Target range maximum of cyclosporine blood concentration two hours post dose in stable liver transplant patients

Recently, single blood level measurement 2 hours after cyclosporine administration (C2) is taken as a more sensitive indicator of drug exposure in de novo transplant recipients than trough levels (C0). However, few studies focused on the determination of the C2 target range maximum and its associated adverse events in stable liver recipients. This prospective study was designed to assess the relative risk of developing CsA related side effects in patients with high C2-levels. Adverse effects were determined clinically, and by using a specially designed questionnaire. Eventual adverse events as well as C2 levels were determined repeatedly up to 4 times in 3-months intervals (observation period 9 +/- 3 months) in 36 long-term liver recipients (1-13.5 years post-transplant), in addition to conventional C0 levels. Cyclosporine dose was adjusted according to a predefined C0 target level range and clinical status. Totally 103 questionnaires and the corresponding paired CsA blood level records were obtained. C0 levels and C2 levels ranged from 90 to 287 (143 +/- 31) ng/ml and from 212 to 1358 (672 +/- 203) ng/ml respectively. No patient experienced a rejection episode during the observation period, demonstrating the efficiency of the immunosuppressive therapy. However, 33/36 patients (91%) showed symptoms attributable to CsA therapy. C2 levels above 750 ng/ml, determined at least twice in an interval of 3 months, were identified as a relevant risk factor for the presence of multiple adverse effects, which were defined as the combination of hypertension, renal insufficiency and more than two neurological complaints (RR = 3.11, p<0.01). This risk population was not completely identified by determination of C0 level.     

Eosinophilic Pustular Folliculitis in Infancy: Report of Two New Cases

Eosinophilic pustular folliculitis (EPF) is a cutaneous inflammatory follicular disorder of unknown etiology. The diagnosis is made on the basis of clinical and histopathologic features. We describe two patients who had recurrent episodes of pruritic follicular papular and pustular lesions on the face, extremities, and trunk. The eruptions lasted for 1 month with intermittent remissions. Laboratory tests disclosed no infectious or parasitic etiology in patient 2. In patient 1 we isolated methicillin-resistant Staphylococcus aureus in a blood culture. He had sepsis with lung and liver involvement. EPF is a self-limited dermatosis. On occasion, skin lesions may become superinfected, resulting in localized pyoderma or rarely systemic infection (sepsis). Histologically both of our patients showed a moderate mixed inflammatory infiltrate with numerous eosinophils centered around hair follicles. Their lesions responded well to topical corticosteroids.     

Comprehensive asthma management for underserved children

In response to the 'asthma epidemic', local organisations in San Francisco formed the Yes We Can Urban Asthma Partnership, which uses a comprehensive medical/social model for paediatric asthma care. The Yes We Can Urban Asthma Partnership reaches out to high-risk children in different clinical settings: urgent visits, the hospital, a comprehensive specialty asthma clinic, and through an expanded community health worker programme. This article highlights the initial development, implementation, and evaluation of the success of this innovative management programme to address the problem of paediatric asthma in underserved urban areas.     

Multidisciplinary approach to "accidental" falls in the elderly: A case report

Falls in the elderly are commonly and often wrongly identified as "accidental". We report a case of an elderly woman admitted to first aid for a trauma due to an accidental fall. Geriatric multidisciplinary evaluation revealed mild cognitive impairment associated with depressive symptoms; both findings made the anamnesis uncertain. Syncope algorithm was applied and "tachy-brady form of sick sinus syndrome" was diagnosed. Differential diagnosis between "accidental" and "apparently accidental" falls in elderly patients is very difficult but a multidisciplinary geriatric evaluation can clarify the correct diagnosis.     

Her-2/neu evaluation in Sister Mary Joseph's nodule from breast carcinoma: a case report and review of the literature

Sister Mary Joseph's nodule (SMJN) involving the umbilicus can often be a clinical sign of metastatic cancer, but rarely cancer originating from the breast. We report a rare case of umbilical metastases from breast cancer and reviewed the literature. A 54-year-old woman was referred to a pre-surgery clinic for an examination of an umbilical nodule. The patient had a history of ductal breast carcinoma. Cytological smear from fine needle aspiration showed epithelial neoplastic cells resembling those of breast carcinoma. Neoplastic cells from tissue were positive for cytokeratin 8–18, estrogen and progesterone receptor and negative for E-cadherin and had a low proliferative index. Her-2/neu immunodetection showed a 2+ equivocal positive rate, but Her-2/neu gene amplification was found on the cytological smear by fluorescence in situ hybridization analysis. Similar results were obtained within a tissue section. Concordant findings have been obtained when comparing the recent American Society of Clinical Oncology/College of American Pathologists scoring system. Fine needle aspiration from the SMJN is a useful tool for the diagnosis of metastatic breast cancer. Furthermore, the predictive biomarkers for tumors of the breast, hormonal receptors and Her-2/neu not only assist with the identification of the source of the metastatic disease but also provide clinical information for patient management.     

