Pembrolizumab-induced myocarditis with complete atrioventricular block and concomitant myositis in a metastatic bladder cancer patient: a case report and review of the literature

BACKGROUND

The cardiovascular system is among the least systems affected by immune-related adverse events. We report a rare life-threatening case of pembrolizumab-induced myocarditis with complete atrioventricular block and concomitant myositis in a metastatic bladder cancer patient.

CASE PRESENTATION

An 82-year-old Caucasian female with invasive urothelial carcinoma, started on first-line pembrolizumab, was admitted four days after receiving her second dose for severe asthenia, diffuse muscle aches, neck pain, and lethargy. In the emergency department, she had several episodes of bradycardia reaching 40 beats per minute associated with general discomfort and fatigue. Electrocardiography showed a third-degree atrioventricular heart block, while the patient remained normotensive. Cardiac damage parameters were altered with elevated levels of creatine phosphokinase of 8930 U/L, suggestive of immune checkpoint inhibitor-induced myositis, and troponin T of 1.060 ng/mL. Transthoracic echocardiography showed a preserved ejection fraction. Pembrolizumab-induced myocarditis was suspected. Therefore, treatment was initiated with high-dose glucocorticoids for 5 days, followed by a long oral steroid taper. A pacemaker was also implanted. Treatment resulted in the resolution of heart block and a decrease in creatine phosphokinase to the normal range.

CONCLUSION

Life-threatening cardiac adverse events in the form of myocarditis may occur with pembrolizumab use, warranting vigilant cardiac monitoring. Troponin monitoring in high-risk patients, along with baseline echocardiography may help identify this complication promptly to prevent life-threatening consequences.

Learning From COVID-19: What Would It Take to Be Better Prepared in the Eastern Mediterranean Region?

The COVID-19 transmission in the Eastern Mediterranean Region (EMR) was influenced by various factors such as conflict, demographics, travel and social restrictions, migrant workers, weak health systems, and mass gatherings. The countries that responded well to COVID-19 had high-level political commitment, multisectoral coordination, and existing infrastructures that could quickly mobilize. However, some EMR countries faced challenges due to political instability and fragile health systems, which hindered their response strategies. The pandemic highlighted the region's weak health systems and preparedness, fragmented surveillance systems, and lack of trust in information sharing. COVID-19 exposed the disruption of access and delivery of essential health services as a major health system fragility. In 2020, the World Health Organization (WHO) conducted a global pulse survey, which demonstrated that the EMR experienced the highest disruption in health services compared to other WHO regions. However, thanks to prioritization by the WHO and its member states, significant improvement was observed in 2021 during the second round of the WHO's National Pulse Survey. The pandemic underscored the importance of political leadership, community engagement, and trust and emphasized that investing in health security benefits everyone. Increasing vaccine coverage, building regional capacities, strengthening health systems, and working toward universal health coverage and health security are all priorities in the EMR. Emergency public health plays a key role in preparing for and responding to pandemics and biological threats. Integrating public health into primary care and investing in public health workforce capacity building is essential to reshaping public health and health emergency preparedness.

Strengthening Primary Healthcare in Jordan for Achieving Universal Health Coverage: A Need for Family Health Team Approach

Achieving Universal Health Coverage (UHC) is a strategic objective of the Jordanian government and has been prioritized in its strategies and plans. However, there are several challenges affecting primary healthcare in Jordan and the health system in general that prevent Jordan from achieving UHC. This paper highlights the importance of team-based care in the form of Family Health Teams (FHTs) to realize Jordan's goal of achieving UHC. FHTs are a team-based approach that brings together diverse professionals to provide a comprehensive, efficient, patient-centered primary care system that meets the changing needs of Jordan's population and refugees. However, the implementation of FHT may encounter obstacles, including individual, organizational, institutional, and external barriers. To overcome such obstacles, several actions and processes need to be taken, including political commitment and leadership, implementing good governance and policy frameworks, allocating resources and funding, multisectoral collaboration, and engagement of communities and stakeholders. The successful implementation of FHTs requires participation from government officials, parliamentarians, civil society, and influential community, religious, and business leaders. A strategic policy framework, effective oversight, coalition building, regulation, attention to system design, and accountability are also essential. In conclusion, adopting the FHT approach in Jordan's Primary Healthcare system offers a promising path towards achieving UHC, improving healthcare access, quality, and efficiency while addressing the unique challenges faced by the country's healthcare system.

