Management of oral complications of disease-modifying drugs in rheumatoid arthritis

Stomatitis is a troublesome adverse effect of disease-modifying anti- rheumatic drug (DMARD) therapy in rheumatoid arthritis (RA) patients. This review presents data to examine the incidence, clinical features and consequences of DMARD-related stomatitis, and suggests an algorithm for its clinical management. The specific objectives of the two studies presented here were to determine the incidence of DMARD-related stomatitis and its effect on DMARD continuation, and secondly to identify the clinical and laboratory risk factors. We investigated two cohorts of patients: (i) a retrospective survey of data collected from drug monitoring clinics run for patients on DMARDs from 1987 to 1994 involving 1539 patients and 2394 drug exposures; (ii) a prospective study of 25 consecutive RA patients presenting with DMARD-related stomatitis compared to 29 RA controls with no history of DMARD stomatitis. The retrospective survey showed that 2% of DMARD patients stopped therapy because of stomatitis, but 55% of these were able to resume the same therapy. In the case control study. 24% of patients discontinued temporarily and 8% permanently. Cases of DMARD-related stomatitis differed from controls in that they had a higher incidence of previous mouth ulcers (40% vs 14%), they smoked less (8% vs 31%) and Schirmer's test was more often abnormal (44% vs 21%). There were no differences in RA severity, disease activity or oral hygiene. Haematinic deficiencies were equally common in cases and controls: 30% for iron, 8% for vitamin B12 and 24% for folic acid. Herpes simplex virus was involved in a minority (8%) of cases. In conclusion, the occurrence of stomatitis in RA patients on DMARD should not lead to cessation of drug therapy, but to a careful evaluation so that patients may be maintained on effective treatment.      

Pituitary adenomas in patients with Cushing disease: initial experience with Gd-DTPA-enhanced MR imaging

To assess the role of magnetic resonance imaging in the evaluation of adrenocorticotropic-hormone (ACTH)-producing pituitary adenomas, and the effect of intravenously administered gadolinium-diethylenetriaminepentaacetic acid (DTPA) on lesion/pituitary contrast, imaging was performed in 13 patients with clinical and chemical evidence of Cushing disease. Images were obtained at 0.5 T before and after the injection of Gd-DTPA (0.1 mmol/kg). Lesions were identified in eight of 12 precontrast and ten of 12 postcontrast studies. In these 12 patients adenomas were found at transsphenoidal surgery. The other patient, with normal images, was found to have an ectopic source of ACTH. Coronal images corresponded remarkably well with the neurosurgeon's intraoperative findings. Serial T1-weighted images disclosed early enhancement of the pituitary gland and delayed enhancement of the cystic adenomas. The discrepancy in times to peak enhancement accounted for improved lesion/pituitary contrast in some early images and for reversal or diminution of lesion/pituitary contrast in later images.     

Transthoracic fine-needle aspiration in the aetiological diagnosis of community-acquired pneumonia

To investigate the safety and practicability of conducting transthoracic fine-needle aspiration (TFNA) in a general hospital setting, we applied the TFNA procedure to 20 patients hospitalized with community-acquired pneumonia (CAP) within 36 h of admission. Also, a preliminary assessment was made of the potential value of adding TFNA to conventional methods of diagnostic microbiology. TFNA was easy to perform and caused little discomfort, and no serious adverse events were observed. In spite of ongoing antimicrobial treatment, a likely aetiological diagnosis was established for 14 of 20 (70%) of the patients. TFNA may provide important additional information on the aetiology of CAP.     

Risk factors for adverse outcomes of bacterial meningitis

Objective : To identify risk factors for adverse outcomes from bacterial meningitis.
Methodology : From a cohort of 166 children with bacterial meningitis who were studied prospectively, 130/158 (82%) survivors underwent neurological, neuropsychological, audiological and behaviour assessments 5–9 years following their illness.
Results : Major adverse outcomes included 8/166 (4.8%) deaths and severe neurological, intellectual or audiological sequelae in 11/130 (8.5%) children followed. Another 24 (18.5%) had cognitive, auditory or behaviour disorders. Bivariate analysis found age ≤12 months, tertiary referral, symptoms >24 h before diagnosis, seizures, focal neurological signs, deteriorating conscious state in hospital, Streptococcus pneumoniae infection and serum sodium concentration < 130 mmol/L were associated with adverse outcomes. Multivariate analysis showed age ≤12 months, symptoms >24 h, seizures after 72 h in hospital and focal neurological signs as independent risk factors. These were present in 18/19 (95%) children with major sequelae, but absent in 9/24 (37.5%) children with minor disabilities.
Conclusions : As minor disabilities following meningitis cannot be predicted, all survivors require assessment during their early school years.     

Expression of the epidermal growth factor receptor family in prostate carcinoma before and during androgen-independence

Novel palliative strategies for patients with androgen-independent prostate cancer (AIPC) include targeting the epidermal growth factor receptor (EGFR) family. The aim of the present study was to investigate intrapatient changes of EGFRs during the development of AIPC. In total, 106 symptomatic AIPC patients were identified in whom prostatic biopsies (adenocarcinoma) were available both before the start of androgen deprivation (PRTR biopsy) and after the development of AIPC (AIPC biopsy). All four known subgroups of the EGFR family were determined by immunohistochemistry (IHC): c-erbB-1 (EGFR), c-erbB-2 (HER2/neu), c-erbB-3 (HER3) and c-erbB-4 (HER4). Moderate to strong membrane-specific staining was recorded semiquantitatively (<10% vs >/=10%=IHC stained tumour cells: 'negative' vs 'positive' staining). The medical records were reviewed for clinical variables. During the development of AIPC, intrapatient changes occurred in two opposite directions for each of the four EGFRs: negativity changed to positivity, and vice versa, statistically significant only for the increase of c-erbB-1 expression (P=0.001). The c-erbB-2 expression in the AIPC biopsy was associated with a significantly shorter survival from the time of the AIPC biopsy (P=0.029). Our results support ongoing therapeutic attempts of EGFR inhibition in subgroups of patients with prostate cancer. Further research is needed to understand the function of EGFRs in this malignancy.     

Laparoscopic navigation pointer for three-dimensional image–guided surgery

Background The main drawback with the laparoscopic approach is that the surgeon is unable to palpate vessels, tumors, and organs during surgery. Furthermore, the laparoscope provides only surface view of organs. There is a need for more advanced visualizations that can enhance the view to include information below the surface of the organs for planning of the procedure and for control and guidance during treatment.Methods We propose three-dimensional (3D) navigation technology based on preoperatively acquired magnetic resonance or computed tomography data used in combination with a laparoscopic navigation pointer (LNP). The LNP has an attached position tracker that allows the surgeon to control the display of images interactively before and during surgery. This study evaluated the patient registration accuracy, the feasibility of image-based navigation and, qualitatively, the navigation precision in the retroperitoneum during laparoscopic surgery.Results This technology was used during the treatment of six patients (involving adrenalectomies and a neuroma protruding into the pelvis). An average patient registration accuracy of 6.90 mm was achieved. The precision during navigation in the retroperitoneum was, in some cases, better than the patient registration accuracy suggested. The technology helped the surgeons to understand better the anatomy and to locate blood vessels.Conclusions In the reported cases, the LNP was a useful tool for image guidance in laparoscopic surgery, both for planning the surgical approach in detail and for guidance. The authors believe that adominal 3D image guidance using an LNP has a large potential for improving laparoscopic surgery, especially when vessels and anatomic relations may be difficult to identify using only a laparoscope. Accordingly, they believe this new technology could increase safety and make it easier for the surgeon to perform successful laparoscopic surgery.