Multiple cardiovascular involvement in a case of relapsing polychondritis

Relapsing polychondritis is a multisystem disease characterized by recurrent inflammation of the cartilaginous tissue. Cardiovascular manifestations of relapsing polychondritis are rare but are the second most common cause of death in these patients. We report a case of relapsing polychondritis who underwent aortic valve replacement uneventfully but presented six months later with myocardial infarction due to bilateral coronary ostial stenosis.

Nanoscale scanning transmission electron tomography

Electron tomography enables the study of complex three-dimensional objects with nanometre resolution. In materials science, scanning transmission electron microscopy provides images with minimal coherent diffraction effects and with high atomic number contrast that makes them ideal for electron tomographic reconstruction. In this study, we reviewed the topic of scanning transmission electron microscopy-based tomography and illustrated the power of the technique with a number of examples with critical dimensions at the nanoscale.

[Control of hypertension in nursing homes]

In a cross sectional study we determined prevalence of hypertension among institutionalized old subjects. Prevalence of hypertension was 69%. Among detected hypertensive patients, 76% received an antihypertensive drug treatment. 61% of the declared hypertensive patients and 80% of the treated hypertensive patients had their blood pressure controlled. The general practitioners should better detect and treat this common geriatric problem associated with a high comorbidity.

Incidence, mortality and survival in cutaneous melanoma

Cutaneous melanoma remains a challenge despite increased levels of awareness, education and targeted health policies. Worldwide incidence rates for cutaneous melanoma have risen faster than those for any other malignancy in Caucasian populations over the last 30 years. Despite improving survival rates (defined as the ratio of those who survive the disease against incidence) over this period, mortality rates, generally, have continued to climb. Mortality from melanoma is greater than that caused by all other types of skin cancer, especially in men. In Britain the percentage of increase in the male age standardised mortality rate surpassed that of all other malignancies assessed (1993-2002) by Cancer Research UK. A literature-based study was conducted with review of publications identified through Medline and EMBase, 1980-December 2005, databases. We present a review of the current literature on incidence, mortality and survival rates of melanoma including a discussion on the aetiological factors, behaviour modification associated with public education campaigns and recent health policies and the effect these are having on melanoma figures. It is likely that any fall in mortality rates from melanoma in the near future will be secondary to early detection. Changes resulting from primary prevention are unlikely to be noticeable for several decades.

[Management of arterial hypertension in octogenarian]

Hypertension is the most common chronic condition for which elderly people see a health provider and is increasing in prevalence as people age. The most powerful risk factor for death, cardiovascular death, and hypertension in large populations is age. In the very elderly patient the most common abnormality is elevated systolic blood pressure, which is much more predictive of stroke and heart disease death. With the exception of the Antihypertensive and Lipid Lowering to prevent Heart Attack Trial (ALLHAT), recent trials have emphasized the overriding importance of lowering blood pressure rather than the specific agent chosen to begin therapy. A metaanalysis of 7 clinical trials that enrolled 1.670 subjects > 80 years od age indicated that active antihypertensive drug therapy significantly reduce stroke by 34% and heart failure by 39% was associated with a non significant 6 increase in mortality. The Hypertension in the Very Elderly Trial (HYVET) will enrol 2.100 patients > 80 years of age and will compare 2 groups randomized to indapamide +/- perindopril versus placebo +/- placebo for incident stroke during 5 years follow-up. This study should answer lingering question about whether active antihypertensive therapy is associated with a major and significant reduction in cardiovascular morbidity and mortality in this age group as it clearly does in younger hypertensives. For frail patients, further studies are needed to assess the potential risks associated to antihypertensive therapy according to the characteristics of the geriatric patient.

Quantitative analysis of chimerism using a short tandem repeat method on a fluorescent automated DNA sequencer

Stem cell transplantation (SCT) is the treatment of choice for a number of malignant and nonmalignant diseases. Monitoring of SC engraftment or microchimerism (MC) is important for diagnosis of relapse, rejection or graft vs. host disease (GVHD). The goal of this study was to develop a sensitive and relatively simple method for MC lineage analysis using the Visible Genetics fluorescence automated sequencer. Sensitivity of the method was studied by polymerase chain reaction (PCR) amplification of informative short tandem repeats (STR) using donor/recipient DNA mixtures as the templates and DNA extracted from donor and recipient CD3+, CD19+ and CD15+ cells mixed at various ratios. Semi-quantitative analysis was performed using the Visible Genetics software and percent of donor specific signal was calculated. The sensitivity of this method varied from 0.8% to 6.2% for both DNA and cellular MC in CD3+, CD19+ and CD15+ subsets. Regression analysis revealed linearity (r = 0.94) between the number of donor cells in the mixture and intensity of MC fluorescent signal. These data indicate that the Visible Genetics polyacrylamide gel sequencer can be successfully used for MC analysis in SC recipients providing a relatively high level of sensitivity.