Automated right ventricular strain by speckle tracking echocardiography in patients with systemic scleroderma

Introduction

In patients with scleroderma the morphological remodeling and alteration of right ventricular (RV) function begins even before the setting of pulmonary artery hypertension (PAH). These alterations are associated with worse outcomes and high mortality.

Purpose

Early detection of RV dysfunction is possible using advanced imaging techniques and can lead to specific therapeutic measures before installation of PAH. Purpose of this study is to evaluate new indices, based on speckle tracking technology, for identification of subclinical RV systolic failure.

Methods

Twenty-five (25) scleroderma patients without any signs or symptoms of PAH and twenty-five (25) healthy subjects were included in the present study. Two-dimensional echocardiography (2DE) and two-dimensional speckle-tracking echocardiography (2DSTE) were performed. All the usual 2DE, Doppler and tissue Doppler imaging measurements were obtained for the evaluation of RV function. Moreover, TAPSE, maximum systolic myocardial velocity from TDI of lateral tricuspid valve annulus (SRV), auto RV global longitudinal strain (aRVGLS) and auto RV free wall longitudinal strain (aRVFWLS) by 2DSTE were measured. aRVGLS is a new index, with appropriate RV function echo logistics in new technology echo systems, independent from known manual measurements.

Results

In scleroderma patients significantly higher systolic pulmonary artery pressure was recorded, although it remained within normal limits in both groups. Scleroderma patients had significant decreased RV systolic function with significantly lower TAPSE and SRV. Both aRVGLS and aRVFWLS were also significantly lower in scleroderma patients compared to the control group. aRVGLS was the best predictor of early RV systolic impairment in patients with scleroderma.

Conclusions

Scleroderma is a severe systematic disease associated with high mortality rates. RV remodeling, dysfunction, and progressive pulmonary artery hypertension are among the most important internal organ manifestations of this disease. Early detection of RV dysfunction is possible by 2DSTE, and may be helpful to guide further therapy in these patients.

Funding Acknowledgement

Type of funding sources: None.

Recommendations on pregnancy, childbirth and aftercare in epidermolysis bullosa: a consensus-based guideline

Linked Comment:A.W. Lucky and E. Pope. Br J Dermatol 2022; 186:602–603.

Plain language summary available online

Management of Hip Fractures at an Academic Center: Challenges and Opportunities

OBJECTIVE

To assess characteristics of patients with hip fractures and investigate the extent of osteoporosis-related care they receive at a tertiary referral center in Lebanon.

METHODS

A retrospective review of charts of 400 patients admitted with a hip fracture to the American University of Beirut-Medical Center, between January 1, 2011 and December 31, 2015. We reviewed medical records of adults admitted with a nonpathologic/nontraumatic hip fracture, and evaluated basic demographics and relevant clinical information, associated risk factors, and the management received.

RESULTS

The mean age of the population was 78 ± 10 years and men constituted 37%. Women were more likely to be assessed and/or treated. On admission, 21% were taking calcium and 18% vitamin D supplementation. During hospitalization, vitamin D level was assessed in only 39% of patients; a dietary and an osteoporosis consult were requested on only 32% and 22% of the cases, respectively. One-fourth to a third of patients were discharged on calcium or vitamin D, and less than 5% on bisphosphonates. Bone mineral density was measured in a minority although 21% had a history of previous contralateral hip fracture. One year mortality rate in a subset where follow-up available was 12% in men and 7% in women.

CONCLUSION

A large care gap in the management of patients admitted with hip fracture persists despite clear national osteoporosis guidelines. This study provides a strong impetus for establishing and monitoring a fracture liaison service to understand and address barriers to providing optimal care to patients with osteoporosis.

