Squamous Cell Carcinoma in Situ (Bowen''s Disease) in Renal Transplant Patients Treated with 5% Imiquimod and 5% 5-Fluorouracil Therapy

BACKGROUND: Depending upon the patient's age at transplant, skin type, sun exposure, and the need for immunosuppressive therapy to prevent rejection, there is escalation in the development of cutaneous malignancies in organ transplant patients a number of years after transplantation. Thus, with the expansion in these procedures over the past decades, and the ever-lengthening survival of these patients, we are seeing an increase in cutaneous malignancies in this patient population. OBJECTIVE: To determine if combined therapy with 5% 5-fluorouracil and 5% imiquimod may be useful in the treatment of squamous cell carcinoma in situ. METHODS: We present five renal transplant patients, all more than 10 years posttransplantation, three with insulin-dependent diabetes, who developed multiple areas of squamous cell carcinoma (SCC) in situ. All these patients were on chronic immunosuppressive chemotherapy to prevent rejection, but were otherwise doing well. All the patients had biopsy-proven SCC in situ on their lower extremities that even in normal patients may be a challenge to treat. RESULTS: We treated these five patients with a combination of a local immune therapy, imiquimod cream, and a topical chemotherapeutic agent, 5% 5-fluorouracil (5-FU), with clearing of the areas of SCC in situ. CONCLUSION: Although immunotherapy must be used with caution in organ transplant patients to avoid graft rejection, topical imiquimod is a local immune modulator that potentiates local innate and possible adaptive immunity without measurable effects on systemic immunity. In addition, there is evidence that cytokines induced by imiquimod may improve the therapeutic efficacy of topical 5% 5-FU in the treatment of SCC in situ.     

A randomized prospective comparison of nadolol, captopril with or without ticlopidine on disease progression in IgA nephropathy

To determine if angiotensin converting enzyme inhibitors (ACEI) and antiplatelet agents have any added advantages over beta-blockers in preventing disease progression in IgA nephropathy (IgAN), 52 patients with IgAN with at least two features suggestive of progressive disease, namely, proteinuria >1 gm/day, mean blood pressure (MBP)>107 mmHg, serum creatinine 0.12–0.4 mmol/L and the presence of glomerulosclerosis and/or tubulointerstitial fibrosis on initial biopsy were randomized to receive nadolol (N), captopril (C) and captopril plus ticoplidine (CT). In hypertensive subjects, the dose N and C was adjusted to normalize MBP. In normotensive subjects the dose was adjusted to achieve a reduction of MBP of 5–10mmHg. Five patients withdrew prematurely before reaching the end of the study period. The results after a minimal period of 3 years follow-up were available in the remaining 47 patients (n=16, 12 and 19 in groups N, C and CT, respectively). Target of blood pressure (BP) treatment was achieved in all patients and the post-treatment MBP was comparable among the three groups. In C and CT, peripheral blood renin increased significantly while in CT, in vitro platelet aggregation decreased significantly following treatment. Urinary protein and albumin excretion decreased significantly in all treatment groups but there was no difference among the three groups. Progression of renal failure as measured by life table analysis of the percentage of patients with doubling of serum creatinine and by the slope of the reciprocal of serum creatinine (mean±SEM: ?0.021±0.014; ?0.016±0.010 and ?0.017±0.008 for N, C and CT, respectively) and of glomerular filtration rate as measured by plasma disappearance of injected Cr⁵¹EDTA over time (mean±SEM: ?0.556±0.157, ?0.739±0.304 and ?0.543±0.274 for N, C and CT) were similar among the three groups. In this small comparative study, ACEI does not appear to be better than long-acting beta-blocker in retarding disease progression in patients with IgAN and ticlopidine confers no additional benefit.     

Malignant melanoma presenting as bilateral breast masses

Malignant melanoma presenting initially with disseminated disease is common. However, bilateral breast masses as the initial symptom of malignant melanoma are rare. One such case is detailed here, together with a review of literature.     

Congenital coronary aneurysms with angina pectoris and myocardial infarction treated with saphenous vein bypass graft

A young woman with bilateral congenital coronary arterial aneurysms associated with myocardial infarction and angina pectoris was successfully treated with a saphenous vein bypass graft. Possible clinical and laboratory manifestations of such aneurysms are discussed, and possible complications of saphenous vein graft surgery in treatment of this lesion are noted. The finding of coronary arterial aneurysms during coronary arteriography warrants close follow-up study since in many patients the lesion appears to progress to myocardial infarction.     

Cimetidine reduces running-associated gastrointestinal bleeding

A prospective observational study was undertaken to compare the effect of cimetidine usage immediately before and during a 100-mile running race on the frequency of detectable gastrointestinal bleeding and to relate these data to the frequency and intensity of gastrointestinal symptoms and to training data collected from pre- and postrace questionnaires. Nine of 25 runners in the 1989 Old Dominion 100-mile Endurance Race took 800 mg of cimetidine 1 hr before the start and at 50 miles. Sixteen other runners acted as controls and were not different in age, gender, or training data. All runners also submitted three stool specimens from the week before the race and from the first three bowel movements after the race on standard Hemoccult cards. All runners were Hemoccult negative before the race. One of the 9 (11%) cimetidine runners and 14 of the 16 (87.5%) control runners were Hemoccult positive afterwards (P less than or equal to 0.05). Nausea and vomiting were less in those runners taking cimetidine (P less than or equal to 0.05). There was no difference in the race performance as related to the ability to finish or in the number of miles run during the race. This study may help to define the etiology of this common gastrointestinal bleeding in these ultradistance runners and may be useful in preventing some of the symptoms associated with long-distance running.     

Acute,fulminating amebiasis with multiple complications

Summary A case has been presented in which the patient had acute fulminating amebiasis, complicated by hemorrhage, perforation of the colon, obstruction of the small bowel, pleuropulmonary disease and hepatic involvement. Treatment is discussed in the light of known therapeutic types of management which were altered to meet the demands of a combination of complications. Treatment was begun by administration of chloroquine, Diodoquin? and tetracycline orally. When vomiting intervened, emetine and tetracycline were administered parenterally. Hemorrhage responded to antiamebic treatment and anemia was corrected by blood replacement. Perforation was treated by administration of high doses of broad-spectrum antibiotic agents, emetine and fluids. Obstruction of the small bowel, subsequent to perforation, was bypassed by a jejunoileostomy and transverse colostomy after repair of traumatically-induced perforation of the friable bowel. Pneumonitis, amebic pleural effusion and hepatic involvement were treated by administration of emetine and chloroquine.     

Ezetimibe coadministered with fenofibrate: some safety questions

I would like to comment on some questions in reference to thearticle of Dr Farnier and co-workers on the coadministrationof ezetimibe with fenofibrate in patients with mixed     

The Interleukin-1 Axis and Risk of Death in Patients With Acutely Decompensated Heart Failure

Background

Soluble ST2 (sST2), which is the soluble form of interleukin (IL)-1 receptor-like 1, identifies risk in acutely decompensated heart failure (ADHF). IL-1β is an inflammatory cytokine that has deleterious effects in myocardial remodeling and function. IL-1β inhibition has beneficial effects after acute myocardial infarction. However, the role of IL-1β in ADHF and its relationship to ST2 remain unclear.