“Pseudo-Narrowing” during right coronary angioplasty: How to diagnose correctly without withdrawing the guidewire

The straightening of a sinuous proximal segment of a coronary artery using the stiffness of the guidewire has recently been recognized as likely to cause false coronary lesions. The accurate diagnosis between a true dissection and a pseudo-lesion is usually only done once all intra-coronary material has been removed into the guiding catheter. Such a manoeuvre may prove dangerous in case of dissection. We propose to demonstrate that it is possible to diagnose this phenomenon while leaving the guidewire within the coronary artery, and withdrawing it progressively until its floppy segment rests equally on either side of the suspect lesion.     

Liver transplantation in exertional heat stroke: a medical dilemma

Background Exertional heat stroke (EHS) is a life-threatening condition caused by an extreme elevation in core body temperature. Hepatic involvement is one of the hallmarks of heat stroke, affecting nearly all heat stroke patients. It is usually manifested by increased serum levels of liver enzymes, but acute liver failure has also been reported. Liver transplantation has been proposed as a potential treatment in cases of severe liver failure, but there are no unanimous criteria pointing to the right stage in which to conduct the transplantation.Case presentation We report a case of an 18-year old patient who suffered heat-induced liver failure. The patient was referred for orthotopic liver transplantation (OLT) but spontaneously recovered completely with conservative treatment.Conclusions This case demonstrates the complexity of the decision for liver transplantation in EHS. The various prognostic criteria of acute hepatic failure and their relevance to EHS are critically reviewed, with an aim to assess their application for such a condition.     

The clinical and laboratory spectrum of dedicator of cytokinesis 8 immunodeficiency syndrome in patients with a unique mutation

Mutations in the dedicator of cytokinesis 8 (DOCK8) gene cause a combined immunodeficiency usually diagnosed as autosomal recessive hyper IgE syndrome. We sought to reveal the varying manifestations in patients with a unique mutation in DOCK8 gene by a retrospective medical record review. Ten patients from five consanguineous families and three tribes were included. Seven patients were homozygous for the c.C5134A, p.S1711X mutation, and the remaining three patients were their siblings manifesting hyper IgE syndrome features without a genetic diagnosis. Prior to the genetic diagnosis, the clinical diagnosis was “hyper IgE syndrome” in six patients and “anti-pneumococcal antibody deficiency,” “recurrent pneumonia with bronchiectasis,” and “asthma with hypereosinophilic syndrome” each diagnosed once. One additional patient was diagnosed due to family history. The age of presentation varied from 1 to 16 months. Eczema was diagnosed in all patients, food allergies in three, and severe herpes keratitis or malignancy or autoimmunity in two patients. Elevated IgE was recorded in nine patients; however, in six patients, the initial serum IgE concentration was equal to or less than three times the normal concentration for age, and in these patients, the median age at IgE evaluation was 7.5 months compared with 21.5 months in patients with an initial IgE concentration above three times the normal concentration for age (P = 0.067). The spectrum of disease manifestations in patients with a unique mutation in DOCK8 is variable. The genotype-phenotype correlations may be modified by genetic and/or epigenetic modifiers beyond the monogenic effect. Younger patients tend to have lower IgE concentrations at the initial measurement of IgE.     

High performance liquid chromatographic determination of etofibrate and its hydrolysis products

High performance liquid chromatographic (HPLC) method is presented for the determination of etofibrate (EF) and its hydrolysis products. The method was based on HPLC separation of EF from its hydrolysis products using cyanopropyl column at ambient temperature with mobile phase consisting of acetonitrile-10 mM potassium dihydrogen phosphate, pH was adjusted to 4.1 using phosphoric acid (50:50, v/v). Quantitation was achieved with UV detection at 221 nm based on peak area. The flow rate was 1.5 ml min(-1). The proposed method was used to investigate the kinetics of acidic hydrolysis process of EF at different temperatures and the apparent pseudo first-order rate constant, half-life and activation energy were calculated. The kinetics of alkaline hydrolysis process of EF using 0.01 M sodium hydroxide at different temperatures cannot be studied as the drug is rapidly hydrolyzed in alkaline medium. The pH-rate profile of hydrolysis of EF in Britton-Robinson buffer solutions within the pH range 2-10 were studied.     

The Effect of Roux-en-Y Gastric Bypass on Zinc Nutritional Status

Background Researchers have found that zinc nutritional status in obese and diabetic subjects is altered: low zinc concentrations in plasma and erythrocytes, with high urinary zinc excretion, were observed. This study evaluated the effect of Roux-en-Y gastric bypass (RYGBP) on plasma, erythrocyte and urinary zinc concentration. Methods 22 morbidly obese patients were studied before and 6 months after RYGBP. Fasting blood sample and 24-hour urine were collected in the pre- and postoperative phases. A software analyzed the diet information from 3-day food records after RYGBP. Zinc nutritional status was evaluated by determination of the concentration of this mineral in plasma and erythrocytes, and the urinary excretion of zinc / 24 hours by atomic absorption spectrophotometry. Results The diets consumed by the patients had adequate average concentrations of zinc. Zinc concentration in plasma, erythrocytes and urine were within the values of normality before RYGBP, with mean values of 93.25 ± 19.34 μg/dL, 43.85 ± 7.76 μg Zn/gHb and 583.05 ± 359.30 μg Zn/24 hours, respectively. At 6 months after RYGBP, there was a change in these parameters to 69.82 ± 10.95 μg/dL, 51.80 ± 6.92 μg Zn/gHb, 535.29 ± 216.40 μg Zn/24 hours in the concentration of plasma, erythrocyte and urinary zinc. Conclusion These results suggest that RYGBP promoted, besides change in body composition, an alteration in the zinc plasma and erythrocytes concentrations which in the medium and long term, could cause problems for these patients.     

