Life-threatening gastrointestinal bleeding related to the treatment of strongyloidiasis hyperinfection in an immunocompromised patient

The clinical course and sequel of the life-threatening gastrointestinal (GI) bleeding during the treatment of strongyloides helmintic hyperinfection induced by immunosuppression in a patient with multiple myeloma is presented. A 55-year old male patient was diagnosed with strongyloides infection with stool analysis and intestinal biopsy shortly after his combined chemotherapy for myeloma. He was commenced on albendazole anthelmintic therapy. However, after initiation of the treatment he suffered life-threatening GI bleeding. Repeated endoscopies, including intraoperative enteroscopy, concluded to diffuse multifocal intestinal bleeding. The patient required huge amounts of red blood cells and plasma transfusions and correction of haemostasis with recombinant activated factor VII. Abdominal aorto-angiography showed numerous microaneurysms ("berry aneurysms") in the superior and inferior mesenteric arteries' territories. While the biopsy taken prior to the treatment with albendazole did not show evidence of vasculitis, the biopsy taken after initiation of therapy revealed leukoclastic aggregations around the vessels which was also consistent with vasculitis. These findings suggest that--in addition to direct destruction of the mucosa-vasculitis could be an important additive factor to the massive GI bleeding during the anthelmintic treatment. This might result from substances released by the worms that have been killed with anthelmintic drugs. Current guidelines advise steroids to be tapered and stopped in case of systematic parasitic infections as they reduce immunity and precipitate parasitic hyperinfection. In our pinion, steroid therapy might be of value in the management of strongyloides hyperinfection related vasculitis--in addition to the specific anthelmintic treatment. Indeed, steroid therapy of vasculitis with other means of supportive care yielded in sequel of the bleeding and in recovery of the patient.     

Bcl-2 Is a Useful Prognostic Marker in Dukes’ B Colon Cancer

Background: Currently, the use of adjuvant therapy specifically in Dukes B colon cancers is controversial, emphasizing the importance of identifying prognostic markers to select patients for such therapy. Bcl-2 plays an important role in apoptosis regulation of solid tumors, such as colon and breast cancer, and is normally expressed in the base of the colonic crypts. The purpose of this study is to determine whether or not bcl-2 expression can be used to predict survival in Dukes B colon cancer patients.Methods: Charts of 76 patients operated on at the Royal Victoria Hospital from 1986 to 1992 were reviewed. Bcl-2 staining was done with the avidin-biotin-peroxidase complex method using commercially available monoclonal bcl-2 antibodies. Two pathologists graded the intensity of bcl-2 staining on a scale of 0–3 and estimated the percentage of tumor cells staining positively (T-percent). Univariate and multiple regression of factors on overall survival (OS) and disease-free survival (DFS) was done with a Cox proportional hazards model and Kaplan-Meier survival curves.Results: The mean age was 71.2 years, with 41 female and 35 male patients. Mean tumor size was 5.4 cm with tumor grades of 19 well, 52 moderate, and 5 poorly differentiated. Tumors expressing bcl-2 had a similar DFS (P = .14) but a significantly improved OS (P = .04) compared with the bcl-2 negative tumors. The risk ratio for DFS was 0.49 (95% CI, 0.19–1.26) and for OS was 0.35 (95% CI, 0.13–0.94).Conclusions: These data indicate that enhanced bcl-2 expression, specifically in Dukes B colon carcinomas, is associated with improved survival. Thus, patients whose tumors do not express bcl-2 should be considered for adjuvant therapy.Presented at the 51st Annual Meeting of the Society of Surgical Oncology, San Diego, California, March 26–29, 1998.     

Reduction-stabilization of a vicious callus of the lower cervical spine by bilateral anterior approach

The authors report a new technique which allows reduction and stabilization of cervical fractures healed in a vicious position. The procedure allows total removal of bony and discal protrusions, a correction of the pathological kyphosis by osteotomy of posterior facets. Advantages and drawbacks of this technique are discussed.     

Emotional reactivity and debilitating beliefs during hospitalization predict future adjustment to first myocardial infarction in men

Research efforts are being made to identify personality and cognitive variables predictive of poor adjustment following myocardial infarction. Sixty-two male patients were examined after a first and uncomplicated myocardial infarction to determine whether dispositional emotional reactivity and debilitating beliefs measured during hospitalization can predict work engagement, social activities involvement, and ambulation/independence six months later. A structural model with direct paths between emotional reactivity, debilitating beliefs, and the above outcomes, as well as partial mediation of emotional distress and illness preoccupation, was tested using the CALIS procedure. The model explained 33%, 48% and 82% of the variance in the three outcomes, respectively. Work engagement was indirectly related through emotional distress to earlier emotional reactivity and debilitating beliefs. Social activities involvement was both directly and indirectly related through emotional distress to debilitating beliefs; and also indirectly related through emotional distress to emotional reactivity. Ambulation/independence was directly and negatively related to debilitating beliefs. Prolonged emotional distress was predicted by emotional reactivity and debilitating beliefs. Illness preoccupation turned out to be an independent outcome that was positively related to emotional reactivity. Thus, measuring dispositional emotional reactivity and debilitating beliefs at the hospitalization stage may be helpful in detecting patients at risk of poor future adjustment.     

