Challenges in diagnosis and management of Cryptococcal immune reconstitution inflammatory syndrome (IRIS) in resource limited settings.

In many resource-limited settings, cryptococcal meningitis (CM) contributes up to 20% of all deaths with further complications due to Immune Reconstitution Inflammatory Syndrome (IRIS). We present a case report on a patient who developed CM-IRIS and then subsequent CM-relapse with a fluconazole-resistant organism and then later CM-IRIS once again, manifesting as cystic cryptococcomas, hydrocephalus, and sterile CSF. In this case we, demonstrate that CM-IRIS and persistent low level cryptococcal infection are not mutually exclusive phenomena. The management of IRIS with corticosteroids may increase the risk of culture positive CM-relapse which may further increase the risk of recurrent IRIS and resulting complications including death. We also highlight the role of imaging and fluconazole resistance testing in patients with recurrent meningitis and the importance of CSF cultures in guiding treatment decisions.

Urinary estrogen metabolites, prostate specific antigen, and body mass index among African-American men in South Carolina.

INTRODUCTION: Estrogen metabolites have been linked to risk of breast cancer, and we were interested in whether they are associated with prostate specific antigen (PSA) and other factors associated with prostate cancer. African-American (AA) men in South Carolina have among the highest prostate cancer rates in the world, and thus provide an ideal population in which to investigate this hypothesis. METHODS: We recruited AA men attending prostate cancer screenings in and around Columbia, South Carolina. Because very few men had elevated PSAs, we restricted our study to the 77 men whose PSA was below the cutpoint used by the screening program to indicate need for diagnostic workup. These men provided spot urine samples and answered demographic and lifestyle questions including self-reported body weight, height, exercise, tobacco use, medications, cancer history and age. Levels of urinary 2-hydroxyestrone (2-OHE1) and 16alpha-hydroxyestrone (16alpha-OHE1), and their ratio (2/16) and blood PSA levels were determined. RESULTS: After adjusting for a statistically significant interaction between age and BMI, we found a reduction of 14.2% in 2-OHE1 for each 1.0 ng/ml increase in PSA (p=0.05). For obese AA men only (BMI> or =30 kg/m2), 2-OHE1 increased by 36% for each decade of age (p=0.009). CONCLUSIONS: Estrogen metabolites may be related to PSA level in AA men. Older men with BMIs greater than 30 kg/m2 had an unexpected increase in 2-OHE1, suggesting a dysregulation of this estrogen metabolism pathway. Further studies of estrogen metabolites may provide insights into prostate cancer risk factors.

Computerized tomography cisternography of the trigeminal nerve for stereotactic radiosurgery. Case report.

A-60-year-old man with medically intractable left-sided maxillary division trigeminal neuralgia had severe cardiac disease, was dependent on an internal defibrillator and could not undergo magnetic resonance imaging. The patient was successfully treated using computerized tomography (CT) cisternography and gamma knife radiosurgery. The patient was pain free 2 months after GKS. Contrast cisternography with CT scanning is an excellent alternative imaging modality for the treatment of patients with intractable trigeminal neuralgia who are unable to undergo MR imaging.

Role of esophagogastroscopy in application and follow-up of high-dose-rate brachytherapy (HDRB) for treatment of esophageal carcinoma.

