Color duplex sonography in post-therapeutic neck evaluation

PURPOSE: Assessment of the clinical utility of color duplex sonography for post-therapeutic evaluation of the neck. PATIENTS AND METHODS: Eighty neck sides were evaluated in a prospective nonrandomized study during the post-therapeutic course. Of these, 74 previously had undergone surgery, and 60 subsequently had additional radiotherapy. The diagnostic procedures applied were clinical examination, computed tomography, positron emission tomography, and color duplex sonography. The mean observation period was 18.6 months. RESULTS: Seven of 80 (8.75%) neck sides exhibited recurrent disease, and 76.2% of the lymph nodes resected during the postoperative observation period showed malignancy. Color duplex echography could detect all lymph nodes. Sensitivity was 100%, and the specificity was 95.8%. The sensitivity and specificity of computed tomography and positron emission tomography were found to be 85.7% and 97.2%, respectively. Palpation had a sufficient specificity (95.8%) but only a very poor 14.2% sensitivity in the post-therapeutic neck. CONCLUSION: In complex tissue alterations of the post-therapeutic neck, color duplex echography is a highly sensitive and easily applied diagnostic procedure for the detection of recurrent disease. It allows a high-resolution depiction of intranodal vascularization and adjacent structures. Problems may occur in the evaluation of vessels in nodes with a diameter of 6 millimeters and below. This may impair specificity in some cases.     

Acute mediastinitis: a severe complication of transdermal therapy in a patient with ischaemic heart disease. A case report

Acute mediastinitis is an uncommon and potentially devastating infection. Generally, mediastinitis occurs as a postoperative infection following median sternotomy. We describe a case of acute mediastinitis in a patient with ischaemic heart disease, secondary to the spread of cutaneous infection of the chest wall in the application site of transdermal nitroglycerine patches.     

Survival in second primary malignancies of patients with head and neck cancer

Second primary tumours occur frequently in patients with a history of head and neck malignancies. Delays in making an early and correct diagnosis can seriously affect the therapy management and survival. This was a retrospective study of 120 patients with a history of head and neck cancer, presenting with a second primary tumour. Current follow-up strategies and the use of routine sonographic imaging of the head and neck regions were evaluated, and the impact that tumour chronology, the tumour site and the various treatment modalities have on the survival were assessed. Forty-two per cent of patients developed a metachronous second malignancy more than five years after diagnosis of the index tumour. The accuracy of colour-duplex sonography in detection of second primaries in the head and neck was 82.3 per cent. First and second primary tumours located in the larynx were observed to have the highest five-year survival rate. Patients who developed metachronous tumours had a five-year survival rate of 68.9 per cent for the index tumours, and a 26 per cent five-year survival rate with the occurrence of a second neoplasm. With synchronous tumours a mean survival time of 18 months and a five-year survival rate of 11.9 per cent was found (p < 0.0001). Where clinically appropriate an aggressive treatment strategy was employed and yielded the most favourable results with a five-year survival rate of 66.8 per cent and 35.9 per cent for index tumours and second primary malignancies, respectively. Since more than 40 per cent of the metachronous second primaries in patients with a history of head and neck malignancy occur beyond the five-year follow-up period, an extended protocol with individually adjusted close monitoring of high-risk patients seems appropriate. Colour-duplex sonography is a valuable screening investigation for the early detection of second primary tumours. The treatment of a second primary is often less successful than for the same malignancy occurring primarily. The prognosis of synchronous tumours is significantly lower when compared to malignancies of a metachronous nature, despite some encouraging individual results. Only the early implementation of aggressive treatment methods for second primaries is successful in terms of survival.     