Hospital burden of long-term genitourinary and gastrointestinal toxicity after radical radiotherapy for prostate cancer

Introduction

Treatment options for prostate cancer (PCa) include radical radiotherapy (RT) and radical prostatectomy, both of which have comparable oncological outcomes. The aim of this study was to investigate the hospital burden of long-term genitourinary and gastrointestinal toxicity among patients with PCa who were treated with radiotherapy at our institution.

Prevalence of depression in Parkinson’s disease in a Lebanese tertiary clinic

Introduction: Diagnosis of Parkinson’s disease can be emotionally and psychologically challenging to patients. The aim of this study is to investigate the association between Parkinson’s disease and depression and the impact of the disease stage and patients’ age and gender on this association. Method: This is a cross-sectional retrospective study on 200 patients aged above 35 years old from 10 different nationalities. Results: Depression was diagnosed in 46% of the patients enrolled. Most of these patients were treated with an antidepressant. Young age, female gender, and moderate Parkinson’s disease stage were found to be significantly associated with depression (odds ratio of 1.19, 1.23, and 1.22, respectively, p < .05). Conclusion: This study, the first of its kind in Lebanon and the Middle East and North Africa region, highlights the importance of studying depression in Parkinson’s disease and the need for identifying and treating depression symptoms when treating Parkinson’s disease patients.     

Comparative associations of baseline frailty status and age with postoperative mortality and duration of hospital stay following metastatic brain tumor resection

Metastatic brain tumors are the most common intracranial neoplasms diagnosed in the United States. Although baseline frailty status has been validated as a robust predictor of morbidity and mortality across various surgical disciplines, evidence within cranial neurosurgical oncology is limited. Adult metastatic brain tumor patients treated with resection were identified in the National Inpatient Sample during the period of 2015–2018. Frailty was quantified using the 11-point modified frailty index (mFI-11) and its association with clinical endpoints was evaluated through complex samples multivariable logistic regression and receiver operating characteristic (ROC) curve analyses. Among 13,650 metastatic brain tumor patients identified (mean age 62.8 years), 26.8% (n?=?3665) were robust (mFI?=?0), 31.4% (n?=?4660) were pre-frail (mFI?=?1), 23.2% (n?=?3165) were frail (mFI?=?2), and 15.8% (n?=?2160) were severely frail (mFI?≥?3). On univariable assessment, these cohorts stratified by increasing frailty were significantly associated with postoperative complications (13.6%, 15.9%, 23.9%, 26.4%; p?<?0.001), mortality (1.2%, 1.4%, 2.7%, 3.2%; p?=?0.028), and extended length of stay (eLOS) (15.7%, 22.5%, 28.9%, 37.7%; p?<?0.001). Following multivariable logistic regression analysis, frailty (by mFI-11) was independently associated with postoperative mortality (aOR 1.34, 95% CI 1.08, 1.65) and eLOS (aOR 1.26, 95% CI 1.17, 1.37), while increasing age was not associated with these endpoints. ROC curve analysis demonstrated superior discrimination of frailty (by mFI-11) in comparison with age for both mortality (AUC 0.61 vs. 0.58) and eLOS (AUC 0.61 vs. 0.53). Further statistical assessment through propensity score adjustment and decision tree analysis confirmed and extended the findings of the primary analytical models. Frailty may be a more robust predictor of postoperative outcomes in comparison with age following metastatic brain tumor resection.

     

A mathematical model for pulsatile release: controlled release of rhodamine B from UV-crosslinked thermoresponsive thin films

A controlled drug delivery system fabricated from a thermoresponsive polymer was designed to obtain a pulsatile release profile which was triggered by altering the temperature of the dissolution medium. Two stages of release behaviour were found: fast release for a swollen state and slow (yet significant and non-negligible) release for a collapsed state. Six cycles of pulsatile release between 4 °C and 40 °C were obtained. The dosage of drug (rhodamine B) released in these cycles could be controlled to deliver approximately equal doses by altering the release time in the swollen state. However, for the first cycle, the swollen release rate was found to be large, and the release time could not be made short enough to prevent a larger dose than desired being delivered. A model was developed based on Fick's law which describes pulsatile release mathematically for the first time, and diffusion coefficients at different temperatures (including temperatures corresponding to both the fully swollen and collapsed states) were estimated by fitting the experimental data with the theoretical release profile given by this model. The effect of temperature on the diffusion coefficient was studied and it was found that in the range of the lower critical solution temperature (LCST), the diffusion coefficient increased with decreasing temperature. The model predicts that the effective lifetime of the system lies in the approximate range of 1-42 h (95% of drug released), depending on how long the system was kept at low temperature (below the LCST). Therefore this system can be used to obtain a controllable pulsatile release profile for small molecule drugs thereby enabling optimum therapeutic effects.