Caution with sentinel node biopsy in cutaneous melanoma

No justification outside of a trial

Risk and predictors of fatigue after infectious mononucleosis in a large primary-care cohort

BACKGROUND

Fatigue has been found to complicate infectious mononucleosis (IM) when patients are directly asked about it. We do not know whether such fatigue is clinically significant, nor whether IM is a specific risk for fatigue (or whether it can follow other common infections). Various risk markers for post-infectious fatigue have been identified, but findings are inconsistent.

AIM

To determine the risk of clinically reported fatigue (compared with depression) after IM (compared with both influenza and tonsillitis) in patients attending primary care, and to examine risk markers for post-IM fatigue.

DESIGN

Comparison of matched primary-care cohorts.

METHODS

We identified 1438 adult patients with a positive heterophil antibody test for IM from the UK General Practice Research Database. These patients were individually matched on age, sex and practice to two comparison groups; one with a clinical diagnosis of influenza and the other of tonsillitis.

RESULTS

The odds ratios (ORs) (95%CI) for reported fatigue after IM vs. influenza and tonsillitis were 4.4 (2.9-6.9) and 6.6 (4.2-10.4), respectively. Risk markers for post-IM fatigue included female sex and premorbid mood disorder. By comparison, the ORs for depression after IM vs. influenza and tonsillitis were 1.6 (0.9-2.6) and 2.3 (1.4-3.9), respectively.

DISCUSSION

IM is a specific and significant risk for clinically reported fatigue, which is both separate from, and more common than, depression. Female sex and premorbid mood disorder are risk markers for fatigue. These can be used both to target prevention strategies and to explore aetiological mechanisms.

Imaging features of retroperitoneal and pelvic schwannomas

AIM

To describe the imaging features of retroperitoneal and pelvic schwannomas.

MATERIALS AND METHODS

The presenting cross-sectional imaging for 18 sequential patients with retroperitoneal or pelvic schwannomas was reviewed retrospectively. Note was made of tumour diameter, position, homogeneity, margin, shape, calcification and invasion into adjacent structures. Where MRI had been performed, T1 and T2 signal intensity relative to skeletal muscle, and the degree and pattern of enhancement with gadolinium, were also assessed.

RESULTS

Imaging from 13 patients was available for review. The mean tumour diameter was 8.7 cm (range 4 to 15 cm); 9 schwannomas were located in the pelvis and 4 in the retroperitoneum; 12 cases showed smooth, regular margins and 1 case irregular, invasive margins. The tumours were homogeneous in 5 cases and heterogeneous with cystic change in 8; in 2 cases there was smooth expansion of a sacral nerve root exit foramen, and in 1 there was bony destruction of the sacrum and extension of tumour into the spinal canal. In 5 cases MRI was performed; on T1-weighted images all tumours were isointense; on T2-weighted images 4 tumours were hyperintense and 1 was isointense to skeletal muscle. In all cases the diagnosis was confirmed by core biopsy.

CONCLUSION

Retroperitoneal and pelvic schwannomas typically form large, well-circumscribed masses in the retroperitoneum or presacral area, and frequently undergo cystic degeneration. They can occasionally cause bony changes in the spine, but otherwise do not invade or obstruct adjacent structures. Although they are rare, it is important for the radiologist to recognize the typical appearance of schwannomas because they can be mistaken for malignant tumours.

[Early screen of the Alzheimer's disease by the general practitioner. Review of the literature]

The Alzheimer's disease is the more frequent dementia. The general practitioner has a place in her early screen. He'll investigate the instrumental activities of daily living, the cognitive impairment and the depressive affects. He'll use short validated sales.

Elevated tumour markers prior to complete tumour removal in patients with pseudomyxoma peritonei predict early recurrence

OBJECTIVE

To assess the potential value of pre-operative CEA, CA 125 and CA 19-9 in identifying Pseudomyxoma peritonei (PMP) patients at risk of recurrence following complete cytoreductive surgery and intraperitoneal chemotherapy.

METHOD

Between March 1996 and October 2001, 35 patients, with documented pre-operative tumour marker measurements, underwent complete cytoreduction. Outcome in the 32 survivors was recorded.

RESULTS

Median age was 53 years (range: 32-74). There were 17[53%] females. In 9/32[28%] all tumour markers were normal. The most common abnormality was elevated CEA level in 14/32[44%]. Median follow up was 23 months (range: 11-74). Recurrence was detected in 8/32[25%]. The 2-year recurrence free interval was 53% in those with elevated CEA compared with 94% with normal CEA. The 2-year disease free intervals were 100% in 9 patients with normal preop markers compared with 66% for the group with at least one abnormal marker.

