CD30 expression is common in mediastinal large B-cell lymphoma

Large B-cell lymphoma manifesting in the mediastinum shows distinctive clinical and immunophenotypic features and is recognized as a unique type of large B-cell lymphoma in the Revised European-American Lymphoma classification. Fifty-one cases of primary mediastinal large B-cell lymphoma were retrieved from the immunodiagnosis laboratory database files and were stained with anti-CD30 (Ber-H2). Of the 51 cases, 35 (69%) stained for CD30. This staining ranged from strong membrane staining of all or almost all of the neoplastic cells to positivity of rare individual cells. Eleven cases (22%) were negative; 4 (8%) were equivocal. Only 1 case was uninterpretable owing to B-5 fixation and lack of a positive internal control. Thus, the majority of mediastinal large B-cell lymphomas express the Hodgkin marker CD30. This finding may result in misdiagnosis of large cell lymphoma as Hodgkin disease.

Mediastinal bronchogenic cyst manifesting as a catastrophic myocardial infarction

Congenital bronchogenic cysts of the lung and mediastinum develop from the ventral foregut during embryogenesis. These cysts are often incidental radiologic findings in adults, but patients can be seen with symptoms of chest pain, cough, dyspnea, or any combination of these. Acute presentations are unusual and have rarely been reported. We present the unique case of a 36-year-old man seen with an acute coronary syndrome and sudden hemodynamic collapse. The patient sustained a massive and ultimately fatal myocardial infarction, compression of the left main coronary artery by a bronchogenic cyst was demonstrated at postmortem examination. If detected, bronchogenic cysts should be surgically excised to limit associated morbidity and mortality.

Beta2-adrenergic receptor overexpression in the developing mouse heart: evidence for targeted modulation of ion channels

1. We studied the effect of overexpression of the beta2-adrenergic receptor (beta2-AR) in the heart on ion channel currents in single cells isolated from hearts of fetal and neonatal transgenic and wild-type mice. The beta2-AR transgene construct was under the control of the murine alpha-myosin heavy chain (alpha-MHC) promoter, and ion channel activity was measured at distinct developmental stages using whole-cell and perforated patch clamp techniques. 2. We found no change in L-type Ca2+ channel current (ICa) density in early embryonic stages (E11-13) of beta2-AR transgenic positive (TG+) mice, but significant increases in ICa density in intermediate (E14-16, 152 %) and late (E17-19, 173.7 %) fetal and neonatal (1 day post partum, 161 %) TG+ compared with transgenic negative (TG-) mice. This increase in ICa was accompanied by a negative shift in the peak of the current-voltage relationship in TG+ mice. 3. Transient (< 3 min) or prolonged (16-24 h) exposure of TG- neonatal stage myocytes to 8-Br-cAMP (300 microM) increased ICa density and caused a shift in the current-voltage relationship to a similar extent to that seen in TG+ mice. In TG+ myocytes, 8-Br-cAMP had no effect. Exposure of TG+ cells to Rp-cAMPS reversed both the shift in voltage dependence and reduced the peak current density observed in these myocytes. We concluded from these results that the L-type Ca2+ channel is maximally modulated by cAMP-dependent protein kinase (PKA) in TG+ mice and that the alpha-MHC promoter is functional in the ventricle as early as embryonic day 14. 4. In contrast, we found that slow delayed rectifier K+ channels were not changed significantly at any of the developmental stages studied by the overexpression of beta2-ARs compared with TG- mice. The sensitivity of murine slow delayed rectifier K+ channels to cAMP was tested by both transient and prolonged exposure to 8-Br-cAMP (300 microM), which increased the slow delayed rectifier K+ channel current (IK,s) density to a similar extent in both TG- and TG+ neonatal myocytes. In addition, we found that there was no difference in the concentration dependence of the response of ICa and IK,s to 8-Br-cAMP. 5. Thus, overexpression of the beta2-AR in the heart results in distinct modulation of ICa, but not IK,s, and this is not due to differences in the 8-Br-cAMP sensitivity of the two channels. Instead, these results are consistent with both compartmentalization of beta2-AR-controlled cAMP and distinct localization of L-type Ca2+ and slow delayed rectifier K+ channels. This cAMP is targeted preferentially to the L-type Ca2+ channel and is not accessible to the slow delayed rectifier K+ channel.

Randomised controlled trial of novel, simple, and well supervised weight reducing diets in outpatients

OBJECTIVES

To investigate the contribution of novelty and simplicity to compliance with a low energy diet among obese outpatients.

DESIGN

Three arm randomised trial for 16 weeks.

SETTING

NHS hospital obesity clinic.

SUBJECTS

45 patients aged over 17 years with a body mass index >27 who were not diabetic, pregnant, or lactating.

INTERVENTIONS

Conventional 3.4 MJ diet (control), isoenergetic novel diet of milk only, or milk plus one designated food daily. Follow up visit every 4 weeks.

MAIN OUTCOME MEASURE

Weight loss.

RESULTS

Mean weight loss (kg) after 16 weeks on control, milk only, and milk plus diets was 1.7 (95% confidence interval 0.3 to 3.7), 9.4 (5.9 to 12.9), and 7.0 (2.7 to 11.3) respectively. Weight loss on the novel diets was significantly greater than on the control diet.

CONCLUSIONS

Dietary treatment can achieve as much weight loss in obese outpatients over 16 weeks as has been reported for the most successful drug treatment, but compliance with the prescribed diet is poor unless the diet is novel and simple.

Management of the clinically positive neck in organ preservation for advanced head and neck cancer

BACKGROUND

To investigate clinicopathologic predictive criteria for the optimal management of neck metastases in patients with advanced head and neck cancers treated with combined chemoradiotherapy.