Primary small cell carcinoma of the nasal cavity with an unusual oral manifestation

Small cell carcinoma (SCC) is a malignancy that mainly occurs in the lung, with primary lesions in the head and neck being very rare. This neoplasm has an aggressive growth pattern, high recurrence rate, and tendency to metastasize to other sites via the lymphatics and bloodstream. The prognosis of patients with SCC is poor, as the 5-year survival is only 13%. Treatment options include surgical excision, multiple-agent chemotherapy, and radiation therapy. We report a rare case of primary SCC of the nasal cavity presenting as a lesion of the hard palate and describe its clinical, histologic, and immunohistochemical features.     

Lifestyles and Cardiovascular Risk in Individuals With Functional Psychoses

PURPOSE.  This study aims to examine known determinants of cardiovascular risk in Italian patients with functional psychoses.
DESIGN AND METHODS.  A cross-sectional study design was used to examine cardiovascular risk factors and lifestyle behaviors of 123 individuals with functional psychosis and compare clinically relevant data with those of the general Italian population.
FINDINGS.  A significant proportion of patients manifested frank hypertension (6.9%), hypercholesterolemia (20.5%), diabetes (6.5%), or a body mass index of more than 30 (20.3%). Many also smoked (63.0%) or ingested alcohol every day (26.0%), did not eat fruits or vegetables (8.0%), or did not exercise on a daily basis (34.0%).
PRACTICE IMPLICATIONS.  Patients with psychosis manifest significant rates of potentially reversible risk factors for cardiovascular diseases. Mental health nurses should advocate for and implement well-resourced counseling programs to reduce the prevalence of smoking and metabolic syndrome in mental health populations.     

Omalizumab (Xolair) in children with seasonal allergic rhinitis: Leukotriene release as a potential in vitro parameter to monitor therapeutic effects

To investigate the effect of omalizumab, a humanized monoclonal antibody, in addition to specific immunotherapy (SIT) on in vitro sulfidoleukotriene release (SLT) (A) before, (B) directly after, and (C) 1 yr after treatment with omalizumab. Children and adolescents (6.3-17.6 yr) with sensitization to birch and grass pollens and suffering from seasonal allergic rhinitis were included in a Phase III, placebo-controlled, multicenter clinical study. Within the four-arm study, patients were randomly chosen to receive SIT for either birch or grass pollen and either subcutaneous omalizumab or placebo for 24 wk during the pollen season. Thereafter, omalizumab or placebo treatment ended, but SIT therapy continued. Blood samples were collected from 92 (A, B) and 78 children (C), respectively. Leukocytes were isolated and stimulated with grass and birch pollen allergens. In the supernatants, SLT (LTC4, LTD4, LTE4) were measured using ELISA [cellular allergen stimulation test, DPC-Biermann, Germany]. At the end of treatment the combination of omalizumab + SIT-grass [median SLT-release: 2125 (before) and 416 ng/ml (after omalizumab treatment); p < 0.001] as well as omalizumab + SIT-birch [1404 and 207 ng/ml; p < 0.001] resulted in significantly lower SLT release after stimulation with the corresponding allergen compared to placebo + SIT-grass [2231 and 2490 ng/ml] or placebo + SIT-birch [1324 and 2489 ng/ml]. One year after omalizumab or placebo treatment, there was no significant difference in SLT release between the 4 groups (omalizumab + SIT-grass: 2855; SIT-grass + placebo: 2543; omalizumab + SIT-birch: 2417; SIT-birch + placebo: 2573 ng/ml). These results strongly suggest that the observed effects of decreased SLT release after omalizumab treatment were attributable to the treatment with omalizumab, rather than to SIT therapy.     

Thrombotic thrombocytopenic purpura in advanced prostate cancer: Case report and published work review

Thrombotic thrombocytopenic purpura (TTP) is a generalized disorder of the microcirculation characterized by microangiopathic hemolytic anemia (MHA), thrombocytopenic purpura and systemic microvascular thrombi. TTP has been previously described in two patients with prostate cancer (PC). We report a third case of TTP in a 61-year-old man with hormone-refractory bone metastatic PC. The syndrome presented with confusion, anuric acute renal failure, thrombocytopenia and MHA. A satisfactory recovery was achieved after plasma exchange (PE). TTP should be included in the coagulation disorders occurring in PC patients. Early treatment with plasma exchange is recommended in these particular cases.