Bone Health Following Bariatric Surgery: An Update

Obesity rates are increasing rapidly, and bariatric surgery is currently the most effective tool for weight loss. Recently, bariatric surgery induced bone loss has gained attention. Such detrimental effect on bone is multifactorial and causes may include nutrient deficiencies, gut and gonadal hormonal changes, mechanical unloading, loss of lean mass, increased bone marrow fat, and increased risk of fall. This review describes the available evidence on bone loss and fracture risk following bariatric surgery and summarizes the guidelines on the topic. Increased bone resorption starts early postsurgery, and bone markers peak at 1-2 yr. Across studies, the drop in areal bone mineral density is inconsistent at the lumbar spine, while a 2%-5% drop at 6 mo and a 6%-10.5% at 9-12 mo are observed at the total hip. Conversely, studies using quantitative CT showed a 6%-7% decrease in volumetric bone mineral density at the lumbar spine at 6-12 mo postsurgery. These studies also report significant bone loss at the radius and tibia, in addition to alteration in bone microarchitecture. Fracture risk increases 2 yr after surgery, more so following malabsorptive procedures. Fractures were reported at axial, weight bearing sites and at appendicular sites. The available evidence is very heterogeneous, and mostly derived from studies on Roux-en-y gastric bypass in premenopausal women. Data on restrictive procedures is scarce. Our findings suggest that the early postoperative phase represents the "golden window" to intervene and promote bone health. More research is needed to determine the effect of different bariatric procedures on bone, to identify optimal interventions to prevent bone loss and to characterize high risk individuals who should be targeted.

Vitamin D supplementation in obesity and during weight loss: A review of randomized controlled trials

Vitamin D deficiency is common in obese individuals and during weight loss. The recommended vitamin D doses in this specific population are higher than for healthy adults. We reviewed vitamin D supplementation trials in obesity, and during medical or surgical weight loss, and report the effects on 25-hydroxyvitamin D [25(OH)D] concentrations and other relevant outcomes. We conducted a systematic search in PubMed, Medline, Embase and the Cochrane library for relevant randomized controlled trials (RCTs) of oral vitamin D supplementation for at least 3 months in obese individuals without weight loss (OB), and those on medical weight loss (MWL) (2010-2018), and following bariatric surgery (Bar S) (without time restriction). Two reviewers screened the identified citations in duplicate and independently and performed full text screening. One reviewer completed data extraction. We identified 13 RCTs in OB, 6 in MWL and 7 in Bar S. Mean baseline 25(OH)D concentrations ranged between 7 and 27 ng/ml in OB, 15-29 ng/ml in MWL and 15-24 ng/ml in Bar S. In OB (Total N 2036 participants), vitamin D doses of 1600-4000 IU/d increased mean 25(OH)D concentrations to ≥30 ng/ml. Based on three trials during MWL (Total N 359 participants), vitamin D doses of 1200-4600 IU/d for 12 months increased 25(OH)D concentration to ≥30 ng/ml. In Bar S (Total N 615 participants), doses ≥2000 IU/d were needed to reach 30 ng/ml. The change in 25(OH)D concentration was inversely proportional to the administered dose, and to BMI and baseline level with doses of 600-3000 IU/day. With these doses, the change in 25(OH)D concentration [Δ25(OH)D] per 100 IU/d was 0.5-1.2 ng/ml. Three trials assessed bone mineral density as a primary outcome, but only one of them showed a protective effect of vitamin D against bone loss at all sites post-Bar S. There was no effect of vitamin D on weight loss. Data on extra-skeletal parameters, namely glycemic and vascular indices were mostly identified in OB, and findings were inconsistent. In conclusion, Vitamin D doses ≥1600-2000 IU/d may be needed to reach a 25(OH)D concentration of 30 ng/ml in obese individuals and following bariatric surgery. The optimal concentration in this population is unknown, and whether the above doses protect against weight loss induced bone loss and fractures still needs to be confirmed. There is no clear evidence for a beneficial effect of vitamin D supplementation on cardio-metabolic parameters in obese individuals, and data on such parameters with weight loss are very scarce. Well-designed long term RCTs assessing the effect of vitamin D supplementation during weight loss on patient important outcomes are needed.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Failure of systemic oral doxycycline in preventing ocular toxoplasmic retinochoroiditis in French military personnel

This paper describes two cases of toxoplasmic chorioretinitis presenting in two French soldiers who had been receiving oral doxycycline for malaria prophylaxis. This is despite the proven effectiveness of oral doxycycline in treating Toxoplasma gondii, the most common cause of this infection. The lack of effectiveness of oral doxycycline in these two cases most likely reflected that the ocular concentration of 100 mg daily doxycycline is too low to treat or prevent Toxoplasmic retinochoroiditis (TC). Clinicians should therefore be aware that soldiers taking prophylactic oral doxycycline are still at risk of developing ocular TC with potentially sight-threatening consequences if not treated adequately.

