"Nobody understands": on a cardinal phenomenon of palliative care

In the clinical practice of palliative medicine, recommended communication models fail to approximate the truth of suffering associated with an impending death. I provide evidence from patients' stories and empiric research alike to support this observation. Rather than attributing this deficiency to inadequate training or communication skills, I examine the epistemological premises of the biomedical language governing the patient-physician communication. I demonstrate that the contemporary biomedicine faces a fundamental aporetic occlusion in attempting to examine death. This review asserts that the occlusion defines, rather than simply complicating, palliative care. Given the defining place of aporia in the care for the dying, I suggest that this finding shape the clinicians' responses to the needs of patients in clinical care and in designing palliative research. Lastly, I briefly signal that a genuinely apophatic voice construing the occlusion as a mystery rather than an aporia may be superior to the present communication and empathy models.     

Possible direct cytoxicity effects of cyclophosphamide on cultured human follicles: an electron microscopy study

Purpose : To evaluate the direct effect of cyclophosphamide on cultured human ovarian follicles. Methods : Human ovarian cortical slices from premenopausal women were incubated with medium containing cyclophosphamide (0.0005–0.5 mg/mL) for 2–48 h and assessed by transmission electron microscopy. Noncultured specimens and samples cultured without cyclophosphamide were used as controls. Results : There were significantly more damaged granulosa cell nuclei after incubation with 0.5 mg/mL cyclophosphamide for at least 4 h. There were also more changes in the basement membrane after incubation with cyclophosphamide at concentrations of 0.05 and 0.5 mg/mL. Conclusions : Although the cyclophosphamide dose that caused damage to the granulosa cell nuclei was above the pharmacological level, our results suggest that cyclophosphamide, and not only its active metabolite phospharamide mustard, might have a destructive effect on human follicles, as it remains in the circulation longer. This effect could be mediated by damage to the granulosa cells and perhaps the basement membrane.     

Correlation between digital palpation of pedal pulses and duplex Doppler ultrasonography in evaluating vascular status of the lower limbs in adult diabetics

The aim of this study was to determine the correlation between findings of palpation of pedal vessels and duplex Doppler ultrasonography, which has been proved to be a more reliable method of evaluating blood flow. This was a double-blind prospective cross-sectional study of adult diabetics aged 18 years and above, with no history of previous or current foot lesions. Each enrolled patient was assigned a number and then interviewed to obtain pertinent clinical information. The vascular status of the lower limbs of the patients was evaluated by palpation of the posterior tibialis and dorsalis pedis arteries. The patients then had duplex Doppler ultrasonography of the vessels of the legs and feet by an independent examiner using the Mindray M7/M7T Diagnostic Ultrasound System with Colour Doppler mode. Data obtained was analysed using IBM SPSS Statistics Version 20. There were 14 males and 33 females; mean age was 56.74 years (range 32–82). Ninety four feet of adult diabetics were examined clinically. Palpation of the right and left posterior tibial artery was normal in 51 % of the patients. Palpation of the right and left dorsalis pedis artery was normal in 74.5 and 80.9 % of the patients, respectively. All 47 patients had duplex Doppler ultrasonography. Spearman’s and kappa correlations demonstrated no correlation between the findings on palpation and duplex Doppler ultrasound of the pedal vessels. There is no correlation between results of palpation of pedal pulses and duplex Doppler ultrasonography.     

Intraepidermal proliferation of Merkel cells within a seborrheic keratosis: Merkel cell carcinoma in situ or Merkel cell hyperplasia?

Intradepidermal proliferation of Merkel cells without any dermal component has been interpreted as either a hyperplastic process secondary to chronic ultraviolet radiation or a neoplastic process, namely Merkel cell carcinoma (MCC) in situ. The recent criteria that have been proffered to diagnose MCC in situ, unfortunately, are identical to those that have been applied to Merkel cell hyperplasia in the past, posing a diagnostic quandary when faced with an intraepidermal proliferation of Merkel cells. Most previously reported cases of MCC in situ have occurred within associated epithelial lesion that includes solar (actinic) keratosis and squamous‐cell carcinoma in situ. Similarly, Merkel cell hyperplasia has been reported to occur in association with a variety of epithelial lesions as well as on chronically sun‐damaged skin. Herein, a case of an intraepidermal proliferation of Merkel cells within a seborrheic keratosis is presented accompanied by a discussion on whether the proliferation represents another case of Merkel cell carcinoma in situ or an incidental hyperplastic process on chronically sun‐damaged skin.     