Pharmacokinetics of fluphenazine, a highly lipophilic drug, estimated from a pulse dose of a stable isotopomer in dogs at steady state.

The potential utility of a pulse dose of a deuterium-labeled isotopomer (FLU-D(4)) in elucidating the pharmacokinetics of fluphenazine (FLU) at steady state was investigated in dogs. The single-dose oral pharmacokinetics of FLU in dogs were established. After resting the dogs for 3 weeks, the animals were dosed to steady state with oral FLU administered at 12-h intervals. Following 15 doses, one dose of FLU was replaced by a pulse dose of FLU-D(4), after which dosing with FLU was resumed. FLU and FLU-D(4) plasma concentrations were determined by tandem mass spectrometry. Comparable estimates of apparent oral clearance were calculated from (i) a single dose of FLU, (ii) a pulse dose of FLU-D(4), and (iii) over a dosing interval at steady state. Average steady-state plasma concentrations were reliably predictable from a pulse dose of FLU-D(4).     

Population pharmacokinetics of levofloxacin, gatifloxacin, and moxifloxacin in adults with pulmonary tuberculosis

The objective of this study was to determine the population pharmacokinetic parameters of levofloxacin, gatifloxacin, and moxifloxacin following multiple oral doses. Twenty-nine patients with tuberculosis at the University Hospital in Vitória, Brazil, participated. Subjects received multiple doses of one drug (levofloxacin, 1,000 mg daily, or gatifloxacin or moxifloxacin, 400 mg daily) as part of a 7-day study of early bactericidal activity. Serum samples were collected over 24 h after the fifth dose and assayed using validated high-performance liquid chromatography assays. Concentration-time data were analyzed using noncompartmental, compartmental, and population methods. The three drugs were well tolerated. Levofloxacin produced the highest maximum plasma concentrations (median, 15.55 microg/ml; gatifloxacin, 4.75 microg/ml; moxifloxacin, 6.13 microg/ml), largest volume of distribution (median, 81 liters; gatifloxacin, 79 liters; moxifloxacin, 63 liters), and longest elimination half-life (median, 7.4 h; gatifloxacin, 5.0 h; moxifloxacin, 6.5 h). A one-compartment model, with or without weight as a covariate, adequately described the data. Postmodeling simulations using median population parameter estimates closely approximated the median values from the original data. Area under the concentration-time curve/MIC ratios for free drug were high. All three quinolones showed favorable pharmacokinetic and pharmacodynamic indices, with the most favorable results in this population being seen with levofloxacin at the comparative doses used.     

Spectrophotometric and liquid chromatographic determination of trimebutine maleate in the presence of its degradation products

Three methods are presented for the determination of trimebutine maleate (TM) in the presence of its degradation products. The first method was based on a high performance liquid chromatographic (HPLC) separation of TM from its degradation products using an ODS column at ambient temperature with a mobile phase consisting of acetonitrile-5 mM heptane sulfonic acid disodium salt (45:55, v/v, pH 4) with UV detection at 215 nm. The second method depends on using first derivative spectrophotometry (1D) by measurement of the amplitude at 252.2 nm. The third method depends on using first derivative of the ratio spectrophotometry (1DD) by measurement of the amplitude at 282.4 nm where a normalized spectrum of 3,4,5-trimethoxy benzoic acid is used as divisor. The proposed HPLC and 1D methods were used to investigate the kinetics of acidic and alkaline degradation processes. The pH-rate profile of degradation of TM in Britton-Robinson buffer solutions within the pH range 2-11.9 was studied.     

Interferon-induced Raynaud's syndrome

OBJECTIVE: To review the clinical features, diagnosis, treatment, and outcome of interferon-induced Raynaud's phenomenon. METHODS: The medical literature was reviewed from 1967 to November 2001 with the assistance of a MEDLINE search using the key words: Raynaud, Interferon, ischemia, thrombosis and necrosis. A qualitative review was performed after the articles were abstracted and the relevant information was summarized. RESULTS: Twenty-four cases of interferon-induced Raynaud's phenomenon (including our patient) are described. Interpheron-alpha was the most common causative agent (14 cases). The symptoms appeared weeks to years after beginning treatment and varied from mild vasospasm to occlusion of digital arteries and tissue necrosis (14 cases), sometimes necessitating finger amputation (6 patients). Digital plethysmography, arteriography and capillaroscopy were valuable diagnostic tools. In 4 cases, cardiac, ophthalmic, or central nervous system drug-induced ischemia accompanied the peripheral Raynaud's phenomenon. Of the 15 cases with a documented outcome, withdrawal of the drug alone resulted in complete (6 patients) or partial (1 patient) recovery. In the others, supportive therapy was needed. The recovery period lasted from 2 weeks to 3 months. In 2 patients, continuation of treatment was possible. CONCLUSIONS: Raynaud's phenomenon and related complications must be recognized as possible side effects of interferon therapy. Early diagnosis and withdrawal of the drug may prevent unnecessary morbidity and disability.