Detection of extra-regional tumour recurrence with 18F-FDG-PET/CT in patients with recurrent gynaecological malignancies being considered for radical salvage surgery.

AIM: To compare the detection rate of extra-regional metastases in patients with recurrent gynaecological malignancies being considered for radical salvage surgery with combined 2-[18F]-fluoro-2-deoxy-d-glucose (18F-FDG) positron-emission tomography (PET)/computed tomography (CT) compared to conventional imaging. MATERIALS AND METHODS: A retrospective review was performed of all patients in a provincial database with recurrent gynaecological malignancies being considered for pelvic exenteration that underwent restaging with CT/PET between March 2011 and October 2014. Findings on PET and conventional imaging (CT±pelvic MRI) were abstracted. Disease sites were classified according to the location (regional nodal metastases, extra-regional nodal metastases, peritoneum, or other distant sites) and diagnostic certainty (definitive or equivocal). The proportion of patients positive for extra-regional recurrence was calculated for PET and conventional imaging. In addition, the proportion of patients with indeterminate lesions only was calculated for each modality and the sites of indeterminate findings were tabulated. RESULTS: There were 85 patients (median age, 50 years; range: 30-81 years) with carcinoma of cervix (n=51), endometrium (n=18), vagina (n=6), or vulva (n=10). Extra-regional recurrence was detected in 8/85 (9.4%) and 24/85 (28.2%) patients on conventional imaging and PET, respectively (p=0.0017). The greatest impact of PET compared to conventional imaging was in the detection of extra-regional nodal metastases. PET had significantly fewer examinations equivocal for extra-regional recurrence versus conventional imaging (6/85 [7.1%] and 38/85 [44.7%], respectively, p<0.001). CONCLUSION: In patients with recurrent gynaecological malignancies being considered for radical salvage surgery, PET may identify significantly more extra-regional recurrence than conventional imaging. PET may also result in fewer equivocal lesions. The impact of these results on patient management and outcome should be confirmed in future prospective trials.

Piperacillin/tazobactam-induced immune-mediated thrombocytopenia in the intensive care unit.

WHAT IS KNOWN AND OBJECTIVE: Drug-induced immune-mediated thrombocytopenia is a rare adverse event that remains a diagnostic challenge, especially in the critically ill population. There are only two previously reported cases of rapid and profound thrombocytopenia after administration of piperacillin/tazobactam. CASE SUMMARY: A 64-year-old man experienced several episodes of isolated thrombocytopenia after receiving piperacillin/tazobactam. Interestingly, the degree of thrombocytopenia varied with the amount of corticosteroid therapy the patient was receiving. Due to the complexity of thrombocytopenia in critically ill patients, other potential causes were extensively worked up and ruled out. WHAT IS NEW AND CONCLUSION: We describe the first case of piperacillin/tazobactam-induced immune-mediated thrombocytopenia that was mitigated by the administration of corticosteroid therapy. This case highlights the importance of identifying potential drug-related causes of isolated thrombocytopenia.

Anaesthetic management of a caesarean section in a patient with Marfan's syndrome and aortic dissection.

This report describes a case of a Stanford Type B aortic dissection (originating distal to the left subclavian artery and extending to the aortic bifurcation and proximal left iliac artery) in a 31-year-old primigravid woman who was at 39 weeks gestation and had Marfan's syndrome. The dissection was managed conservatively. Caesarean section was performed under epidural anaesthesia with aggressive control of hypertension. Postoperatively, there was no extension of the dissection and no aneurysm formation. She was discharged from hospital two weeks after delivery and remained asymptomatic at six months. There are no plans for surgical intervention.

Severe gastrointestinal bleeding after hematopoietic cell transplantation, 1987-1997: incidence, causes, and outcome.