Conservative management of an atypical intra-sinusal ossifying fibroma associated to an aneurysmal bone cyst

Ossifying fibroma (OF) is a benign fibro-osseous lesion mainly occurring in young adults and seems to originate from the periodontal ligament. Aneurysmal bone cyst (ABC) is a benign intraosseous lesion characterized by blood-filled spaces of various sizes. These two lesions can specifically affect the jaws and are commonly described in the literature. However, few cases describing an association of OF and ABC have been reported in the literature, especially in the maxillary sinus. We report the case of a 40-year-old male patient affected with an asymptomatic lesion with a dual component of OF and ABC laying in the maxillary sinus. Our aim is to discuss its clinical and morphological features as well as treatment results.

Composite vector formulation for multiple siRNA delivery as a host targeting antiviral in a cell culture model of hepatitis C virus (HCV) infection

Hepatitis C virus (HCV) infection is a major cause of chronic liver disease and cancer worldwide. RNA interference (RNAi)-based gene therapies have emerged recently as a promising tool to treat chronic viral infections. Indeed, small interfering RNAs (siRNAs) provide an opportunity to target host factors required for the viral life cycle. In this study, we evaluated a novel nanovector-based approach for siRNA delivery in a model of chronically infected hepatic cells. We designed original composite nanoparticles by coating the calcium phosphate core with siRNAs targeting HCV host-factors and pyridylthiourea-grafted polyethyleneimine (πPEI). Using combinations of different siRNAs, we observed an efficient and prolonged decrease of HCV replication. Moreover, we showed that the layer-by-layer technique of coating applied to our nanoparticles triggers a sequential release of siRNAs acting on different steps of the HCV life cycle. Together, our results demonstrate the efficacy of these nanoparticles for siRNA delivery and open new perspectives for antiviral therapies.

Road traffic injuries and data systems in Egypt: addressing the challenges

OBJECTIVE

Road traffic injuries (RTIs) are a major cause of global mortality and morbidity, killing approximately 1.3 million people and injuring 20 to 50 million each year. The significance of this public health threat is most pronounced in low- and middle-income countries where 90 percent of the world's road traffic-related fatalities take place. Current estimates for Egypt show a road traffic fatality rate of 42 deaths per 100,000 population-one of the highest in the Eastern Mediterranean Region. RTIs are also responsible for 1.8 percent of all deaths and 2.4 percent of all disability-adjusted life years (DALYs) lost in the country. Despite this, studies surrounding this topic are scarce, and reliable data are limited. The overall goal of this article is to define the health impact of RTIs in Egypt and to identify the strengths and weaknesses of each data source for the purpose of improving the current RTI data systems.

METHODS

A 2-pronged approach was undertaken to assess the burden of RTIs in Egypt. First, a thorough literature review was performed using PubMed, Embase, ISIS Web of Knowledge, and Scopus databases. Articles pertaining to Egypt and road traffic injuries were selected for screening. With assistance from Egyptian colleagues, a comprehensive exploration of data sources pertaining to RTIs in Egypt was undertaken and secondary data from these sources were procured for analysis.

RESULTS

The literature review yielded a total of 20 studies, of which 6 were multi-country and 5 were hospital-based studies. None examined risk factors such as speeding, alcohol, or seat belt use. Secondary data sources were acquired from national hospital-based injury surveillance; a community-based health survey; pre-hospital injury surveillance; the Ministry of Transport; the General Authority for Roads, Bridges and Land Transport; death certificates; and the central agency for public motorization and statistics. Risk factor data are also limited from these sources.

