Treatment of perianal infection following bone marrow transplantation

PURPOSE: Bone marrow transplantation (BMT) is often associated with profound neutropenia. Allogeneic transplant recipients also have defects in both humoral and cellular immunity and thus are subject to increased risk of serious, often life-threatening, infection even beyond the period of granulocyte recovery. The current study was undertaken to evaluate patients who required operative intervention for perianal sepsis following BMT. METHODS: The bone marrow transplant database at a single institution was used to identify all patients diagnosed with perianal infections after autologous or allogeneic BMT. Charts were reviewed in a retrospective manner. RESULTS: Over a ten-year period ending in November 1993, 963 BMT were performed at the City of Hope National Medical Center. Twenty-four patients were diagnosed with perianal infections foEowing their transplants. Fifteen patients did not have purulent collections requiring drainage and were treated with antibiotics and supportive measures alone. Nine patients (37.5 percent) required surgical intervention between 10 and 380 days following transplantation. At the time of surgical intervention, seven patients had purulent collections and two patients had acute and chronic inflammation, tissue necrosis, and fibrosis. Of the two patients with an absolute neutrophil count less than 1,000, a purulent collection was found in one of the patients. Cultures taken from perianal abscesses were almost all polymicrobial, and the most common organisms were Escherichia coli, Bacteroides, Enterococcus,and Klebsiella.For those patients undergoing surgical intervention, mean time to complete wound closure by secondary intention was 37.6 days; five patients healed in less than 15 days, two patients healed at 93 and 114 days, and two patients had persistent, open wounds at time of death, which was unrelated to their perianal disease. Five patients were receiving systemic steroids at time of surgical intervention; this did not appear to affect time to wound healing. CONCLUSIONS: Perianal infections are a rare complication of BMT. Majority of these infections are polymicrobial, and organisms isolated are similar to those seen in the perianal infections of nonimmunosuppressed patients. Despite steroid use, granulocytopenia does not exclude the possible presence of purulent collections, and clinical examination should guide the decision for surgical drainage. In general, perianal wound healing is not prolonged in BMT patients.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

Improved Assessment of Significant Activation in Functional Magnetic Resonance Imaging (fMRI): Use of a Cluster-Size Threshold

The typical functional magnetic resonance (fMRI) study presents a formidable problem of multiple statistical comparisons (i.e, > 10,000 in a 128 x 128 image). To protect against false positives, investigators have typically relied on decreasing the per pixel false positive probability. This approach incurs an inevitable loss of power to detect statistically significant activity. An alternative approach, which relies on the assumption that areas of true neural activity will tend to stimulate signal changes over contiguous pixels, is presented. If one knows the probability distribution of such cluster sizes as a function of per pixel false positive probability, one can use cluster-size thresholds independently to reject false positives. Both Monte Carlo simulations and fMRI studies of human subjects have been used to verify that this approach can improve statistical power by as much as fivefold over techniques that rely solely on adjusting per pixel false positive probabilities.     

Transient acantholytic dermatosis treated with isotretinoin

Transient acantholytic dermatosis is a self-limiting benign disease. It is characterized by multiple pruritic erythematous papules and papulovesicles found predominantly on the trunk and extremities. This primary acantholytic dermatosis affects individuals older than 40 years. We present a case study of an individual who received a regimen of isotretinoin (Accutane) for treatment of severe pruritus after conventional forms of therapy failed to alleviate his condition and abate the formation of new lesions.     

Anterior stromal puncture for recurrent erosion: further experience and new instrumentation

Anterior stromal puncture has recently been proposed as a new treatment for recalcitrant cases of recurrent corneal erosion. Concerns about the risks of corneal perforation and scarring, as well as doubts regarding its efficacy have prevented many patients from benefiting from this procedure. We introduce a new, inexpensive, commercially available instrument designed to standardize this technique, minimize scarring, and prevent corneal perforation. In a clinical trial involving 25 consecutive patients with recurrent erosions resistant to vigorous conservative treatment, the first 11 patients underwent stromal puncture in which a straight tuberculin needle was used; the following 14 were treated with a newly designed prototype needle. All patients in this series remained free of erosions after completion of stromal puncture, except for one woman with marked diffuse anterior basement membrane dystrophy, who went on to develop spontaneous bilateral erosions. Follow-up ranged from 2 months to 30 months (mean, 13 months). There were no complications of stromal puncture, and subjective and objective evaluations revealed no significant postoperative glare. Microscopic analysis of eye bank eyes subjected to anterior stromal puncture procedures demonstrated that the new prototype needle provided shallower penetration and thus less likelihood of perforation or excessive scarring than the straight needle. Also, postoperative discomfort and scarring appeared to be significantly less in patients treated with the prototype needle.     

Fluorescein angiographic findings and results of laser treatment in circumscribed choroidal hemangioma

We studied retrospectively 12 eyes with a solitary choroidal hemangioma in 12 patients over a period of 13 years. A peculiar, even hyperfluorescence of the tumor within the retinal venous phases occurred in all 12 cases. In all but four patients, laser therapy was performed to reduce subretinal fluid and partially destroy the tumor. Two of the three eyes without extensive retinal detachment or cystoid macular edema at the initial visit regained a final vision of 20/30 or better. The remaining 5 patients with the two major complications had a final vision of 20/80 or worse due to degenerative retinal changes. We believe that laser treatment is definitely advisable in the early stages of a circumscribed choroidal hemangioma.The study was performed at the Institute of Ophthalmology, University of Nijmegen.     

