Charcoal tattoo localization for differentiated thyroid cancer recurrence in the central compartment of the neck.

Recurrence of differentiated thyroid cancer can often require further surgical options. Reoperations may carry significant risk of surgical complications; additionally, as the anatomy is subverted, there is the possibility of leaving residual neoplasm. In order to avoid such problems during reoperation for differentiated thyroid cancer recurrence, we have introduced the technique of preoperative ultrasound-guided tattooing localization of the lymphatic structure to be removed with a 4% solution of active charcoal. Using ultrasound guidance, the lesion is identified and 0.5-2 ml of colloidal charcoal is injected near the lesion. The extraction of the needle is accompanied by injection at constant pressure of other charcoal as to leave a trace of colouring along the path of the needle up to the skin. The preoperative injection was well tolerated in all cases. In the last 5 years, we have used this technique in 13 patients with suspected recurrence in the central compartment (all from papillary carcinomas). Postoperative ultrasound and histological examination confirmed the removal of the lesion in all patients; in one case, the lesion was a parathyroid cyst. Complications were observed in two of 13 (15.4%) cases (one transitory hypoparathyroidism, and one transitory vocal cord paresis). Considering our experience, charcoal tattoo localization can be considered a safe, low-cost technique that is extremely useful for facilitating surgical procedures, and reduces the risk of iatrogenic damage.

Improved Survival of Non-Ventilated Very-Low-Birth-Weight Infants at Madadeni Hospital; KwaZulu-Natal

Most reports of survival of very-low-birth-weight (VLBW) babies focus on infants in tertiary care centres in large metropolitan areas.1-5 Extrapolating data from major centres to peripheral hospitals is problematic because of various factors; including poor socio-economic conditions; absence of intensive/special-care facilities and equipment; and limited number of staff with knowledge and skills in neonatal care in smaller hospitals.3 We were able to raise the survival rate (SR) from 21 to 40 following the use of low-cost measures between 2002 and 2005

Intense immunosuppressive therapy followed by autologous peripheral blood selected progenitor cell reinfusion for severe autoimmune disease.

Autologous stem cell transplantation (HSCT) has been shown to be effective in curing a large spectrum of autoimmune disorders. Case reports are being collected in the EBMT/EULAR Autoimmune Disease Stem Cell Project registry, which reports transplant-related mortality (TRM) of 6%. In order to reduce TRM and preserve the anti-autoimmune effect we evaluated a more immunoablative as opposed to myeloablative conditioning regimen for the autotransplant of severe immunomediated diseases. We enrolled patients affected by systemic lupus erythematosus (SLE: 3 patients), by autoimmune thrombocytopenic purpura (AITP: one patient), by thrombotic thrombocytopenic purpura (TTP: one patient), by pure red cell aplasia (PRCA: one patient), and by a severe cryoglobulinemia (one patient). All patients were mobilized with cyclophosphamide (Cy) 4 g/m2 + G-csf. Conditioning regimen consisted of Cy 50 mg/kg/day (days -6 and -5); anti-T-globulin (ATG) 10 mg/kg/day and 6-methylprednisolone (PDN) 1 g/day (days -4, -3, and -2). Immunomagnetically selected CD34+ cells were re-infused on day 0. In three patients neutrophil count fell below 0.5 x 10(9)/l, while a PLT count below 20 x 10(9)/l was registered in two patients. Extrahematological toxicity was very low. Four patients (2 SLE, 1 TTP, 1 cryoglobulinemia) are in complete corticosteroid-free remission with a median follow up of 335 days. The third SLE patient improved considerably; however, he still needs low-dose corticosteroid maintenance. The AITP and PRCA patients achieved a CR but soon relapsed; nevertheless, the procedure restored a steroid-sensitive status. The use of this immunoablative conditioning regimen in auto-HSCT transplant was shown to be effective in controlling disease progression and could be a valuable strategy in reducing TRM.

Crohn's disease complicated by relapsed extranodal Hodgkin's lymphoma: prolonged complete remission after unmanipulated PBPC autotransplant.

Crohn's disease and ulcerative colitis are inflammatory bowel diseases (IBD), which are thought to result from an inappropriate immunologic (autoimmune) response to luminal antibodies. Allogeneic stem cell transplantation (SCT) performed for coincidental diseases is able to cure both leukaemia and Crohn's disease. Autologous SCT is currently performed worldwide for severe autoimmune diseases (SADs) because of its reduced transplant-related mortality (TRM). We report the case of a 30-year-old male patient with a 10-year history of severe Crohn's disease, who developed Hodgkin's disease and received an unmanipulated peripheral blood autologous transplant. Three years after the transplant the patient is in complete treatment-free remission of both diseases.