CONCLUSION

The results of this article clearly highlight the significant burden that road traffic injuries pose on the health of the Egyptian population. The hospital-based injury surveillance system that has been established in the country and the use of International Classification of Diseases (ICD-10) coding brings the system very closely in line with international guidelines. There is, however, some considerable room for improvement, including the need to extend the coverage of the surveillance system, the inclusion of injury severity scores and disability indicators, and standardization of the sometimes rather disparate sources from various sectors in order to maximally capture the true burden of RTIs.

Evaluation of gastrointestinal transit in clinical practice: position paper of the American and European Neurogastroenterology and Motility Societies

BACKGROUND

Disorders of gastrointestinal (GI) transit and motility are common, and cause either delayed or accelerated transit through the stomach, small intestine or colon, and affect one or more regions. Assessment of regional and/or whole gut transit times can provide direct measurements and diagnostic information to explain the cause of symptoms, and plan therapy.

PURPOSE

Recently, several newer diagnostic tools have become available. The American and European Neurogastroenterology and Motility Societies undertook this review to provide guidelines on the indications and optimal methods for the use of transit measurements in clinical practice. This was based on evidence of validation including performance characteristics, clinical significance, and strengths of various techniques. The tests include measurements of: gastric emptying with scintigraphy, wireless motility capsule, and (13)C breath tests; small bowel transit with breath tests, scintigraphy, and wireless motility capsule; and colonic transit with radioopaque markers, wireless motility capsule, and scintigraphy. Based on the evidence, consensus recommendations are provided for each technique and for the evaluations of regional and whole gut transit. In summary, tests of gastrointestinal transit are available and useful in the evaluation of patients with symptoms suggestive of gastrointestinal dysmotility, since they can provide objective diagnosis and a rational approach to patient management.

Analysis of Topoisomerase IIa and HER2 Status in 126 Patients from the US Oncology 9735 Trial of Adjuvant Chemotherapy with Docetaxel/Cyclophosphamide (TC) vs Doxorubicin/Cyclophosphamide (AC) in Early Breast Cancer

Background: HER2/neu (HER2) positive breast cancers are associated with worse survival, resistance to cyclophosphamide/methotrexate/fluorouracil, and hypothesized to be sensitive to anthracyclines. It has been postulated that only a subset of HER2 positive breast cancers are sensitive to anthracyclines. Investigators have been working on how to identify this subset of patients, thus sparing patients from anthracyclines that have potential cardiac and bone marrow toxicities. Overexpression of the topoisomerase IIa gene (TOP2A) is the putative biomarker for sensitivity to anthracyclines. Testing tumors for overexpression of this gene may help identify patients who will not benefit from anthracylines. TOP2A is located in the same amplicon as the HER2 gene and can be assessed for overexpression by a FISH assay.Materials and Methods: Paraffin tissue blocks were obtained in 126 patients entered on US Oncology trial 9735 which recruited patients between 1997 and 2000. Data on HER2 status and outcome was previously reported (JCO 27:1177-1183, 2009). TOP2A status was then assessed by fluorescent in situ hybridization (FISH) using the LSI TOP2A Spectrum Orange Probe (Vysis). A total of 20 cells were counted and a gene ratio of greater than 2.0 was considered positive. Clinical data and outcome were available for statistical analysis.Results: We found that none of the 97 HER2 negative cases demonstrated overexpression of TOP2A by FISH analysis. TOP2A was overexpressed in 43% of the 29 HER2 positive cases. An analysis of outcome will be presented at the meeting, although the number of cases limits this observation.Discussion: Our study supports the observation that TOP2A is not overexpressed in HER2 negative disease and is only observed in a subset of cancers overexpressing HER2. Clinical correlation of outcome will be necessary to confirm whether or not TOP2A is a reliable biomarker of sensitivity to anthracyclines. The ongoing US Oncology trial of TC vs. TAC in HER2 negative breast cancer (USOR Trial 06-090) should provide that evidence.Supported in part by a grant from sanofi-aventis.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2134.

The influence of co-morbid IBS and psychological distress on outcomes and quality of life following PPI therapy in patients with gastro-oesophageal reflux disease

BACKGROUND

A subset of patients with gastro-oesophageal reflux disease (GERD) does not achieve complete symptom resolution with proton pump inhibitor (PPI) therapy. The factors which affect response to PPI therapy in GERD patients remain unclear.