Colour Doppler imaging in the demonstration of an orbital varix.

Colour Doppler imaging (CDI) is a recent development in ultrasonography. It allows simultaneous two-dimensional structural imaging and Doppler evaluation of blood flow. Quantitative information on flow velocity is obtained by pulsed Doppler spectral analysis, the colour information being used to choose the vessel of interest. Using this technique the authors examined a patient with an orbital varix previously diagnosed by clinical findings and computed tomography. Dynamic evaluation with real-time direct imaging of flow facilitated the diagnosis of this orbital disorder without the need for any contrast material. This technique may prove to be a useful adjunct to computed tomography for the evaluation of suspected vascular lesions of the orbit.     

Inhibition of hepatic glucose production by SDZ 51641

The new oral hypoglycemic agent SDZ 51641 was evaluated in nondiabetic rats and a rat model of human non-insulin-dependent diabetes mellitus. Diabetes was induced with a single injection of 37.5 mg/kg streptozocin, and the rats exhibited hyperglycemia in the fed state with normal insulin levels. Treatment of nondiabetic animals with 100 mg/kg SDZ 51641 given orally significantly decreased serum glucose and ketone levels within 4 h without affecting insulin levels. Nonesterified fatty acids increased more than twofold during the same period. Its effect on ketone and fatty acid levels suggests that SDZ 51641 acts as an inhibitor of fatty acid oxidation. Diabetic rats treated with SDZ 51641 exhibited a significant acute hypoglycemic response, which was more pronounced after 3 days of treatment. The compound also significantly decreased serum cholesterol and triglyceride levels 27 and 53%, respectively. When endogenous hepatic glucose production was assessed in nondiabetic and diabetic animals via continuous infusion of [3-3H]glucose, we found that hepatic glucose production was elevated 43% in diabetic compared with control animals. When diabetic rats were treated with 100 mg/kg SDZ 51641, hepatic glucose production decreased to normal levels within 6 h. Hyperinsulinemic-euglycemic clamp studies indicated that SDZ 51641 had no effect on insulin-stimulated glucose utilization. Measurement of [1-14C]oleate oxidation in isolated hepatocytes demonstrated that SDZ 51641 inhibited long-chain fatty acid oxidation in a concentration-dependent manner. The compound was ineffective at inhibiting long-chain fatty acid oxidation in epitrochlearis or soleus muscles.(ABSTRACT TRUNCATED AT 250 WORDS)     

Farm Work is Dangerous for Teens: Agricultural Hazards and Injuries Among North Carolina Teens

Children who work in agriculture suffer more than 23,000 injuries and 300 fatalities on American farms every year. Using survey data collected from a random sample of working teens (ages 14 to 17) in North Carolina, the authors analyze the farm-based hazard exposure and injury experiences of teens who work on farms. The group of farmworking teens (N = 141) is 72 percent male, has a mean age of 16.6 years, and is, on average, in the 10th grade. The data show that teens working on farms in North Carolina are exposed to significant safety hazards throughout their farmworking careers. A majority of the respondents in this group of farmworkers reported exposure to tractors, large animals, all-terrain vehicles, farm trucks, and rotary mowers, and more than one-third reported exposure to pesticides and tobacco harvesters. Common reported injuries include insect stings, cuts, burns, and falls. The researchers find that gender, age, and farmwork experiences are related to variations in types of hazards to which teens are exposed and in the types of injuries they suffer. These variables also are related to the overall complexity of the teens' farmwork experiences and the burden of injury endured by teens.     

Oral contraceptive use and cardiovascular disease: is the relationship real or due to study bias?

BACKGROUND. Epidemiologic studies link oral contraceptive use with several cardiovascular events, but the literature is difficult to summarize, and potential biases remain poorly addressed. This study uses meta-analysis to summarize study results and to analyze the influence of study characteristics, including susceptibility to bias, on study outcome. METHODS. Forty-seven case-control and cohort studies of oral contraceptives and four cardiovascular events were coded for relative risk (RR) and study characteristics, including adherence to 14 bias-control standards. Key RRs were pooled to summarize findings for each disease type. Univariate determinants of the magnitude of the relative risks were identified, and partial correlation analysis was performed for each disease type. RESULTS. Relative risks were significantly greater than 1.0 for venous thromboembolism (RR = 2.8, CI = 2.4 to 3.2), stroke (RR = 1.8, CI = 1.6 to 2.0), and myocardial infarction (RR = 1.6, CI = 1.4 to 1.8), but not for death due to any cardiovascular cause (RR = 1.0, CI = 0.8 to 1.3). Study characteristics were diverse, and potential biases were frequently uncontrolled. For three of ten study characteristics identified as independently influencing relative risk, methodologically stronger studies of venous thromboembolism tended to have higher RRs. The RRs for stroke and myocardial infarction were lower in studies that were methodologically stronger with regard to variables identified as important. In studies of cardiovascular death, bias-control standards identified as important were generally well addressed by the studies. CONCLUSIONS. Oral contraceptive use does not appear to increase overall cardiovascular mortality. The associations noted with stroke and myocardial infarction may be due to methodologic flaws in the studies, while the association with venous thromboembolism is more likely to be valid.