OBJECTIVE: Severe GI bleeding after hematopoietic cell transplantation is commonly due to lesions that are unusual in nontransplant patients. The frequency of GI bleeding appears to have decreased over the last decade, but the reasons have not been readily apparent. We sought to determine the incidence of severe bleeding during two time periods, to describe the causes and outcomes of bleeding, and to analyze the reasons behind an apparent decline in severe bleeding over the decade covered. METHODS: During 1986-1987 and 1996-1997, we followed all patients with and without severe bleeding at our institution, a marrow transplant center. RESULTS: Over this decade, the incidence of severe bleeding declined from 50/467 (10.7%) to 15/635 (2.4%) (p < 0.0001). Overall mortality from intestinal bleeding declined from 3.6% to 0.9% (p = 0.002), but mortality in those with bleeding remained high (34% vs 40%). The onset (day 42 vs 47) and platelet counts (35,994 vs 37,600/microl) were similar, but the sites and causes of bleeding were different. During 1986-1987, 27/50 patients bled from multiple GI sites, viral and fungal ulcers, or graft-versus-host disease (GVHD). Over the decade, bleeding from GVHD had decreased 80% (p < 0.0001), and bleeding from viral (p < 0.0001) and fungal (p = 0.023) ulcers almost disappeared. CONCLUSIONS: The incidence of severe GI bleeding has declined significantly over the last decade because of prevention of viral and fungal infections and severe acute GVHD. However, severe bleeding after transplant remains a highly morbid event, particularly among patients with GVHD.

Pseudomembranous colitis: an update.

Clostridium difficile is the most common nosocomial infection of the gastrointestinal tract. Most cases are associated with antibiotic therapy that alters the fecal flora, allowing overgrowth of C difficile with production of its toxins. Diagnosis is made by detection of the organism or toxin in the stools. A variety of different tests can be used, but none is perfect. A stool culture can be positive in someone without diarrhea, ie, a carrier. While the cytotoxin is the gold standard, it is expensive, and there is a delay before results are available. Thus, many laboratories use the enzyme-linked immunoassay tests to detect toxin of C difficile because they are a more rapid screen. Depending on the specific test used, they can detect toxin A, toxin B or occasionally both. Sensitivity and specificity rates vary. First line therapy for C difficile disease should be metronidazole 250 mg qid for 10 days. Vancomycin should be reserved for severe cases where metronidazole has failed or where metronidazole cannot be tolerated or is contraindicated. Recurrent C difficile disease is a particularly vexing clinical problem. A variety of biotherapeutic approaches have been used. Retreatment with antibiotics is almost always necessary. In addition, the nonpathogenic yeast Saccharomyces boulardii has been showed to be of benefit as an adjunct in preventing further recurrences.

Anorectal pathology in AIDS.

Anorectal complaints are common in persons with AIDS and are being seen increasingly because advances in therapy for HIV, such as the new antiretroviral protease inhibitors, have resulted in longer life expectancy for those with HIV infection. In the past, many patients with HIV infection were seen at referral centers; now, however, primary care physicians as well as gastroenterologists and surgeons in the community are managing and caring for these patients. For this reason, it is important for clinicians to recognize the spectrum of anorectal disease in patients with AIDS, as well as its appropriate evaluation and management.

Limited utility of emergency department thoracotomy.

To assess the therapeutic role and cost effectiveness of resuscitative thoracotomy in an urban trauma center, a retrospective review of thoracotomies (n = 273) performed in a trauma unit between 1986 and 1992 was undertaken. A total of 252 thoracotomies were performed for penetrating injuries (92%), and 21 (8%) were performed for blunt trauma. Ten neurologically intact survivors (3.7%) were identified. Mechanisms of injury in survivors were stab wound (n = 6) and gunshot wound (n = 4). There were no neurologically intact survivors when resuscitative thoracotomy was done for blunt trauma. All survivors sustained penetrating truncal injuries; isolated thoracic injuries existed in six patients, while four patients presented with both thoracic and abdominal wounds. All survivors had signs of life either in the field or in the trauma unit. Of the 242 non-survivors who had sustained penetrating trauma, only 49 had signs of life either in the field or upon arrival at the trauma unit. In this group, survival was 17 per cent. Revised Trauma Scores, calculated in the trauma unit, failed to differentiate between survivors and nonsurvivors. In 1992, the average hospital charge for resuscitative thoracotomy was $3413 per patient. Total charges during the study period for resuscitative thoracotomy were approximately $932,000. This represents an expenditure of $93,000 per successful thoracotomy. If thoracotomy was limited to patients sustaining penetrating trauma who demonstrated signs of life, total charges would be approximately $201,367, representing an expenditure of $20,137 per successful thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Value of preoperative bone and liver scans and alkaline phosphatase in the evaluation of breast cancer patients.

