[Central nervous system lymphoma revealed by lymphocytic meningitis in a patient with systemic lupus erythematosus: An unusual association]

INTRODUCTION

We report an unusual observation of central nervous system (CNS) lymphoma in a 60-year-old woman with systemic lupus erythematosus and fatal outcome.

OBSERVATION

The patient had systemic erythematosus lupus for 7 years, treated with mycophenolate mofetil and developed lymphocytic meningitis in 2015 associated to the presence of EBV in the cerebrospinal fluid and a necrotic vermis' lesion. Diagnosis of large B-cell lymphoma was histologically confirmed from stereotaxic biopsy, shortly before she died from neurological complications.

CONCLUSION

Even though the current association is unusual, lymphocytic meningitis with hypoglycorrachia in patients with systemic lupus erythematosus may reveal CNS lymphoma and diagnosis confirmation requires stereotaxic biopsy in order not to delay specific therapeutic management.

Surgical morbidity and clinical outcomes in ovarian cancer - the role of obesity

OBJECTIVE

To evaluate the effect of body mass index on the surgical outcomes in ovarian cancer patients. In addition, we performed a systematic review to compare our outcomes with the current literature.

DESIGN

Retrospective cohort study and a systematic review of the literature.

SETTING

Gynaecology department at the Royal Cornwall Hospital Trust.

POPULATION

Surgically managed stage I-IV ovarian cancer patients between September 2006 and September 2014.

METHODS

Primary and secondary outcome measures were evaluated across BMI categories; BMI <25 kg/m², BMI 25–29.9 kg/m², BMI ≥30 kg/m² and BMI ≥40 kg/m². A systematic review was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

MAIN OUTCOME MEASURES

The primary outcome measure was surgical complications. Secondary outcome measures were other intra- and postoperative outcomes.

RESULTS

Two hundred twenty-eight women were included in the study, of which 84 had a BMI <25 kg/m², 84 women had a BMI 25–29.9 kg/m², and 60 women were obese (BMI ≥30 kg/m²), 13 of whom were morbidly obese. Morbid obesity was associated with increased rates of wound complications. However, BMI did not show an association with other outcomes. In the review, an increasing BMI was associated with increased rates of wound complications and prolonged hospital stay, but did not impact other surgical outcomes.

CONCLUSION

Obesity is associated with increased rates of wound complications and a prolonged hospital stay, but does not appear to affect other operative outcomes including cytoreduction status and 30-day mortality. Therefore, operative management and postoperative care require a multifactorial approach to minimise adverse outcomes.

Disrupted trabecular bone micro-architecture in middle-aged male HIV-infected treated patients

OBJECTIVES

HIV-infected individuals are at increased risk of incident fractures. Evaluation of trabecular bone micro-architecture is an important tool to assess bone strength, but its use has not yet been reported in middle-aged HIV-infected male individuals. The aim of the study was to compare bone micro-architecture between HIV-infected and HIV-uninfected men.

METHODS

In this cross-sectional study, 53 HIV-infected male individuals with a mean (± standard deviation) age of 49 ± 9 years who had been receiving antiretroviral therapy including tenofovir disoproxil fumarate (DF) for at least 60 months were compared with 50 HIV-uninfected male controls, matched for age and ethnic origin. We studied the volumetric bone density and micro-architecture of the radius and tibia using high-resolution peripheral quantitative computed tomography (HR-p QCT).

RESULTS

Volumetric trabecular bone density was 17% lower in the tibia (P < 10(-4) ) and 16% lower in the radius (P < 10(-3) ) in HIV-infected patients compared with controls. By contrast, the cortical bone density was normal at both sites. The tibial trabecular micro-architecture differed markedly between patients and controls: bone volume/total volume (BV/TV) and trabecular number were each 13% lower (P < 10(-4) for both). Trabecular separation and inhomogeneity of the network were 18% and 24% higher in HIV-infected patients than in controls, respectively. The radial BV/TV and trabecular thickness were each 13% lower (P < 10(-3) and 10(-2) , respectively). Cortical thickness was not different between the two groups.

CONCLUSIONS

The findings of lower volumetric trabecular bone density and disrupted trabecular micro-architectural parameters in middle-aged male HIV-infected treated patients help to explain bone frailty in these patients.

Malignant catatonia and neuroleptic malignant syndrome: How different/similar are they?

Introduction

Catatonia is a neuropsychiatric syndrome that appears in medical, neurological or psychiatric conditions. There are presentation variants: “malignant catatonia” (MC) subtype shares many characteristics with the neuroleptic malignant syndrome (NMS), possibly reflecting common pathophysiology.