CONCLUSION

PMP patients with elevated CEA, or more than one abnormal serum tumour maker, are at risk of developing recurrent disease.

Increased expression of unusual EP repeat-containing proteins in the midgut of the tsetse fly (Glossina) after bacterial challenge

Proteins containing a glutamic acid-proline (EP) repeat epitope were immunologically detected in midguts from eight species of Glossina (tsetse flies). The molecular masses of the tsetse EP proteins differed among species groups. The amino acid sequence of one of these proteins, from Glossina palpalis palpalis, was determined and compared to the sequence of a homologue, the tsetse midgut EP protein of Glossina m. morsitans. The extended EP repeat domains comprised between 36% (G. m. morsitans) and 46% (G. p. palpalis) of the amino acid residues, but otherwise the two polypeptide chains shared most of their sequences and predicted functional domains. The levels of expression of tsetse EP protein in adult teneral midguts were markedly higher than in midguts from larvae. The EP protein was detected by immunoblotting in the fat body, proventriculus and midgut, the known major immune tissues of tsetse and is likely secreted as it was also detected in hemolymph. The EP protein was not produced by the bacterial symbionts of tsetse midguts as determined by genome analysis of Wigglesworthia glossinidia and immunoblot analysis of Sodalis glossinidius. Bacterial challenge of G. m. morsitans, by injection of live E. coli, induced augmented expression of the tsetse EP protein. The presence of EP proteins in a wide variety of tsetse, their constitutive expression in adult fat body and midguts and their upregulation after immunogen challenge suggest they play an important role as a component of the immune system in tsetse.

Delay in referral to a specialist soft-tissue sarcoma unit

BACKGROUND

Soft-tissue sarcoma is a rare neoplasm which can occur almost anywhere in the body. There are no specific symptoms and signs and the disease can mimic more common benign and malignant conditions. It is not surprising, therefore, that diagnosis and referral to a specialist unit is often delayed.

METHODS

A prospective audit was undertaken in 216 patients referred to a specialist unit with suspected or proven soft-tissue sarcoma over a 12 month period. All patients were interviewed to determine the chronology of symptoms and signs, and the referral and diagnostic pathway. Delay in referral was defined as three months or greater from first presentation to a doctor to review at our unit.

RESULTS

There were 159 patients with previously untreated soft-tissue sarcomas. Thirty-one patients had delays in referral, and the overall median delay was 14 months (range 4-96 months). The delay was caused by the general practitioner in 13 patients, the patient (after general practitioner referral) on two occasions, by the hospital or referring specialist in seven patients, and was multifactorial in nine patients.

CONCLUSIONS

A fifth of patients with soft-tissue sarcoma encountered important delays in referral to this specialist unit. This duration of delay is likely to have had a detrimental effect on treatment options and outcomes, including survival in some patients.

Computational approaches to the determination of active site structures and reaction mechanisms in heterogeneous catalysts

We apply quantum chemical methods to the study of active site structures and reaction mechanisms in mesoporous silica and metal oxide catalysts. Our approach is based on the use of both molecular cluster and embedded cluster (QM/MM) techniques, where the active site and molecular complex are described using density functional theory (DFT) and the embedding matrix simulated by shell model potentials. We consider three case studies: alkene epoxidation over the microporous TS-1 catalyst; methanol synthesis on ZnO and Cu/ZnO and C-H bond activation over Li-doped MgO.

Incidence and outcome of critical illness amongst hospitalised patients with haematological malignancy: a prospective observational study of ward and intensive care unit based care

To determine the incidence and outcome of critical illness amongst the total population of hospital patients with haematological malignancy (including patients treated on the ward as well as those admitted to the intensive care unit), consecutive patients with haematological malignancy were prospectively studied. One hundred and one of the 1437 haemato-oncology admissions (7%) in 2001 were complicated by critical illness (26% of all new referrals). Fifty-four (53%) of these critically ill patients survived to leave hospital and 33 (34%) were still alive after 6 months. The majority (77/101) were not admitted to the intensive care unit but were managed on the ward, often with the assistance of the intensive care team. Independent risk factors for dying in hospital included hepatic failure (odds ratio 5.3, 95% confidence intervals 1.3-21.2) and central nervous system failure (odds ratio 14.5, 95% confidence intervals 1.7-120.5). No patient with four or more organ failures or a Simplified Acute Physiology Score II >/= 65 survived to leave hospital. There was close agreement between actual and predicted mortality with increasing Simplified Acute Physiology Score II for all patients, including those not admitted to intensive care.