We reviewed the results of 133 bone scans and 63 liver scans (computed tomography, liver-spleen radionuclide scan, or ultrasonography) obtained for the preoperative evaluation of breast cancer patients. Information on the preoperative staging of breast cancer (TNM classification) was available in 131 of 133 patients. Bone scans had a low preoperative yield as only 4 of 133 patients (3%) had a positive bone scan that correlated with the results of plain films. Only 1 of 63 patients had a liver scan suggestive of possible metastasis. We also found that the alkaline phosphatase level was not a good predictor of bone or liver metastases in breast cancer patients. In 103 patients with normal bone scans, the majority (54%) had elevated alkaline phosphatase levels; conversely, 9 of 30 patients (30%) with abnormal scans had normal alkaline phosphatase levels. Furthermore, 51 of 63 patients (81%) with elevated alkaline phosphatase levels had normal liver scans. Approximately $74,000 was spent on these liver and bone scans.

The effect of superoxide dismutase alleles on aging in Drosophila.

The effects of superoxide dismutase on aging were tested using two different experimental approaches. In the first, replicated populations with postponed aging were compared with their controls for frequencies of electrophoretic alleles at the SOD locus. Populations with postponed aging had consistently greater frequencies of the allele coding for more active SOD protein. This allele was not part of a segregating inversion polymorphism. The second experimental approach was the extraction of SOD alleles from different natural populations followed by the construction of different SOD genotypes on hybrid genetic backgrounds. This procedure did not uncover any statistical effect of SOD genotype on longevity or fecundity. There were large effects on longevity and fecundity due to the family from which a particular SOD genotype was derived. To detect the effects of SOD genotypes on longevity with high probability would require a ten-fold increase in the number of families used.

Intrapartum Doppler velocimetry, amniotic fluid volume, and fetal heart rate as predictors of subsequent fetal distress. I. An initial report.

This study examines the usefulness of umbilical artery Doppler velocimetry, amniotic fluid volume assessment, and fetal heart rate data in the early intrapartum period as predictors of subsequent fetal distress. A total of 109 patients seen in the latent phase of labor in the labor and delivery area were studied. Both an abnormal initial fetal heart rate and an amniotic fluid index less than or equal to 5.0 cm were associated with a significant increase in the incidence of intrapartum fetal distress. Conversely, a systolic/diastolic ratio greater than 3.0 by Doppler ultrasonography was not associated with increased fetal morbidity. Overall, the sensitivities, specificities, and positive predictive values of the fetal heart rate tracing and the amniotic fluid volume assessment were comparable. Doppler systolic/diastolic ratios showed very poor sensitivity and positive predictive value. We conclude that the fetal heart rate tracing or the assessment of amniotic fluid volume in the early intrapartum period are reasonable predictors of subsequent fetal condition. The lack of patients with the absence of or reverse umbilical velocity preclude conclusions with regard to Doppler systolic/diastolic ratios for this purpose.

Maternal and fetal blood flow velocity waveforms in patients with preterm labor: relationship to outcome.

Elevated systolic/diastolic ratios obtained by umbilical and uterine velocimetry have been used to predict adverse pregnancy outcome. We performed pretherapy umbilical and uterine velocimetry by means of continuous-wave Doppler ultrasonography on 92 patients who came for treatment in preterm labor. Fourteen (15.2%) and 12 (13%) patients had elevated uterine (greater than 2.6) and umbilical (greater than 3.5) systolic/diastolic ratios, respectively, and 9 (9.8%) patients had both ratios elevated. Overall 17 (18.5%) patients had at least one abnormal systolic/diastolic ratio. Patients with abnormal Doppler waveforms had a significantly shorter gestation, infants with lower birth weights, and a higher incidence of adverse pregnancy outcome as determined by meconium, cesarean section for fetal distress, low 1- and 5-minute Apgar scores, and days in the neonatal intensive care unit, compared with patients with normal systolic/diastolic ratios. There was no significant difference in the ability of uterine, umbilical, or combined velocimetry to predict preterm birth or adverse pregnancy outcome. Doppler studies in preterm labor patients may help to identify patients at increased risk for preterm birth and poor pregnancy outcome. Further studies are warranted to assess its usefulness in the evaluation of these patients.

