confirm and strengthen previous findings that β-blocker use is associated with a reduced risk of melanoma recurrence and death. The results also indicate the strong need for a randomized clinical trial to conclusively assess whether β-blockers afford protection against melanoma recurrence and death.     

Effects on Lipid Profile of Dipeptidyl Peptidase 4 Inhibitors, Pioglitazone, Acarbose, and Sulfonylureas: Meta-analysis of Placebo-Controlled Trials

Introduction

Lipid profile is an important determinant of cardiovascular risk in type 2 diabetes. It is well known that patients with type 2 diabetes are more likely to be dyslipidemic than the general population. Given the observed connection between glucose and lipid metabolism in patients with type 2 diabetes, it is conceivable that different glucose-lowering agents can have a varying impact on the lipid profile. When metformin monotherapy fails, other drugs can be added to achieve sufficient glycemic control. Available oral agents include pioglitazone, acarbose, dipeptidyl peptidase 4 (DPP-4) inhibitors, and insulin secretagogs. The present meta-analysis was designed to assess the effect of DPP-4 inhibitors, pioglitazone, insulin secretagogs, and acarbose on blood lipids when compared to placebo.

Methods

An extensive search (any date up to November 1, 2011) was performed for all trials performed on the following classes of drugs: gliptin, insulin secretagogs, pioglitazone, and acarbose. The following endpoints were considered: endpoint total, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) and triglycerides.

Results

The difference in mean total cholesterol values at endpoint versus baseline was significantly higher in patients on pioglitazone, sulfonylureas, and DPP-4 inhibitor treatment (but not on acarbose) than those on placebo, demonstrating that treatment with these drugs (except acarbose) is associated with a significant reduction in total cholesterol. With respect to triglycerides, a significant reduction could be observed with acarbose, pioglitazone, and DPP-4 inhibitors, but not with sulfonylureas. HDL-C appeared to be increased by treatment with acarbose and pioglitazone, and decreased by sulfonylureas.

Conclusion

The present meta-analysis shows that available glucose-lowering drugs may have varying effects on the lipid profile. DPP-4 inhibitors, acarbose, and pioglitazone seem to have a more favorable effect on the lipid profile than sulfonylureas.