AIMS

To determine the prevalence and impact of irritable bowel syndrome (IBS) and psychological distress (PD) on GERD symptoms and disease-specific quality of life (QoL) before and after PPI therapy and to assess the same outcomes before and after PPI therapy in non-erosive reflux disease (NERD) and erosive oesophagitis (EO) GERD patients.

METHODS

Patients undergoing oesophago-gastroduodenoscopy (OGD) for heartburn were recruited. Participants completed validated surveys: Digestive Health Symptom Index, Reflux Disease Questionnaire, Quality of Life in Reflux and Dyspepsia and Brief Symptom Inventory (BSI). IBS was defined as >3 Manning criteria and PD as BSI score >63. At OGD, patients were classified as NERD or EO. Patients were treated with rabeprazole 20 mg/day for 8 weeks before completing follow-up surveys.

RESULTS

Of 132 GERD patients enrolled, 101 completed the study. The prevalence rates of IBS and PD were 36% and 41%, respectively. IBS independently predicted worse QoL before and after PPI therapy. PD independently predicted worse GERD symptoms and QoL before and after PPI therapy. There were no differences in symptoms or QoL between NERD and EO patients before or after PPI therapy.

CONCLUSIONS

IBS and PD impacted GERD symptoms and QoL before and after PPI therapy. Symptoms and QoL before and after PPI therapy were similar in NERD and EO patients.

Oesophageal hypersensitivity is associated with features of psychiatric disorders and the irritable bowel syndrome

BACKGROUND

Twenty per cent of patients with heartburn do not respond to proton pump inhibitors (PPIs). Many have normal oesophageal acid exposure. We hypothesized that such PPI non-responders have heightened oesophageal sensation, and that oesophageal hypersensitivity is associated with psychiatric features including somatization and anxiety.

AIM

To compare oesophageal sensation in subjects with heartburn categorized by response to PPI, and to correlate oesophageal sensation with psychiatric features.

METHODS

Twenty-one PPI responders, nine PPI non-responders and 20 healthy volunteers completed questionnaires of psychiatric disorders and gastrointestinal symptoms. Subjects underwent oesophageal sensory testing with acid perfusion and balloon distension.

RESULTS

Healthy volunteers displayed higher thresholds for sensation and discomfort from balloon distension than heartburn subjects (sensation P = 0.04, discomfort P = 0.14). Psychiatric disorders were associated with increased intensity of sensation (P = 0.02) and discomfort from acid (P = 0.01). Somatization was associated with increased discomfort from balloon distension (P = 0.006). Features of irritable bowel syndrome were associated with increased sensation and discomfort.

CONCLUSIONS

Heartburn subjects tend to have heightened oesophageal sensation, suggesting that oesophageal hypersensitivity may persist despite therapy with PPI. Oesophageal hypersensitivity is associated with features of psychiatric disease and with the irritable bowel syndrome, which might partly explain the aetiology of heartburn symptoms that are refractory to PPI.

Plasmacytoma of the larynx diagnosed by fine-needle aspiration cytology: a case report

Extramedullary plasmacytoma is a rare lesion. The use of fine-needle aspiration for diagnosis of plasmacytoma has been described in a few sporadic reports. To the best of our knowledge, none of these reports described the cytologic findings from plasmacytoma of the larynx. We report on a case of laryngeal plasmacytoma in a 79-yr-old man diagnosed by fine-needle aspiration cytology. The patient had a history of a plasmacytoma involving the sixth thoracic vertebra diagnosed in 1996, which progressed to multiple myeloma in 1997. He received treatment in the form of local radiation to the skeletal vertebrae and chemotherapy. Two years later, the patient presented with a large neck mass. Computed tomography (CT) was done at an outside facility, and the radiologic impression was of a large right glottic carcinoma with invasion into the right thyroid cartilage. Because of the history of multiple myeloma, a fine-needle aspiration (FNA) biopsy was performed of the laryngeal mass. Cytologic examination demonstrated atypical plasma cells arranged in a dissociative fashion, consistent with a plasmacytoma. Although there are previous surgical pathology reports of laryngeal plasmacytoma, to the best of our knowledge, this is the first report of plasmacytoma of the larynx diagnosed by FNA cytology.

