Treatment of cefuroxime-induced neurotoxicity with continuous venovenous haemofiltration.

A 61-year-old woman with decreased consciousness, myoclonus, tremors, nystagmus and bradypnoea, due to cefuroxime-induced neurotoxicity, was admitted to the intensive care unit. Continuous venovenous haemofiltration (CVVH) rapidly reduced plasma cefuroxime concentrations and improved neurological manifestations within the next few hours. Retrospective pharmacokinetic assessment showed a total cefuroxime clearance of 166 ml/min during the CVVH.

Moderate dose capecitabine in older patients with metastatic breast cancer: a standard option for first line treatment?

Single agent capecitabine is effective and well tolerated in metastatic breast cancer (MBC). We have retrospectively analysed capecitabine outcome as 1st, 2nd or 3rd line chemotherapy in 89 elderly patients ≥70 years with locally advanced or MBC treated in our Unit, 55 (62%) as 1st line and 34 (38%) as 2nd or 3rd line. Starting dose was 1000 mg/m(2) twice daily, days 1-14 every 3 weeks, but 36 (41%) started on a 25% dose reduction because of frailty and 12 (13%) reduced dose after the 1st or the 2nd cycle. Overall response rate (ORR) was 45% (95% CI: 35-55%). A further 19 (21%) achieved stable disease (SD) for ≥6 months. Median time to progression (TTP) and overall survival (OS) were 30 (95% CI: 23-37) and 61 (95% CI: 44-77) weeks, respectively. The ORR for 1st line treatment was 51% compared with 35% for 2nd and 3rd line treatment (p = 0.03). No significant difference in efficacy was seen between patients receiving the full versus reduced dose. Capecitabine was well tolerated, although 35% had treatment delays and 57% required dose reduction. Grade 3-4 toxicities were hand-foot syndrome in 11%, lethargy 9% and diarrhoea 2%. Capecitabine is an effective and well-tolerated drug in elderly patients with MBC including for 1st line treatment. Dose reduction is frequently required but does not appear to affect outcome.

Imaging of skeletal metastases in myxoid liposarcoma.

Unlike other soft tissue sarcomas, myxoid/round cell liposarcoma (MRCL) has a tendency to spread to extrapulmonary sites but bone metastases are thought to be uncommon. In case reports, negative bone scintigraphy has been noted in patients with myxoid/round cell liposarcoma and bone metastases but the prevalence and optimal method of diagnosis of bone metastases in this common subtype of liposarcoma are unclear. In an attempt to answer these questions, data were obtained from a prospective database of patients with sarcoma, including MRCL, and the diagnostic imaging used was examined. A variety of imaging tools were used including plain X-rays, bone scintigraphy, computed tomography (CT), and magnetic resonance imaging (MRI). Eight patients (4.3%) developed skeletal metastases all of which were positive on MRI. Bone scintigraphy was negative in two out of four cases, CT was negative in six out of seven, and X-rays were negative in four. Radiography and CT measure mainly cortical bone involvement, whereas MRI examines bone marrow. When investigating patients with MRCL for bone pain, negative X-rays and bone scans do not rule out bone metastases. In our experience, MRI provides the most sensitive technique for the diagnosis of bone metastases in MRCL.

[Deferred consent for inclusion of patients unable to give their consent in studies in the field of emergency medicine]. / Uitgestelde toestemming voor inclusie van beslissingsonbekwame patiënten in studies van spoedeisende geneeskunde.

Respect for individual autonomy, expressed in the concept of informed consent, is a basic principle in research with humans. Many patients in intensive care are unable to give consent because of mental incapacity, and this can be further complicated in emergency research, in which the treatment or experiment needs to be initiated without delay. In those situations consent can be deferred. Randomization is done without prior consent, followed by patients' or relatives' consent at a later stage. Butwhat should one do with the data if the patient dies at an early stage after randomization before consent could be obtained? Should the data be used or not? Should the relatives be asked for consent for using the data? The Dutch Central Committee on Research involving Human Subjects (CCMO) states that asking for consent after the patient has died makes no sense, because with the death of the patient the research has ended. Relatives do not have the authority to give consent for the use of medical data after the patient has died. Data can be used anonymously in the final analysis of the trial. We propose a flowchart for this procedure.

A comparative proteinomic analysis of nipple aspiration fluid from healthy women and women with breast cancer.

This pilot study examines the feasibility of nipple aspiration to distinguish women with breast cancer from healthy women using surface-enhanced laser desorption ionisation time-of-flight mass spectrometry (SELDI-TOF/MS). Nipple aspiration fluid (NAF) was collected from each breast in 21 women newly diagnosed with unilateral breast cancer and 44 healthy women. No differences were found when proteomic profiles of NAF from the cancer-bearing breast and the contralateral non-cancerous breast were compared. In contrast, 9 protein peaks were significantly different between the cancer-bearing breast compared with healthy women and 10 peaks were significantly different between the contralateral healthy breast and healthy women (P<0.05). These data suggest that invasive breast cancer may result in a field change across both breasts and that proteomic profiling of NAF may have more value in breast cancer risk assessment than as a diagnostic or screening tool.

Endoscopic-guided trephination dacryocystorhinostomy (Hesham DCR): technique and pilot trial.

