Successful use of recombinant tissue plasminogen activator in a patient with relapsing peritonitis

Intraperitoneal (IP) administration of either streptokinase (SK) or urokinase (UK) has assumed an adjunctive role to antibiotic therapy in selected patients with relapsing peritonitis. In these circumstances, bacteria may be protected from antibiotics through sequestration in either fibrinous structures or biofilms within the lumen of the peritoneal dialysis (PD) catheter or the peritoneal cavity. In some cases, it appears that disruption of these sheltered microenvironments by thrombolytic agents facilitated eradication of the offending organism and obviated the need for catheter removal, replacement, or interim hemodialysis. Although IP SK has been generally well tolerated as additive therapy in relapsing peritonitis, sporadic reports of significant complications, such as abdominal pain, fever, and severe hypotension, have precluded its more widespread acceptance. The only other thrombolytic agent used in this setting, UK, is presently unavailable because of a manufacturing shortfall. Therefore, adjunctive thrombolytic therapy for relapsing peritonitis is currently restricted. To circumvent these limitations, we devised an IP tissue plasminogen activator (tPA) protocol to eliminate recurring infection in a patient undergoing chronic ambulatory PD. After a third episode of peritonitis caused by Enterobacter cloacae, treated twice previously with an adequate antibiotic regimen, we instilled 6 mL of tPA (1 mg/mL) into the PD catheter for a 2-hour dwell time. The treatment was well tolerated and, in conjunction with a third course of antibiotic therapy, has produced an infection-free interval of 8 months. © 2001 by the National Kidney Foundation, Inc

The role of chemotherapeutic drugs in the evaluation of breast tumour response to chemotherapy using serial FDG-PET

INTRODUCTION: The aims of this study were to investigate whether drug sequence (docetaxel followed by anthracyclines or the drugs in reverse order) affects changes in the maximal standard uptake volume (SUVmax) on [18F]fluorodeoxyglucose positron emission tomography (FDG-PET) during neoadjuvant chemotherapy in women with locally advanced breast cancer. METHODS: Women were randomly assigned to receive either drug sequence, and FDG-PET scans were taken at baseline, after four cycles and after eight cycles of chemotherapy. Tumour response to chemotherapy was evaluated based on histology from a surgical specimen collected upon completion of chemotherapy. RESULTS: Sixty women were enrolled into the study. Thirty-one received docetaxel followed by anthracyclines (Arm A) and 29 received drugs in the reverse order (Arm B). Most women (83%) had ductal carcinoma and 10 women (17%) had lobular or lobular/ductal carcinoma. All but one tumour were downstaged during therapy. Overall, there was no significant difference in response between the two drug regimens. However, women in Arm B who achieved complete pathological response had mean FDG-PET SUVmax reduction of 87.7% after four cycles, in contrast to those who had no or minor pathological response. These women recorded mean SUVmax reductions of only 27% (P < 0.01). Women in Arm A showed no significant difference in SUVmax response according to pathological response. Sensitivity, specificity, accuracy and positive and negative predictive values were highest in women in Arm B. CONCLUSIONS: Our results show that SUVmax uptake by breast tumours during chemotherapy can be dependent on the drugs used. Care must be taken when interpreting FDG-PET in settings where patients receive varied drug protocols

Effect of surgical experience and spine subspecialty on the reliability of the {AO} Spine Upper Cervical Injury Classification System

OBJECTIVE The objective of this paper was to determine the interobserver reliability and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on surgeon experience (&lt; 5 years, 5–10 years, 10–20 years, and &gt; 20 years) and surgical subspecialty (orthopedic spine surgery, neurosurgery, and "other" surgery). METHODS A total of 11,601 assessments of upper cervical spine injuries were evaluated based on the AO Spine Upper Cervical Injury Classification System. Reliability and reproducibility scores were obtained twice, with a 3-week time interval. Descriptive statistics were utilized to examine the percentage of accurately classified injuries, and Pearson’s chi-square or Fisher’s exact test was used to screen for potentially relevant differences between study participants. Kappa coefficients (κ) determined the interobserver reliability and intraobserver reproducibility. RESULTS The intraobserver reproducibility was substantial for surgeon experience level (&lt; 5 years: 0.74 vs 5–10 years: 0.69 vs 10–20 years: 0.69 vs &gt; 20 years: 0.70) and surgical subspecialty (orthopedic spine: 0.71 vs neurosurgery: 0.69 vs other: 0.68). Furthermore, the interobserver reliability was substantial for all surgical experience groups on assessment 1 (&lt; 5 years: 0.67 vs 5–10 years: 0.62 vs 10–20 years: 0.61 vs &gt; 20 years: 0.62), and only surgeons with &gt; 20 years of experience did not have substantial reliability on assessment 2 (&lt; 5 years: 0.62 vs 5–10 years: 0.61 vs 10–20 years: 0.61 vs &gt; 20 years: 0.59). Orthopedic spine surgeons and neurosurgeons had substantial intraobserver reproducibility on both assessment 1 (0.64 vs 0.63) and assessment 2 (0.62 vs 0.63), while other surgeons had moderate reliability on assessment 1 (0.43) and fair reliability on assessment 2 (0.36). CONCLUSIONS The international reliability and reproducibility scores for the AO Spine Upper Cervical Injury Classification System demonstrated substantial intraobserver reproducibility and interobserver reliability regardless of surgical experience and spine subspecialty. These results support the global application of this classification system

Successful use of recombinant tissue plasminogen activator in a patient with relapsing peritonitis

Intraperitoneal (IP) administration of either streptokinase (SK) or urokinase (UK) has assumed an adjunctive role to antibiotic therapy in selected patients with relapsing peritonitis. In these circumstances, bacteria may be protected from antibiotics through sequestration in either fibrinous structures or biofilms within the lumen of the peritoneal dialysis (PD) catheter or the peritoneal cavity. In some cases, it appears that disruption of these sheltered microenvironments by thrombolytic agents facilitated eradication of the offending organism and obviated the need for catheter removal, replacement, or interim hemodialysis. Although IP SK has been generally well tolerated as additive therapy in relapsing peritonitis, sporadic reports of significant complications, such as abdominal pain, fever, and severe hypotension, have precluded its more widespread acceptance. The only other thrombolytic agent used in this setting, UK, is presently unavailable because of a manufacturing shortfall. Therefore, adjunctive thrombolytic therapy for relapsing peritonitis is currently restricted. To circumvent these limitations, we devised an IP tissue plasminogen activator (tPA) protocol to eliminate recurring infection in a patient undergoing chronic ambulatory PD. After a third episode of peritonitis caused by Enterobacter cloacae, treated twice previously with an adequate antibiotic regimen, we instilled 6 mL of tPA (1 mg/mL) into the PD catheter for a 2-hour dwell time. The treatment was well tolerated and, in conjunction with a third course of antibiotic therapy, has produced an infection-free interval of 8 months. © 2001 by the National Kidney Foundation, Inc