Objectives/methods

We present a clinical vignette and review the literature available on online databases about MC/NMS.

Results

We present a man, 41-years-old, black ethnicity, with no relevant medical history. He had two previous episodes compatible with brief psychosis, the last one in 2013, and a history of adverse reactions to low doses of antipsychotics. Since the last episode he was asymptomatic on olanzapine 2.5 mg id. He acutely presented to the Emergency Room with mutism, negativism, immobility and delusional speech, similar to the previous episodes mentioned and was admitted to a psychiatric infirmary, where his clinical condition worsened, showing muscle rigidity, hemodynamic instability, leukocytosis, rhabdomyolysis and fever. Supportive care was provided, olanzapine was suspended and electroconvulsive therapy (ECT) was initiated. After two months, he was discharged with no psychotic symptoms. He is still under ECT and no antipsychotic medication was reintroduced.

Discussion/conclusion

Many studies suggest that clinical or laboratory tests do not distinguish MC from NMS and that they are the same entity. These two conditions are life-threatening and key to treatment is a high suspicion level. There is no specific treatment; supportive care and stopping involved medications are the most widely used measures. ECT is a useful alternative to medication.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

A Case Report of Charles Bonnet Syndrome – The Silent Doubt: Am i Crazy?

Introduction

The Charles Bonnet syndrome refers to symptoms of visual hallucinations that occur in patients with visual acuity or visual field loss. These are often called release hallucinations, reflecting the most widely accepted theory about their pathogenesis. The syndrome is most found in elderly patients, 70–85 years, and this probably reflect the mean age at which the most common underlying conditions are seen. It is probably more common than is thought and because either it is misdiagnosed as psychosis and/or dementia or it is not reported by patients because they fear that the hallucinations represent psychiatric disease.

Objective and method

The authors present the clinical case of a 89-year-old woman, with no previous psychiatric disease, admitted to hospital because of visual hallucinations in form of children and animals. She experienced them during months until she told someone. No psychiatric symptoms were found. The lady had a serious cataract on the left eye with total loss of the visual acuity, as documented by ophthalmologic examination.

Results

The patient initiated quetiapine 300 mg and will have period appointments with a neurologist. Further future information will be presented.

Conclusions

A correct diagnosis is essential to treat these patients and explaining them the meaning of the hallucinations is generally relieving. Many author disagree with antipsychotic agents, while others report benefit.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Trichotillomania in delusional infestation

Introduction

Trichotillomania is described as a recurrent failure to resist impulses to pull out hairs. It is usually associated with obsessive-compulsive disorder and body dismorphic disorder. It is usually confined to one or two sites in the body.

Objective

The aim of our work is to describe a case of delusional infestation with secondary trichotillomania and briefly review the theoretical aspects of this clinical presentation.

Methods

We searched online databases and reviewed current case reports published, using the keywords “delusional infestation”, “Ekbom syndrome” and “trichotillomania” and compared similarities in the presentation, development and outcome. We present a clinical vignette of a 38-year-old female, with no relevant psychiatric history. The patient developed severe itching that she believed was caused by bugs that lived inside her hair follicles, so she pulled out completely all of her eyebrows, eyelashes, pubic and underarms hairs. She maintained some hair on her head, that she repeatedly pulled out and proceeded to break in order to kill the bugs. She claimed to have absolutely no itchiness in the hairless areas of her body.

Results

The patient was referred to psychiatric consultation and was started on oral antipsychotics but, as the review from literature suggested, the clinical evolution only became satisfactory when an antidepressant (SSRI) was added.

Conclusion

Although, trichotillomania is more commonly seen in clinical practice in association with other psychiatric disorders, it may also present itself as a symptom of delusional activity.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The late-onset bipolar disease: A case report

The prevalence of bipolar disorder after 65 years is 0.1 to 0.4%. Mania represents 4.6% to 18.5% of all psychiatric admissions in geriatrics in the USA. It has some specificity in terms of clinical presentation, evolution, prognosis and treatment.

We report the case of a patient who presented a first manic episode after 65 years. E.H, AP, 67 years old, single, without personal and familial psychiatric history, addressed to psychiatric emergencies for psychomotor agitation and euphoric mood. He presented two months ago a manic access with almost total insomnia, euphoria, psychomotor agitation and delusions of grandeur. The balance sheet reveals no incorrections (blood count, thyroid balance, serology: TPHA, VDRL, hepatitis B and C, HIV). The cerebral CT was normal. The patient has been received a quetiapine 200 mg/day, olanxapine 10 mg/day and valproate 1000 mg/day. The evolution after three weeks was favorable.