Successful treatment of resistant thrombotic thrombocytopenic purpura/hemolytic uremic syndrome with autologous peripheral blood stem and progenitor (CD34+) cell transplantation.

The first-line treatment of thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS syndrome) induces a response and survival rate of approximately 85%, even if a considerable number of patients relapse; nevertheless, a number of these patients are resistant to conventional management. Immunoablation followed by stem cell transplantation has been shown to be capable of inducing remissions in a large spectrum of experimental autoimmune disorders. We report here the case of a 20-year-old male patient with the TTP-HUS syndrome who was resistant to conventional treatment and was transplanted with autologous immunoselected CD34+ PBPC after conditioning with cyclosphosphamide, anti-T lymphocyte globulin and prednisone. Seven months after transplant the patient is alive and well, without any further treatment being given.

Autologous peripheral blood stem and progenitor (CD34+) cell transplantation for systemic lupus erythematosus complicated by Evans syndrome.

Immunoablation followed by allogeneic stem cell (SC) transplantation has been shown to be capable of curing a large spectrum of experimental autoimmune disorders, hereditary and/or induced. Superimposable results, albeit with some exceptions, have been obtained in human patients affected by coincidental autoimmune and blood diseases. However, both because of encouragine experimental results and of the procedure's greater safety, autologous SC are being increasingly utilized worldwide. Case reports are being collected in the registry of the European Group for Blood and Marrow Transplantation (EBMT)/European League against Rheumatism (EULAR) Autoimmune Disease Stem Cell Project. Among the severe autoimmune diseases (SADs), which are the target of autologous transplantation, severe refractory systemic lupus erythematosus (SLE) is a condition which may benefit from this procedure. We report here the case of a 19 year old female patient with a six year history of SLE with secondary antiphospholipid syndrome (APS), who later developed refractory Evans syndrome. She was transplanted with autologous mobilized CD34+ SC and progenitor cells after conditioning with cyclosphosphamide, anti-T lymphocyte globulin and prednisone. Eight months after transplant, the patient is alive and well, with normal blood counts and persistent low-titre direct antiglobulin (DAT, Coombs) and anti-nuclear antibody (ANA) tests. Anti-double stranded DNA antibody (Anti-dsDNA), lupus anticoagulant tests and anti-cardiolipin antibody (ACA) test are negative.

Low-dose long-term oral idarubicin in maintenance treatment of elderly acute myeloid leukemia.

BACKGROUND AND OBJECTIVE: Low-dose long-term oral IDA may play a role in maintainance treatment of elderly patients with AML; in fact, continuous exposure to IDA and IDAol could be efficacious in the disease control possibly inducing cell-differentiation and/or apoptosis. METHODS: We enrolled 25 previous responder patients in standard induction therapy to receive maintenance oral IDA 5 mg daily on days 1-14 at 2-week intervals for at least 6 months. We also evaluated the cell-cycle and apoptosis in leukemic cells from patients after IDA administration and, as a control, from HL60 lines exposed to IDA and IDAol in vitro. RESULTS: Long-term long-dose IDA was well-tolerated. Neutrophil and platelet count never below under 1 x 10(9)/L and 50 x 10(9)/L respectively in CR patients, and no infectious complications were encountered. Non-hematological toxicity was also acceptable: easily controlled nausea and vomiting, non-recorded diarrhea or mucositis were reported. The convenience of oral administration contributed to excellent compliance. DNA analysis performed in vivo after IDA and IDAol exposure showed an increase of G2/M cell frequencies and evidence of sub-G1 peak. INTERPRETATION AND CONCLUSIONS: In conclusion, long-term low doses of oral IDA would appear valuable as a maintenance regimen for elderly patients. Our results seem to confirm the preliminary hypothesis that IDA + IDAol induce an increase of apoptosis in leukemic cells.

A placebo-controlled study on urokinase therapy in systemic sclerosis.

A 4-month randomized placebo controlled trial on urokinase therapy in 36 consecutive systemic sclerosis patients randomly treated with urokinase or placebo was conducted. While patients on placebo did not show any significant improvement, in those following urokinase therapy there was a noticeable improvement in skin sclerosis observed via hand-print and ultrasonography of the skin. Vascular involvement improved: this was demonstrated by capillaroscopy results, showing an improvement in pattern and signs of revascularization and the resolution of skin ulcers. Vascular damage is a typical occurrence in systemic sclerosis cases and various vasoactive drugs are used symptoms for some such as Raynaud's syndrome or skin ulcers. At the moment these drugs seem to constitute the most effective therapy, and have few side effects. We have found only one previous study utilizing urokinase therapy for acute digital ischemia in systemic sclerosis. Our study is the first in which urokinase therapy has been used for the treatment of systemic sclerosis in a large number of patients.

