Hypersensitivity to rabbit antithymocyte globulin in an islet transplant recipient: a case report.

OBJECTIVE: The aim was to describe a case of hypersensitivity to rabbit antithymocyte globulin (rATG) occurring in the context of islet transplantation. METHODS: A 36-year-old woman with type 1 diabetes was admitted for islet transplantation. rATG was administered the first day (1.5 mg/kg) with methylprednisolone (2 mg/kg), and on the second day (1.5 mg/kg) without glucocorticoid to avoid potential toxicity to the anticipated islet transplant. RESULTS: At the end of the rATG infusion on the second day she developed hives over her face, chest, and back and tender erythema at her intravenous site (Arthus reaction). Islet transplantation was not performed. She reported exposure to a pet rabbit for 2 years in childhood. Overnight, fever developed and the rash evolved into an erythematous morbilliform eruption affecting the torso. Serum high-sensitivity C-reactive protein (hsCRP) and the erythrocyte sedimentation rate (ESR) were elevated; serum complements C3 and C4 were normal. She received prednisone (50 mg) with subsequent resolution of the rash. Nine days after her initial reaction, she developed a recurrence of the rash and fever with arthralgias; levels of C3 and C4 had fallen. Methylprednisolone (125 mg, twice) was required for symptom improvement, and was gradually tapered as prednisone over the next 4 weeks with resolution of the complement, ESR, and hsCRP abnormalities. Five months after the initial attempt at islet transplantation, she returned to receive 7,879 IE/kg via portal vein infusion under basiliximab, etanercept, tacrolimus, and sirolimus immunosuppression and has required no to low-dose (0.1 U/kg/d) insulin to maintain near-normal glycemic control for > 12 months after transplantation. CONCLUSIONS: Our patient's initial hypersensitivity reaction to rATG was followed by immune-complex type 3 hypersensitivity (serum sickness) requiring high-dose glucocorticoids. Canceling the initial islet infusion proved to be wise, and the patient subsequently did well with islet transplantation under an alternative induction agent.

Evaluation of haemostatic parameters and circadian variations of the haemostatic system in patients with systemic sclerosis and Raynaud's phenomenon.

BACKGROUND: Systemic sclerosis (SSc) is a multisystemic disease characterized by proliferation and swelling of endothelial cells and other disorders. Raynaud's phenomenon (RP) is a disturbance, with unknown pathogenesis, that may be a precursor to SSc. The aim of this study was to investigate possible alterations in the haemostatic system and to examine whether there is a circadian variation in haemostatic variables at the initial stage of SSc. METHODS: In 20 patients with RP (in all patients secondary to SSc) and in 10 controls the levels of thrombomodulin (TM), beta-thromboglobulin (beta-TG), D-dimer (DD), tissue-type plasminogen activator (t-PA) and plasminogen activator-inhibitor (PAI-1) were measured in venous plasma samples taken at 9.00 and 14.00. RESULTS: Only TM levels were found to be higher in patients than in controls. Moreover the PAI-I levels, in the patient group, showed a significant circadian rhythm (with peak values at 9.00). No significant circadian variations for the other parameters were detected. CONCLUSIONS: These data seem to indicate that in patients with RP there is an endothelial damage reflected by a significant elevation of the TM plasma level and a circadian variation in plasma PAI-1, which was higher in the morning. This observation may be an area worth exploring for its importance potential in the knowledge of Raynaud's phenomenon.

Efficacy of morphine sulfate-augmented hepatobiliary imaging in acute cholecystitis.

OBJECTIVE: A review of the English language literature was performed to determine the sensitivity and specificity of morphine sulfate-augmented hepatobiliary imaging for acute cholecystitis. Twenty publications, involving 914 patients, were reviewed from journals published between 1984 and 1999. The analysis of these patients has resulted in the largest combined review study to date. The sensitivity and specificity of morphine-augmented hepatobiliary imaging were calculated to be 96.1% and 88.6%, respectively. After reading this paper, the nuclear medicine technologist should be able to: (a) discuss the clinical use of morphine augmentation during hepatobiliary imaging; and (b) state the sensitivity and specificity of morphine sulfate-augmented hepatobiliary imaging.

Efficacy evaluation of prostaglandin E1 against placebo in patients with progressive systemic sclerosis and significant Raynaud's phenomenon.

BACKGROUND: Raynaud's phenomenon, due to connective tissue diseases, is difficult to treat successfully. Symptomatic improvement has been reported using nifedipine or iloprost, but adverse side effects may limit their use. The purpose of this study was to examine the effects of PGE1 (Alprostadil) in patients with scleroderma and severe Raynaud's disease. METHODS: Twelve females, aged 50-67 years, were included in the study with six of them receiving a 3-hour infusion of alprostadil at the standard dosage of 60 micrograms in 250 cc of physiological infusion for six consecutive days and the remaining six receiving placebo (250 cc of physiological infusion administered in the same manner). RESULTS: After infusion, blood flow, digitally measured by telethermography was increased only in patients treated with alprostadil. The number, frequency and severity of attacks recorded were reduced only in patients treated with alprostadil. No side effects were recorded during and after the infusion. CONCLUSION: In conclusion, alprostadil is effective in the management of Raynaud's phenomenon, due to scleroderma.

Diaphragmatic hernia of Morgagni.

Most cases of Morgagni hernia are asymptomatic and diagnosed incidentally on routine chest x-ray film, but they may occasionally become symptomatic. Symptomatic Morgagni hernias may present in many different ways, making the diagnosis challenging. We describe a patient with a Morgagni hernia, resulting in intractable nausea and vomiting, give a brief review of symptoms, note the different types of abdominal contents herniated, and describe the methods used to make the diagnosis.

Assessing the risk of gestational diabetes in twin gestation.