The late-onset bipolar disorder is characterized by: a less intense euphoria, replaced by anger and irritability, a more elements of persecution, disinhibiting and impulsivity. Respecting to that, this case is an exception. The most common confounding symptoms and behavioral disorders. A higher frequency of neurological diseases is noted in elderly subjects with a bipolar disorder and, so, a neuropsychiatric rigorous evaluation is fundamental to exclude the possibility of an organic pathology for the manic access. The prescription of psychotropic drugs in the elderly must be under monitoring.

Disclosure of interest The authors have not supplied their declaration of competing interest.

Electrochemical oxidation of humic acid and sanitary landfill leachate: Influence of anode material, chloride concentration and current density

The influence of applied current density and chloride ion concentration on the ability of Ti/Pt/PbO2 and Ti/Pt/SnO2-Sb2O4 anodes for the electrochemical oxidation of humic acid and sanitary landfill leachate samples was assessed and compared with that of BDD anode. For the experimental conditions used, results show that both organic load and nitrogen removal rates increase with the applied current density and chloride ion concentration, although there is an optimum COD/[Cl-]0 ratio below which there is no further increase in COD removal. Metal oxide anodes present a similar performance to that of BDD, being the results obtained for Ti/Pt/PbO2 slightly better than for Ti/Pt/SnO2-Sb2O4. Contrary to BDD, Ti/Pt/PbO2 promotes lower nitrate formation and is the most suitable material for total nitrogen elimination. The importance of the optimum ratio of Cl-/COD/NH4 +initial concentrations is discussed.

Sugar and volatile fatty acids dynamic during anaerobic treatment of olive mill wastewater

Biogas production has been the main route used to exploit olive mill wastewater (OMW), after pretreatment and/or in combination with other effluents, but more recently the production of chemicals and biopolymers by biotechnological routes has deserved increasing attention by the scientific community. The present paper aims to explore the potential of fresh OMW as a source of volatile fatty acids (VFAs) and biogas. The time profile of VFAs production and the corresponding sugar consumption was followed by high-performance liquid chromatography, in batch anaerobic assays. The experimental results have revealed the very high potential of the OMW for the production of VFAs, mainly due to the high sugar concentration in the effluent (37.8 g/L) and its complete conversion into VFAs, in a time period of 2-3 days. The most abundant VFAs were acetic (48-50%), n-butanoic (12-27%), iso-pentanoic (12-14%) and propanoic (5-13%). The ratio of VFA containing even and odd carbon chains increased with the reduction in the initial chemical oxygen demand concentration of the samples used in the experiments. The conversion of the VFAs to biogas was inhibited at concentrations of 3.5 g/L of VFAs.

Bevacizumab and Combination Chemotherapy in rectal cancer Until Surgery (BACCHUS): a phase II, multicentre, open-label, randomised study of neoadjuvant chemotherapy alone in patients with high-risk cancer of the rectum

BACKGROUND

In locally advanced rectal cancer (LARC) preoperative chemoradiation (CRT) is the standard of care, but the risk of local recurrence is low with good quality total mesorectal excision (TME), although many still develop metastatic disease. Current challenges in treating rectal cancer include the development of effective organ-preserving approaches and the prevention of subsequent metastatic disease. Neoadjuvant systemic chemotherapy (NACT) alone may reduce local and systemic recurrences, and may be more effective than postoperative treatments which often have poor compliance. Investigation of intensified NACT is warranted to improve outcomes for patients with LARC. The objective is to evaluate feasibility and efficacy of a four-drug regimen containing bevacizumab prior to surgical resection.

METHODS/DESIGN

This is a multi-centre, randomized phase II trial. Eligible patients must have histologically confirmed LARC with distal part of the tumour 4-12 cm from anal verge, no metastases, and poor prognostic features on pelvic MRI. Sixty patients will be randomly assigned in a 1:1 ratio to receive folinic acid + flurourcil + oxaliplatin (FOLFOX) + bevacizumab (BVZ) or FOLFOX + irinotecan (FOLFOXIRI) + BVZ, given in 2 weekly cycles for up to 6 cycles prior to TME. Patients stop treatment if they fail to respond after 3 cycles (defined as ≥ 30 % decrease in Standardised Uptake Value (SUV) compared to baseline PET/CT). The primary endpoint is pathological complete response rate. Secondary endpoints include objective response rate, MRI tumour regression grade, involved circumferential resection margin rate, T and N stage downstaging, progression-free survival, disease-free survival, overall survival, local control, 1-year colostomy rate, acute toxicity, compliance to chemotherapy.