The EPI in Borno State, Nigeria: impact on routine disease notifications and hospital admissions.

An earlier report on the Nigerian expanded programme on immunization (EPI), covering 1974-1988, failed to demonstrate a clear-cut impact of the programme. This report attempts to determine the effectiveness of EPI in Borno State, Nigeria. We analysed trends in routine notifications for diphtheria, pertussis, tetanus, tuberculosis, measles, and pneumonia, from 1985 to 1991; data on poliomyelitis were excluded because of poor documentation, while we included data on pneumonia for comparison. We also performed a before (1983-1987) after (1988-1991) comparison in terms of the intensifications of EPI by age-specific strata amongst paediatric hospitalization for all EPI diseases at the University of Maiduguri Teaching Hospital, the sole referral hospital for childhood infectious diseases. Our results show an apparent reduction in morbidity from diphtheria, pertussis, tetanus, measles and pneumonia, and this was particularly prominent following intense vaccinations between 1988 and 1991. The reduction in these EPI diseases and pneumonia occurred despite the prevailing adverse socioeconomic conditions, and the absence of a specific control strategy for pneumonia in Nigeria. On the other hand, in spite of national BCG coverage of about 90% there has been a recent (1989-1991) increase in the registered cases of tuberculosis in infants and older children in Borno State. There is a need to intensify other intervention measures alongside EPI activities.

Prognostic risk factors and post mortem findings in cerebral malaria in children.

We have examined the possible risk factors for poor prognosis in cerebral malaria in 61 Nigerian children in an area of high malaria transmission. The level of coma, decerebrate rigidity, hypoglycaemia, and high urea levels were indicators of poor prognosis. Pyrexia, vomiting, and anaemia did not influence prognosis. Post-mortem findings suggest gross cerebral oedema and raised intracranial pressure in 4 of 7 cases with petechial haemorrhages and small focal necrosis (Durck's granuloma).

The incidence and outcome of neurological abnormalities in childhood cerebral malaria: a long-term follow-up of 62 survivors.

Of 78 children with cerebral malaria who were referred to the children's emergency room, University College Hospital, Ibadan, Nigeria, between March 1987 and October 1988, 16 (20.5%) died and 62 (79.5%) survived. The survivors were assessed neurologically over 12-16 months to determine the occurrence, associations and outcome of neurological deficits in cerebral malaria. Neurological deficits occurred in 11 (17.7%) of the patients. The prominent manifestations were cortical blindness, monoparesis and speech deficits. Patients with hypoglycaemia, severe convulsions and prolonged unconsciousness were particularly prone to neurological sequelae. Five children finally recovered completely from their sequelae. These observations show that cerebral malaria is an important cause of neurological deficits in Nigerian children.

The prognosis of medical coma in Ibadan: results of multivariate analysis.

During a recent prospective investigation of 116 children with medical coma in Ibadan, 52 (45%) survived intact, 23 (20%) developed residual neurological deficits and the remaining 41 (35%) died. This series is concerned with the use of multivariate analysis in predicting outcome of medical coma in an individual patient, based mostly on clinical information (27 variables) obtained within 12 hours of admission. Stepwise logistic regression analysis revealed that only 17 of the 27 variables have independent significance in predicting outcome. When discriminant analysis was performed on these 17 variables so as to obtain a classification function of outcome (survived intact, survived with deficits and dead), 92% of the cases were correctly classified. Eight children were, however, seriously misclassified. These were four intact survivors and four dead cases who were classified as dead and survived without neurological sequelae, respectively. These results suggest that multivariate analysis of clinical and laboratory information obtained in the comatose state can provide predictive information.

Childhood coma in Ibadan. Relationship to socio-economic factors.

According to the literature, socio-economic factors may contribute more to geographic variations in the aetiology and prognosis of childhood coma than has previously been recognised. This prospective study involving 118 children with strictly defined coma demonstrated that the commonest causes of coma in Ibadan were cerebral malaria (55%), meningitis (13%) and encephalitis (10%). The prognosis was poor. Forty-three (36%) of 118 cases died and 75 (64%) survived, including 23 who showed neurologic deficits. Noteworthy prognostic indices of coma were the aetiology of the condition, the presence of severe anaemia, hypoglycaemia and pneumonia. The findings are discussed in the context of the socio-economic background of children in the tropics.

Intradural lipoma in a child.

We report the case of a 5-year-old Nigerian boy in whom conus medullaris and cauda enquina compression was due to an intradural lipoma, a rare tumour of the spinal canal in the tropics. The literature on the subject is briefly reviewed and the differential diagnoses are discussed. The occurrence of the lesion in this child, without other features of spinal dysraphism, is noteworthy.