METHODS

Prospective study, 48 patients. Mean length follow-up, 23 months.

RESULTS

Neck stage predicted neck response to chemoradiotherapy; N3 necks showed more partial responses (P = 0.04), and N1 necks showed more complete responses (P = 0.12). Primary tumor site strongly predicted the pathologic response found on neck dissection in patients with a clinical partial response (cPR) following chemoradiotherapy. There was no difference in survival between patients with a clinical complete response (cCR) after chemoradiotherapy, and patients with a pathologic complete response (pCR) after neck dissection (P = 0.20); however, when grouped together, these patients survived longer than did patients with a pPR at neck dissection (P = 0.06).

CONCLUSIONS

Clinical response to induction chemotherapy is a poor predictor of ultimate neck control. Induction chemotherapy followed by chemoradiotherapy, and planned neck dissection for patients with persistent cervical lymphadenopathy, provides good regional control.

Borrowing strength from external trials in a meta-analysis

There exists a variety of situations in which a random effects meta-analysis might be undertaken using a small number of clinical trials. A problem associated with small meta-analyses is estimating the heterogeneity between trials. To overcome this problem, information from other related studies may be incorporated into the meta-analysis. A Bayesian approach to this problem is presented using data from previous meta-analyses in the same therapeutic area to formulate a prior distribution for the heterogeneity. The treatment difference parameters are given non-informative priors. Further, related trials which compare one or other of the treatments of interest with a common third treatment are included in the model to improve inference on both the heterogeneity and the treatment difference. Two approaches to estimating relative efficacy are considered, namely a general parametric approach and a method explicit to binary data. The methodology is illustrated using data from 26 clinical trials which investigate the prevention of cirrhosis using beta-blockers and sclerotherapy. Both sources of external information lead to more precise posterior distributions for all parameters, in particular that representing heterogeneity.

Borrowing strength from external trials in a meta-analysis

There exists a variety of situations in which a random effects meta-analysis might be undertaken using a small number of clinical trials. A problem associated with small meta-analyses is estimating the heterogeneity between trials. To overcome this problem, information from other related studies may be incorporated into the meta-analysis. A Bayesian approach to this problem is presented using data from previous meta-analyses in the same therapeutic area to formulate a prior distribution for the heterogeneity. The treatment difference parameters are given non-informative priors. Further, related trials which compare one or other of the treatments of interest with a common third treatment are included in the model to improve inference on both the heterogeneity and the treatment difference. Two approaches to estimating relative efficacy are considered, namely a general parametric approach and a method explicit to binary data. The methodology is illustrated using data from 26 clinical trials which investigate the prevention of cirrhosis using beta-blockers and sclerotherapy. Both sources of external information lead to more precise posterior distributions for all parameters, in particular that representing heterogeneity.

Interaction between the trauma team and families: lack of timely communication

Families of critically ill patients desire early information regarding the condition of their relative. The purpose of this study was to determine how long family members waited before someone from the trauma team met with them to discuss the condition of their relative. This was a prospective, single-blinded study of a convenience sample of 63 trauma patients conducted at a trauma center. Observers recorded the time of arrival of the patient, time of family arrival, and the time the family was first contacted by the trauma team. Families arrived 38 +/- 35 minutes after the patient. The mean time families waited before contact with the trauma team was 37 +/- 34 minutes. This study shows that the trauma team is often slow in communicating with the family of the victim. One member of the caregiving team should be designated to advise the family on the condition of the patient as soon as possible.

Alcohol, the elderly, and motor vehicle crashes

To document the prevalence of alcohol or drug use among elderly drivers admitted to a Level 1 trauma center after motor vehicle crashes, charts from 180 drivers age 60 years or older who were admitted to an urban Level 1 trauma center after motor vehicle crashes were retrospectively reviewed. Overall, 14% of the patients had a positive blood alcohol screen; among men, 21% had a positive screen. Only 55% of the patients were discharged to home. Only one patient ( < 1%) had a toxicology screen positive for another drug abuse. Alcohol/drug abuse counselling was offered to only one patient. These results suggest a relatively of high prevalence of alcohol use in elderly drivers involved in motor vehicle crashes, particularly men. However, abuse of other drugs was uncommon. Physicians treating intoxicated drivers should consider referral for alcohol counselling.

Diffuse large cell lymphoma of the lung: an unusual cause of complete opacification of the hemithorax

Complete opacification on chest radiographs may be due to collapse of the lung, consolidation, massive pleural effusion, empyema, hemothorax, chylothorax, fibrothorax, and other causes. We report a case of complete opacification of the hemithorax produced by large cell lymphoma, a previously unreported cause of this finding. Diagnosis was complicated by the CT finding of replacement of the lung parenchyma by a soft-tissue mass with an associated small pleural effusion, while bronchoscopy failed to reveal any major airway obstruction. Large cell lymphoma should therefore be added to the differential diagnosis when considering causes of complete opacification of the hemithorax. Both the patient and his brother had the combination of Lowe's syndrome and cancer.

Pulmonary lymphangioleiomyomatosis

This paper reports a case of a 50 yr old premenopausal woman with pulmonary lymphangioleiomyomatosis. This asymptomatic woman was found to have 'pulmonary nodules' on routine chest x-ray simulating metastatic lesions. The final diagnosis was possible after pathological examination of the lung biopsy specimens. This case is atypical for 3 reasons: firstly, the patient's age was 50, unusually old for this tumor; secondly, she was asymptomatic; and finally, the pulmonary imaging findings revealed bilateral nodular lesions in contrast to the usual reticular pattern.