OBJECTIVES: (1) Test the feasibility and the safety of guided transnasal trephination in creating a nasolacrimal fistula. (2) Develop an appropriate lacrimal maintainer and test its value in modulating healing at the fistula site. DESIGN: Prospective, noncomparative interventional case series. PARTICIPANTS: Five cadavers and 19 patients. METHOD: A transcanalicular lacrimal probe penetrated the lacrimal fossa to guide the passage of a flexible trephine up the nose, which created the nasolacrimal communication. A special wide-caliber lacrimal maintainer was inserted along lacrimal tubes within the created passage. OUTCOME MEASURES: For cadaveric study, direct inspection after dissection of the facial flap was performed. For the clinical trial, subjective improvement in watery eye, dye testing, lacrimal probing, lacrimal irrigation, and endoscopic nasal examination. RESULTS: The technique resulted in the creation of a regular fistula of reproducible diameter into which a standard-shaped wide caliber maintainer could be inserted. Three months after removal of the maintainer and 6 months after surgery, a patent ostium was achieved in 17 of 18 (94%) patients who had a completed procedure. Relief of symptoms was achieved in 83%. CONCLUSIONS: Guided endoscopic dacryocystorhinostomy provides a simple and safe option for the treatment of nasolacrimal duct obstruction. The lacrimal maintainer is a useful device to achieve a large patent nasolacrimal communication.

Candidemia in intensive care unit patients: risk factors for mortality.

Aim of this study was to evaluate whether risk factors which predict the development of candidemia may also predict death in ICU patients with candidemia. During an 8-year-period all ICU patients whose blood cultures yielded Candida species (n = 40) were retrospectively evaluated in a case-control fashion. The average incidence of Candida bloodstream infections was 5.5 per 10,000 patient days, ranging from 2.4 in 1990 to 7.4 in 1994. C. albicans was the most common pathogen in candidemic patients, but the proportion of non-C. albicans strains showed an increasing trend during 1989-1993, with a major shift towards non-C. albicans species in 1994. The overall mortality of patients with candidemia was 58%. Mortality was highest in the group of patients with multi-organ dysfunction syndrome, especially among those in need of hemodialysis. Risk factors for the development of candidemia, such as age, malignancy, steroid use, i.v. catheterization, and the use of broad-spectrum antibiotics were not correlated with mortality in the ICU patients studied.

Graves ophthalmopathy: intracranial fat prolapse on CT images as an indicator of optic nerve compression.

PURPOSE: To determine the usefulness of a number of imaging features in the differentiation of patients with Graves ophthalmopathy who had optic neuropathy from those who did not. Intracranial herniation of orbital fat through the superior ophthalmic fissure and its clinical importance was also assessed. MATERIALS AND METHODS: The computed tomographic (CT) appearance of the orbital apex was examined in 50 patients without and in 50 patients with Graves ophthalmopathy. The clinical diagnosis of optic neuropathy was made by an ophthalmologist who was unaware of the imaging appearances and was based on clinical features and abnormalities of visual evoked potentials or changes at automated perimetry. RESULTS: Intracranial fat prolapse (P < .001) and optic nerve crowding (P < .05) were the only imaging features that were independently related to optic neuropathy. The presence of intracranial fat prolapse or optic nerve crowding on CT scans helped identify 16 of 17 patients with optic neuropathy. Sensitivity was 94%, specificity was 91%, positive predictive value was 69%, and negative predictive value was 98%. CONCLUSION: Intracranial fat prolapse correlates closely to the presence of optic neuropathy in Graves ophthalmopathy. This sign, in combination with optic nerve crowding, demonstrates a closer correlation to optic neuropathy than previously described imaging features.

Florid xanthelasmata (yellow lids) in orbital Wegener's granulomatosis.

AIMS: A new sign of florid xanthelasmata is described in four male patients with orbital manifestations of Wegener's granulomatosis. METHODS: The case notes of four patients with Wegener's granulomatosis, with orbital involvement accompanied by yellow lid lesions, are reviewed. RESULTS: All the patients had active Wegener's granulomatosis at the time the lid lesions were most florid. The lesions gradually resolved as the inflammatory disease was controlled with immunosuppressive agents. The lesions displayed marked asymmetry and predominantly involved the side with the most severe inflammation. Abnormalities of lipid metabolism were not identified and it is believed that the lesions developed in a susceptible anatomical region affected by a vasculitic process. CONCLUSION: A 'yellow lid' associated with orbital inflammation and is a strong pointer to the clinical diagnosis of Wegener's granulomatosis.

Prediction of enophthalmos by computed tomography after 'blow out' orbital fracture.

In 11 patients with blow out fracture of the orbit, measurement of orbital volume using computed tomography (CT) more than 20 days after injury correlated well with enophthalmos measured from the same scans (r = 0.87, p < 0.001, SEE 0.63 mm), with a 1 cm3 increase in orbital volume causing 0.8 mm of enophthalmos. This confirms the cause of enophthalmos after blow out fracture to be increase in orbital volume rather than fat atrophy or fibrosis. In a further 25 patients scanned within 20 days of injury the degree of enophthalmos was less marked than would be predicted from the orbital volume measurement. This was probably because of the presence of oedema, haemorrhage, or both behind the globe which would prevent immediate development of enophthalmos. CT measurement of orbital volume within 20 days of injury may predict the final degree of enophthalmos and identify those patients at risk of late enophthalmos, allowing appropriate early surgical intervention.

Orbital volume measurement in the management of pure blowout fractures of the orbital floor.

With the recent advent of accurate orbital volume assessment by computed tomography, a retrospective analysis was made of 31 patients with 'pure' blowout fracture of the orbital floor, managed either surgically or conservatively, to determine whether orbital volume measurement could provide an additional parameter of use in the management of such fractures. There was a significant difference in orbital volume discrepancy between patients managed surgically or conservatively suggesting that this investigation may be of use in decision making on surgical intervention in patients with orbital blowout fractures.