DISCUSSION

In LARC, a neoadjuvant chemotherapy regimen - if feasible, effective and tolerable would be suitable for testing as the novel arm against the current standards of short course preoperative radiotherapy (SCPRT) and/or fluorouracil (5FU)-based CRT in a future randomised phase III trial.

TRIAL REGISTRATION

Clinical trial identifier BACCHUS: NCT01650428.

[Prevalence of granulomatous lesions in minor salivary gland biopsy in a case series of 65 patients with tuberculosis]

PURPOSE

The distinction between tuberculosis (TB), a worldwide infectious granulomatosis requiring specific antibiotic therapy, and sarcoidosis, a rare granulomatous disease that may require corticosteroids is not straightforward and may result in diagnostic and therapeutic delay.

METHODS

We prospectively and consecutively evaluated the presence of epithelioid granulomas in minor salivary gland biopsy of 65 consecutive patients with TB.

RESULTS

In our study, 10.8 % of our TB patients had epithelioid granulomas without caseous necrosis identified in their minor salivary gland biopsy, regardless of the location of TB, HIV status and whether or not the sputum examination was positive for tuberculous bacilli.

CONCLUSION

The presence of epithelioid granulomas in minor salivary gland biopsy may not be helpful to the clinician to rule out TB in a patient with suspected sarcoidosis.

Predictors of complications in gynaecological oncological surgery: a prospective multicentre study (UKGOSOC-UK gynaecological oncology surgical outcomes and complications)

BACKGROUND

There are limited data on surgical outcomes in gynaecological oncology. We report on predictors of complications in a multicentre prospective study.

METHODS

Data on surgical procedures and resulting complications were contemporaneously recorded on consented patients in 10 participating UK gynaecological cancer centres. Patients were sent follow-up letters to capture any further complications. Post-operative (Post-op) complications were graded (I-V) in increasing severity using the Clavien-Dindo system. Grade I complications were excluded from the analysis. Univariable and multivariable regression was used to identify predictors of complications using all surgery for intra-operative (Intra-op) and only those with both hospital and patient-reported data for Post-op complications.

RESULTS

Prospective data were available on 2948 major operations undertaken between April 2010 and February 2012. Median age was 62 years, with 35% obese and 20.4% ASA grade ⩾3. Consultant gynaecological oncologists performed 74.3% of operations. Intra-op complications were reported in 139 of 2948 and Grade II-V Post-op complications in 379 of 1462 surgeries. The predictors of risk were different for Intra-op and Post-op complications. For Intra-op complications, previous abdominal surgery, metabolic/endocrine disorders (excluding diabetes), surgical complexity and final diagnosis were significant in univariable and multivariable regression (P<0.05), with diabetes only in multivariable regression (P=0.006). For Post-op complications, age, comorbidity status, diabetes, surgical approach, duration of surgery, and final diagnosis were significant in both univariable and multivariable regression (P<0.05).

CONCLUSIONS

This multicentre prospective audit benchmarks the considerable morbidity associated with gynaecological oncology surgery. There are significant patient and surgical factors that influence this risk.

Degradation of tetracycline at a boron-doped diamond anode: influence of initial pH, applied current intensity and electrolyte

The anodic oxidation of tetracycline was performed in an up-flow reactor, operating in batch mode with recirculation, using as anode a boron-doped diamond electrode. The influence on the degradation rate of solution initial pH (2 to 12), applied current intensity (25 to 300 A m(-2)) and type of electrolyte (sodium sulphate or sodium chloride) were investigated. For the assays run at equal current density, with sodium sulphate as electrolyte, the solution's initial pH of 2 presented the highest absorbance and chemical oxygen demand removals. Regarding the influence of current density, for equal charge passed, the organic load removal rate decreased with the increase in applied current. When sodium sulphate was used as an electrolyte, high-performance liquid chromatography (HPLC) results have shown an almost complete removal of tetracycline after a 2-h assay. HPLC results have also shown the presence of oxamic acid as one of the intermediates of tetracycline anodic oxidation. The complete removal of tetracycline was much faster in the presence of chloride ions that promoted the complete degradation of this antibiotic in 30 min. However, in the presence of chloride ions, the tetracycline mineralization is slower, as observed by the lower organic carbon removal rate when compared to that of the tetracycline degradation in the presence of sulphate.