A sequence of immuno-chemotherapy with Rituximab, mobilization of in vivo purged stem cells, high-dose chemotherapy and autotransplant is an effective and non-toxic treatment for advanced follicular and mantle cell lymphoma

Options for relapsed/refractory indolent lymphoma include chemotherapy, immunotherapy and high-dose therapy with autologous support. The best combination of these approaches, however, is not defined. We treated 10 patients with relapsed/refractory follicular (n = 7) or mantle cell lymphoma (n = 3) using chemotherapy, immunotherapy, high-dose therapy and autotransplant in a sequence of four phases, each designed to play a specific role in tumour eradication. After the debulking with VACOP-B (doxorubicin, cyclophosphamide, etoposide, vincristine, prednisone, bleomycin) (phase 1), 9/10 patients responded but none achieved a molecular response. After the immuno-chemotherapy phase, which combined Rituximab with vincristine and cyclophosphamide, seven patients were in complete response (CR) and three in good partial response (PR), and all those with a molecular marker of disease showed a disappearance of the signal from marrow and blood. Phase 3, which coupled high-dose cytarabine with Rituximab, was effective in mobilizing an adequate number of progenitor cells that were polymerase chain reaction negative in all informative cases. Phase 4 consisted of high-dose therapy with autologous support followed by two doses of Rituximab. Autograft was performed in nine patients. The haematopoietic recovery was as expected. This sequence of chemotherapy, immuno-chemotherapy, stem cell mobilization with in vivo purging and autotransplant, organized in four blocks of treatment, was simple to administer and devoid of toxic effects. It permits rapid attainment of clinical and molecular response and enables the harvest of lymphoma-free peripheral blood progenitor cells even in heavily pretreated patients with relapsed or refractory disease.     

Care protocols for diseases caused by bioterrorism

Epidemics due to bioterrorist actions and prevention and control measures of these infections have been worrying not only the policy makers but also health professionals in general. Health professionals have to recognize these diseases earlier. Information and updated studies about the issue are needed. This study is a literature review in the MEDLINE and LILACS databases, books and online information (from 1993 to 2001) about epidemic aspects of the main diseases due to bioterrorist actions and care recommendations for infection control and occupational risk minimization. Healthcare professionals, who assist patients directly, should be prepared to assist patients who become ill in isolated or epidemic situations.     

Medium-term effects of bisoprolol administration on renal hemodynamics and function in mild to moderate essential hypertension

Arterial hypertension is a significant cause of end-stage renal failure; effective treatment of hypertensive patients reduces the rate of progression of this disorder. β-Blockers, particularly nonselective agents, are associated with deterioration of renal function in patients with chronic renal failure. Previous studies on the interaction of the β₁-selective adrenergic antagonist bisoprolol with kidney function have been performed only acutely and over the short term. This study was designed to evaluate the antihypertensive efficacy and effects on renal hemodynamics and function of bisoprolol during medium-term (6 mo) treatment of patients with mild to moderate essential hypertension. After a 2-wk run-in period on placebo, 87 consecutive hypertensive patients (46 men, 41 women) according to ESH-ESC (European Society of Hypertension/European Society of Cardiology) guidelines, aged from 27 to 64 y (mean age, 50±11 y), without renal or cardiovascular disease, were enrolled and assigned to treatment with bisoprolol 5 mg once daily for 6 mo. At recruitment and at 6 mo after treatment, renal function was assessed and renal hemodynamics evaluated in all patients through radioisotope studies. The mediumterm effects of bisoprolol included a significant reduction in blood pressure and heart rate (P< .001) without significant adverse drug reactions. Moreover, bisoprolol produced no alteration in renal function or hemodynamics, or in cardiac output. Data presented here indicate that bisoprolol 5 mg given once daily to treat patients with mild to moderate essential hypertension is effective and safe for treatment and for preservation of renal performance when given on a medium-term basis.     

Efficacy of combined intravesical immunotherapy and chemotherapy for non-muscle invasive bladder cancer

Intravesical immunotherapy using attenuated bacillus Calmette-Guérin (BCG) strains and intravesical chemotherapy are the modalities most commonly used to treat intermediate- or high-risk patients with non-muscle invasive bladder cancer. BCG has been shown to decrease recurrence rates by up to 67% compared with tumor resection alone, but intensive BCG maintenance regimens are poorly tolerated in a large proportion of patients. Intravesical chemotherapy also decreases the risk of recurrence for these patients, but has diminished efficacy compared with BCG. If BCG dose reduction can be achieved with combined intravesical immunotherapy and chemotherapy, this regimen may improve compliance and thus optimize treatment for these patients by limiting side effects from BCG monotherapy, while at the same time improving oncologic efficacy via the separate anti-tumor mechanisms of these agents. The authors discuss the most recent data regarding combining these agents in an alternating or sequential regimen.