Ketotifen ameliorates capsaicin-augmented acetic acid-induced colitis

Capsaicin-sensitive afferent neurons are involved in maintaining the integrity of the gastro-intestinal mucosa. These neurons are closely apposed to mast cells and could, therefore, lead to their activation. In the present study, the role of capsaicin-sensitive neurons in the pathogenesis of experimental colitis and the possible involvement of mast cells and nitric oxide were evaluated. Rats were treated with capsaicin subcutaneously, 20, 30, and 50 mg/kg, on three consecutive days, a regimen shown to ablate primary afferent neurons. Colitis was induced two weeks later by flushing 2 ml 5% acetic acid into the proximal colon. Control rats received saline, acetic acid, or capsaicin alone. Another group of rats received ketotifen (100 µg/100 g body wt × 2/day) intragastrically 48 hr prior to damage induction and thereafter. Rats were sacrificed 24 hr after damage induction, the colon isolated, damage assessed, explants were organ-cultured for 24 hr for determination of nitric oxide generation, and mucosa extracted for determination of leukotriene B₄ generation and nitric oxide synthase activity. Significant increases in colonic weight, nitric oxide synthase activity, and nitric oxide and leukotriene B₄ generation accompanied the near tripling of acetic acid-induced damage in capsaicin-pretreated rats. Ketotifen pretreatment significantly decreased the macroscopic damage and the increase in colonic weight. The protection provided by ketotifen was accompanied by a significant decrease in leukotriene B₄ generation and nitric oxide synthase activity (80%). The correlation between the extent of colonic damage, nitric oxide synthase activity, and nitric oxide generation in acetic acid-induced colitis in capsaicin-pretreated rats suggests possible involvement of nitric oxide in its pathogenesis. The protective effect of ketotifen in capsaicin-pretreated rats indicates that mast cell activation is not prevented by ablation of afferent neurons.     

Comparative effect of Citrus sinensis and carbimazole on serum T4, T3 and TSH levels

Background:

There are previous independent reports on the anti-thyroid property of Citrus sinensis. This isoflavones and phenolic acid-rich natural agent is widely consumed as dietary supplement, thus the need to investigate its comparative effect with a standard anti-thyroid drug on T₄, T₃ and thyroid stimulating hormone (TSH) levels.

Objective:

To compare the effect of Citrus sinensis and carbimazole (CARB) on blood levels of thyroid hormones (T₄ and T₃) and TSH.

Materials and Methods:

Male wistar albino rats weighing 100-150 g were employed in this research. The rats were randomly assigned to four groups of seven rats per group. Group I served as control and were administered distilled water while groups II-IV were administered with 1500 mg/kg of Citrus sinensis (fresh orange juice; FOJ), 0.1 μg/g of levothyroxine (LVT) and 0.01 mg/g of CARB, respectively, per oral once daily for 28 days. The animals were sacrificed under chloroform anaesthesia and blood sample collected by cardiac puncture and processed by standard method to obtain serum. TSH, T₄ and T₃ were assayed with the serum using ARIA II automated radioimmunoassay instrument.

Results:

The results showed that TSH level was significantly (P < 0.05) decreased in LVT treated group compared with the FOJ group. T₄ was significantly (P < 0.05) decreased in the FOJ and CARB groups compared with the control and LVT groups. LVT significantly increased T₄ when compared with FOJ group. T₃ was significantly (P < 0.05) decreased in the CARB group compared with the control.

Conclusion:

These findings suggest that FOJ alters thyroid hormones metabolism to reduce their serum levels with a compensatory elevations of TSH level in a direction similar to CARB.     

Urticarial vasculitis and recurrent pleural effusion: a systemic manifestation of urticarial vasculitis

A 62-year-old woman with an 8-year history of urticaria, arthralgia and arthritis developed recurrent pleural effusion. A thorough laboratory workup during repeated attacks of concomitant urticaria and pleural effusion disclosed only hypocomplementemia and the histopathological finding of the skin biopsy revealed leukoclastic vasculitis. These findings are compatible with the entity of urticarial vasculitis. It is thus suggested that pleural effusion can form part of the systemic manifestations of urticarial vasculitis.     

Unresolved pneumonia due to endobronchial lipoma and actinomycosis

We report an unusual case of unresolved pneumonia in a 59 yr old woman due to endobronchial lipoma and actinomycosis, two rare diseases that have never been described before in the same person.     

Hairy cell leukemia: report of an unusual case with hepatomegaly due to a large vascular tumor of the liver, mediastinal mass and pleural effusion containing hairy cells

An unusual patient with hairy cell leukemia (HCL) who developed marked hepatomegaly due to a large vascular tumor in the liver is reported. The relation of this vascular tumor to the microscopic splenic pseudosinuses and hepatic angiomatous lesions encountered in HCL is discussed. To the best of our knowledge this represents the first case report of the association of HCL with large macroscopic hemangioma of the liver causing hepatomegaly. The patient also developed a large paratracheal mediastinal mass with a recurrent pleural effusion which was shown to contain many typical hairy cells. This rare finding is discussed in relation to the isolated cases of lymphocytic lymphoma who present with clinical and morphological features mimicking HCL. This patient had HCL according to all established criteria with characteristic morphological, cytochemical and ultrastructural features and the pleural effusion and mediastinal mass were most probably part of the HCL neoplasia, despite the fact that biopsy was not performed.