Prognostic factors in advanced synovial sarcoma: an analysis of 104 patients treated at the Royal Marsden Hospital

AIMS

Key prognostic factors at diagnosis of synovial sarcoma are well defined from the literature. There are few data regarding prognostic parameters in the setting of advanced disease. Our aim was to look specifically at a cohort of patients with advanced synovial sarcoma and to identify potential prognostic factors.

PATIENTS AND METHODS

One hundred and four patients with advanced synovial sarcoma were identified from the Royal Marsden Hospital's sarcoma database between 1978 and 2003. Patient data were analysed retrospectively. Most patients were aged between 20 and 50 years at diagnosis. Seventy-one patients were deceased at the time of analysis. Ninety-two patients received chemotherapy for management of advanced disease (most commonly doxorubicin + ifosfamide).

RESULTS

Median survival following development of advanced disease was 22 months. Predictors of survival with advanced disease were age <35 years (P = 0.03) and response to first-line chemotherapy (P = 0.05). The response rate to doxorubicin plus ifosfamide was 58.6%, and this was superior to either agent when given singly. Metastasectomy was not associated with improved prognosis in this series.

CONCLUSIONS

Synovial sarcoma is a chemosensitive soft tissue sarcoma. Compared with historical controls, survival with advanced disease seems to have improved over the years, possibly as a result of better use of chemotherapy. Age <35 years and response to first-line chemotherapy predict for improved survival with advanced disease.

Stewart–Treves syndrome—treatment and outcome in six patients from a single centre

AIMS

Stewart-Treves syndrome is an angiosarcoma associated with long-standing lymphoedema, most commonly seen as a rare complication of breast cancer treatment, and is associated with a poor outcome. We present results from six patients supporting the use of early radical surgery to improve prognosis.

METHODS

Six patients with Stewart-Treves syndrome were diagnosed and treated at our centre over an 11-year period. Five patients had forequarter amputation and the sixth had a through-hip amputation.

RESULTS

Four of the six patients are alive and well following surgery (at 3, 16, 23, and 135 months after amputation); one patient died from metastatic disease at 15 months and the second died due to an unrelated malignancy.

CONCLUSION

Early diagnosis and treatment by radical ablative surgery confers a reasonable prognosis with this rare but aggressive disease. A nihilistic approach is unjustified.

Surgical management of primary and recurrent retroperitoneal liposarcoma

Background

Surgery plays a dominant role in the initial and subsequent treatment of retroperitoneal liposarcoma (RPLS). This study was a review of outcomes of patients treated at the Royal Marsden Hospital.

Methods

Records of all patients who had surgery for RPLS since 1990 were reviewed, with particular attention to local recurrence and disease-specific survival. Patients with primary RPLS and those with recurrent RPLS, who had palliative surgery after a variable number of operations performed elsewhere, were considered separately.

Results

Seventy-two patients had surgery for primary RPLS, over half of whom underwent resection of a contiguous organ to achieve clearance. Follow-up of at least 12 months was available for 58 patients. Thirty-four patients had no evidence of recurrence after median follow-up of 26 (range 12–151) months. Low-grade tumour and macroscopic clearance of tumour were significantly associated with a reduced risk of local recurrence and improved survival. Forty-seven patients had palliative surgery for recurrent RPLS. Median survival from time of last operation to death was 27 (range 0–79) months. Follow-up was to a median of 68 (range 14–261) months.

Conclusion

Patients with low-grade RPLS that has been completely resected at the initial operation have the most favourable prognosis. Palliative resection is worthwhile to treat troublesome symptoms of recurrence

Aggressive fibromatosis of the abdominal wall, limbs and limb girdles

Background

Aggressive fibromatosis (AF) is a rare soft-tissue tumour. It is histologically benign but locally aggressive and destructive. Surgery is the mainstay of treatment. This was a review of patients treated at the Royal Marsden Hospital between 1986 and 2003.

Methods

Records of patients with abdominal wall (23) and limb or limb girdle (86) AF were studied to determine patient, tumour and treatment characteristics and outcome. Children and patients with intra-abdominal AF were excluded. The data were analysed by Cox regression to calculate univariate hazard ratios.

Results

Twenty-one (19·3 per cent) of 109 patients developed recurrence after a median follow-up of 39 months. Recurrence did not correlate with surgical margin or any other variable.

Conclusion

Wide excisional, function-preserving surgery is the goal in treatment of AF. Surgery for recurrent disease is often curative. Tumours are frequently irresectable at presentation and an initial period of expectant observation is advisable because growth arrest is a common feature of the disease.