Bronchial oncocytoma

CONTEXT

Oncocytomas are generally small and present slow growth. Finding of the tumor usually occurs incidentally. Their incidence is higher among male patients. Oncocytomas in mucous bronchial glands are extremely rare.

CASE REPORT

A 35-year-old male who presented bronchial oncocytoma. The tumor was found after bronchoscopy that investigated an atelectasis of the upper left lobe. Histological examination with optical microscopy revealed a mature neoplasm formed by ovoid cells with thin, granular, eosinophilic cytoplasm and small nuclei similar to oncocytes. Electron microscopy showed mitochondrial hyperplasia. A three-year follow-up after thoracotomy followed by lobectomy and removal of the bronchial tumor was uneventful.

Portal vein thrombosis following splenectomy

AIMS: The aim of this study was to assess the risk and progress of portal vein thrombosis (PVT) after splenectomy. METHODS: A prospective study was conducted in which two groups of patients were compared; each group comprised 50 patients (27 men, 23 women). Patients in the splenectomy group were of mean age 46.3 years. A second group of patients (mean age 48.5 years) had upper abdominal surgery other than splenectomy. All patients were examined before and 2 weeks after operation by duplex Doppler ultrasonography (DDUS) of the portal system. Those who developed PVT were followed up by DDUS at 6 and 12 months. RESULTS: PVT developed in 10 per cent of patients who underwent splenectomy. The portal vein was completely occluded by thrombus in 4 per cent and partially occluded in 6 per cent of patients. Symptoms and signs attributable to PVT (abdominal pain, diarrhoea, nausea, vomiting and mild fever) were found in 80 per cent of those who developed this complication. Follow-up of such patients revealed complete recanalization of portal vein in 40 per cent and partial recanalization in 60 per cent after treatment with antibiotics and long-term anticoagulation therapy. No patient who underwent upper abdominal surgery (other than splenectomy) developed PVT afterwards. CONCLUSIONS: Splenectomy (compared with other upper abdominal surgery) is followed by PVT in 10 per cent of patients but can be treated successfully.

Effect of injection of L-NAME on drinking response

The drinking behavior responses to centrally administered N G-nitro-L-arginine methyl ester (L-NAME; 10, 20 or 40 microg/microl), an inhibitor of nitric oxide synthase, were studied in satiated rats, with cannulae stereotaxically implanted into the lateral ventricle (LV) and subfornical organ (SFO). Water intake increased in all animals after angiotensin II (ANG II) injection into the LV, with values of 14.2 +/- 1.4 ml/h. After injection of L-NAME at doses of 10, 20 or 40 microg/microl into the SFO before injection of ANG II (12 ng/microl) into the LV, water intake decreased progressively and reached basal levels after treatment with 0.15 M NaCl and with the highest dose of L-NAME (i.e., 40 microg). The water intake obtained after 40 microg/microl L-NAME was 0.8 +/- 0.01 ml/h. Also, the injection of L-NAME, 10, 20 or 40 microg/microl, into the LV progressively reduced the water intake induced by hypertonic saline, with values of 5.3 +/- 0.8, 3.2 +/- 0.8 and 0.7 +/- 0.01 ml/h, respectively. These results indicate that nitric oxide is involved in the regulation of drinking behavior induced by centrally administered ANG II and cellular dehydration and that the nitric oxide of the SFO plays an important role in this regulation.

[Association of celiac disease and esophageal small cell carcinoma]

BACKGROUND

Coeliac disease is known to favor the development of neoplasia. Coeliac disease associated with small-cell carcinoma of the esophagus has not been reported to date.

CASE REPORT

A 51-year-old man with coeliac disease known for several years was hospitalized for epigastric pain. Work-up led to the diagnosis of small-cell carcinoma of the lower esophagus. The patient was treated with 6 cycles of chemotherapy using an etoposide-ciplatinum protocol associated with 60 Gy radiotherapy starting at the third cycle. The patient has remained in complete remission 2 years after diagnosis.

DISCUSSION

Small-cell carcinoma of the esophagus is an exceptional finding in a patient with coeliac disease. Chemotherapy associated with radiotherapy has been successful in our patient.