This study examines the hypothesis that twin gestation is a risk factor for gestational diabetes. In a retrospective analysis, the incidence of gestational diabetes in twin and singleton pregnancies was determined in groups matched for maternal age, weight, and parity. One-hour oral glucose challenge tests (50 g) were used to screen 9185 pregnant women. Gestational diabetes was diagnosed when abnormal screens (> or = 130 mg/dL) were followed by two or more abnormal values on a 3-hour (100 g) glucose tolerance test using National Diabetes Data Group (NDDG) criteria. A twin gestation was identified in 1.5% (138/9185) of the pregnancies. Gestational diabetes was diagnosed in 5.8% (8/138) and 5.4% (439/9047) of the twin and singleton pregnancies, respectively. The incidence of gestational diabetes is similar for singleton and twin gestations.

Maintenance oral sulfasalazine prolongs remission in ulcerative proctitis and proctosigmoiditis.

We have retrospectively compared the effectiveness of five different regimens for inducing and maintaining clinical remission in 206 patients with idiopathic proctitis (n = 115) and proctosigmoiditis (n = 91). The five therapeutic regimens were: corticosteroid enemas, 5-aminosalicylic acid (5-ASA) enemas, oral 5-ASA (sulfasalazine or mesalamine), corticosteroid enemas plus oral 5-ASA, or 5-ASA enemas plus oral 5-ASA. Clinical remission was achieved within 28 days of therapy in 47%, and eventually in 94% of these patients. No significant differences in efficacy were found among the five regimens. Most patients ultimately experienced a recurrence of symptoms, but the duration of remission was significantly longer with maintenance oral sulfasalazine or mesalamine (17.2 months) than with no therapy (11.8 months), P less than 0.01. We conclude that several regimens are equally effective in inducing remission of proctitis and proctosigmoiditis, although prolonged therapy may be needed to accomplish this goal. Maintenance oral 5-ASA significantly prolongs symptomatic remission in proctitis and proctosigmoiditis.

Outcome after major dissection during coronary angioplasty using the perfusion balloon catheter.

Coronary artery dissection is an infrequent but serious complication of coronary angioplasty that can lead to periprocedural vessel occlusion, emergency bypass surgery, myocardial infarction or death. Recently, a perfusion balloon catheter was developed that permits passive perfusion of blood through the central lumen of the catheter. It enables prolonged balloon inflations to be performed and has been used to provide distal blood flow after coronary occlusion. To evaluate the effectiveness of the perfusion balloon catheter in patients with major coronary dissections, 36 consecutive patients treated with the perfusion balloon catheter were compared with 46 consecutive patients treated before its availability. The 2 groups were similar in terms of clinical, angiographic and initial procedural characteristics. Use of the perfusion balloon catheter permitted a significantly longer inflation than standard balloon inflation (average 18 +/- 5 min). Angiographic success was significantly greater with the perfusion balloon catheter (84 vs 62% for conventional therapy), whereas complications were markedly reduced (48 vs 78%). With the perfusion balloon catheter there were fewer deaths (2 vs 6%), myocardial infarctions (14 vs 40%) and emergency bypass operations (11 vs 25%). The findings of this retrospective comparison demonstrate that the perfusion balloon catheter is effective for the management of major dissections after coronary angioplasty. The use of the perfusion balloon catheter should be considered when a major coronary dissection occurs and when emergency bypass surgery is contemplated.

Clinical experience with percutaneous brachial coronary angiography in a "Judkins" laboratory.

More than 98% of coronary studies performed in our laboratory are done with the transfemoral approach. In this report, we review our experience with 67 cases in which we used the percutaneous brachial approach as an alternative for patients with peripheral vascular disease. Sixty-six cases (99%) were completed; one case (1%) was aborted due to cardiogenic shock. No death, stroke, or myocardial infarction occurred. Seven patients (10%) had minor complications; none required surgical intervention. The percutaneous brachial approach with standard preformed catheters offers a simple and satisfactory alternative to transfemoral coronary angiography.

Paradoxical Effect of Actinomycin D: Regulation of Synthesis of Wound RNase at Translation in Turnip Tissue.

Cutting of tissue sections induces RNase (EC 2.7.7.16) activity (phase I) in white turnip (Brassica rapa L. var. rapa) which peaks in 4 or 7 hours and then declines rapidly (phase II). The increase is inhibited by cycloheximide; also RNase from tissue bathed in 99.8% D(2)O during phase I underwent a large increase in buoyant density, indicating that the increased activity is due to de novo synthesis. Actinomycin D inhibited induction of RNase only if given within the initial 45 minutes after cutting. When it was applied after 45 minutes, it caused enhancement (super-induction) of RNase activity for over 24 hours. The half-time for degradation of RNase during phase I in the presence of cycloheximide and phase II in the presence and absence of cycloheximide is the same, indicating that the decline in RNase activity is due to cessation of synthesis. Also the rate of degradation of RNase remains the same during superinduction, thus indicating that actinomycin D superinduction is due to maintenance of synthesis of RNase rather than inhibition of its rate of degradation. Consistent with this is the fact that actinomycin D superinduction of RNase is inhibited by cycloheximide. The evidence is consistent with the hypothesis that messenger RNA for RNase is long-lived and the decline in RNase is due to transscription of a regulator gene coding for a specific repressor protein during phase I which inhibits RNase synthesis at the level of translation. Superinduction of RNase activity by actinomycin D is explicable in terms of (a) inhibition of synthesis of the mRNA coding for a repressor protein that inhibits translation of RNase-specific mRNA, or, (b) differential stability of mRNAs in presence of actinomycin D, and competition among mRNAs for factors rate-limiting to translation, thus favoring synthesis of proteins coded by long-lived messengers.