Flexible esophagogastroscopy (EG) and external beam radiotherapy (EBR) have become important means of diagnosing and treating both squamous and adenocarcinoma of the esophagus and gastroesophageal (GE) junction. Recently, new technology, termed high-dose-rate brachytherapy (HDRB), utilizing the placement of radioisotopes in the esophagus by endoscopic techniques has been introduced. This report describes the endoscopic application of the brachytherapy afterloading catheters and the additional role of EG in the posttreatment assessment of these patients. Twenty-four patients (21 esophageal, 3 GE junction) were treated using HDRB delivered by afterloading catheter techniques utilizing flexible EG. Radiation dosages ranged from 5 Gy (500 rads) to 8 Gy (800 rads) delivered to the tumor bed over an average of three applications. All patients were followed to assess swallowing ability, endoscopic evidence of tumor reduction, and complications resulting from intraluminal radiation therapy. Fifteen patients had reduction in intraluminal tumor based on endoscopic evaluation. Seven had partial or complete relief of dysphagia. Nine patients required gastrostomy tube placement for alimentation before or after therapy. Four patients had complications of perforation (1), fistula (1), or bleeding (2) after HDRB. Overall survival ranged from 2 to 27 months (mean = 8.9 months) after the first HDRB treatment. EG proved to be an efficient and safe technique for the introduction of intraluminal esophageal radiation therapy.

The relationship of sanguinaria extract concentration and zinc ion to plaque and gingivitis.

The effects of sanguinaria extract and zinc chloride on plaque growth and gingivitis inhibition were assessed on subjects with initially plaque-free tooth surfaces using a series of oral rinses in a single-blind, crossover, no-oral-hygiene study lasting 2 weeks. A placebo oral rinse containing no sanguinaria or zinc chloride (A), and test rinses containing 150 micrograms/ml sanguinaria and 0.2% zinc chloride (B), 300 micrograms/ml sanguinaria and no zinc chloride (C), and 300 micrograms/ml sanguinaria and 0.2% zinc chloride (D) were evaluated. Subjects using the higher concentration rinses C and D had significantly lower plaque scores than rinse A at 7 and 14 days (p less than 0.05 for C, p less than 0.01 for D). However, groups C and D were not significantly different from each other. Group D had significantly lower plaque (p less than 0.05) and gingivitis (p less than 0.01) scores than group B. Subjects who used rinse B and placebo rinse A had the highest plaque and gingivitis scores and comparison of these two groups revealed no significant difference. At the end of 14 days, the % distribution of 0 plaque and gingivitis scores was greatest among subjects using rinses C and D. Subjects in these 2 groups also had the lowest incidence of plaque and gingivitis scores of 2+. It is concluded that the effects of sanguinaria rinses on developing plaque and gingivitis are influenced more by sanguinaria concentrations than the presence or absence of zinc ion, but that zinc ion may provide a mild enhancement of sanguinaria effectiveness against gingivitis.

Sanguinarine, a new antiplaque agent: retention and plaque specificity.

Sanguinarine, a component of sanguinaria extract, was investigated for anti-plaque activity and retention in the oral cavity. Oral rinses containing sanguinaria extract showed antiplaque activity in humans. Uptake and retention levels of sanguinarine in plaque and saliva were determined by high-pressure liquid chromatography and sanguinarine levels in plaque were higher than in vitro minimum inhibitory concentrations against oral aerobic and anaerobic bacteria. Further, sanguinarine was able to disclose plaque with the aid of long-wave ultraviolet light and was retained longer than erythrosine and sodium fluorescein as shown by measurement of plaque area. It was concluded that sanguinarine has a high specificity and retention in dental plaque. The plaque-retentive properties in combination with antimicrobial action may be responsible for its clinical anti-plaque efficacy.

Carcinoma of the uterine cervix: results of radiation therapy at a regional community teaching hospital.

We analyzed the results of radiation therapy for carcinoma of the uterine cervix in 144 patients treated at a regional referral hospital. The local control was good in early stage disease, with only two pelvic failures in 92 stages I and II patients. Survival at 40 months was 86%, 83%, 48%, and 75% for stages I, IIa, IIb, and IIb (barrel-shaped lesions), respectively. Many IIb lesions could have been staged as IIb (barrel-shaped lesions). Control and survival in late disease was poor. The complications were minimal.

Radiation dermatitis: a case report.

A unique form of vasculitis occurring six months after radiation therapy for postoperative breast cancer is described herein. This rare, unexplainable reaction is a very unusual occurrence.