Placenta previa in twin gestations.

The incidence of placenta previa in twin gestations was compared to that found in singleton pregnancies over a ten-year period. During this period, eight placenta previas occurred in 1,464 twin pregnancies, for an incidence of 0.55%, which was significantly higher (P less than .05) than the incidence of 0.31% in singleton pregnancies (458 placenta previas in 148,197 singleton pregnancies). We conclude that a twin gestation confers an added risk of placenta previa.

Cerebral, umbilical, and uterine resistance using Doppler velocimetry in postterm pregnancy.

The purpose of this study is to assess alterations in vascular resistance as measured by Doppler ultrasound in the postterm fetus. Forty-five postterm patients (greater than or equal to 287 days gestation by "good" dates) underwent Doppler velocimetry and calculation of systolic to diastolic (S/D) ratios of the umbilical, internal carotid, and uterine artery waveforms within 7 days of delivery. Patients were divided into two groups. Group 1 consisted of 26 patients with normal antepartum fetal surveillance that included reactive nonstress test and an amniotic fluid index (using the four-quadrant technique) equal to or greater than 5 cm. Group 2 consisted of 19 patients with antepartum compromise on the antepartum fetal surveillance tests. There was significantly greater (p less than .05) morbidity in group 2 compared to group 1 as judged by cesarean section for fetal distress (47% vs 15%), meconium at delivery (53% vs 4%), and 5-minute Apgar score less than 7 (30% vs 4%). There were no significant differences in the umbilical and uterine artery S/D ratios in the two groups, although patients in group 2 had significantly lower cerebral S/D ratios (3.6 +/- .5) compared to group 1 (4.4 +/- 0.4) (p less than .05). The ratio of cerebral to placental (umbilical) resistance in group 2 was significantly lower (1.1 +/- .3) compared to group 1 (1.8 +/- .3) (p less than .05). There was a low incidence of abnormal umbilical (greater than 3) and uterine (greater than 2.6) S/D ratios in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Placental vascular resistance using umbilical velocimetry in patients undergoing cesarean section for fetal distress.

Peak systolic (S) to lowest end-diastolic (D) ratios (S/D) of umbilical velocimetry have been used to assess downstream placental vascular resistance and predict adverse pregnancy outcome. The purpose of this study is to assess S/D ratios in patients undergoing cesarean section for clinical fetal distress. Fifty-six patients were identified who had umbilical velocimetry performed during antepartum fetal surveillance (nonstress testing and amniotic fluid index) within 7 days of undergoing cesarean section for fetal distress at Women's Hospital (Los Angeles, CA). The mean gestational age at delivery was 36.5 +/- 2.5 weeks. Thirty (53.6%) patients had elevated S/D ratios (greater than 3), 24 (42.9%) had abnormal amniotic fluid indices, and 20 (35.7%) had abnormal nonstress testing. Group 1 (N = 30) patients delivered small-for-gestational-age (SGA) fetuses and group 2 (N = 26) patients delivered appropriately grown (AGA) fetuses. In group 1, 24 (80%) patients had abnormal S/D ratios and 16 (53.3%) had abnormal amniotic fluid indices, compared to only 6 (23.1%) with abnormal S/D ratios and 8 (30.8%) with abnormal amniotic fluid indices in group 2 (p less than .05). In contrast, 14 (53.8%) of the 26 patients in group 2 had abnormal nonstress testing compared to only 6 (20%) of the 30 patients in group 1 (p less than .05). Eighteen (69.2%) of the 26 patients in group 2 were post-term pregnancies; 20 (66.7%) of the 30 patients in group 1 had chronic hypertension, pregnancy-induced hypertension, or superimposed preeclampsia.(ABSTRACT TRUNCATED AT 250 WORDS)