Glucagonoma-associated dilated cardiomyopathy refractory to somatostatin analogue therapy

A 67-year-old woman presented with a generalised rash associated with weight loss and resting tachycardia. She had a recent diagnosis of diabetes mellitus. Biochemical evaluation revealed elevated levels of circulating glucagon and chromogranin B. Cross-sectional imaging demonstrated a pancreatic lesion and liver metastases, which were octreotide-avid. Biopsy of the liver lesion confirmed a diagnosis of well-differentiated grade 2 pancreatic neuroendocrine tumour, consistent with metastatic glucagonoma. Serial echocardiography commenced 4 years before this diagnosis demonstrated a progressive left ventricular dilatation and dysfunction in the absence of ischaemia, suggestive of glucagonoma-associated dilated cardiomyopathy. Given the severity of the cardiac impairment, surgical management was considered inappropriate and somatostatin analogue therapy was initiated, affecting clinical and biochemical improvement. Serial cross-sectional imaging demonstrated stable disease 2 years after diagnosis. Left ventricular dysfunction persisted, however, despite somatostatin analogue therapy and optimal medical management of cardiac failure. In contrast to previous reports, the case we describe demonstrates that chronic hyperglucagonaemia may lead to irreversible left ventricular compromise. Management of glucagonoma therefore requires careful and serial evaluation of cardiac status. Learning points: In rare cases, glucagonoma may present with cardiac failure as the dominant feature. Significant cardiac impairment may occur in the absence of other features of glucagonoma syndrome due to subclinical chronic hyperglucagonaemia. A diagnosis of glucagonoma should be considered in patients with non-ischaemic cardiomyopathy, particularly those with other features of glucagonoma syndrome. Cardiac impairment due to glucagonoma may not respond to somatostatin analogue therapy, even in the context of biochemical improvement. All patients with a new diagnosis of glucagonoma should be assessed clinically for evidence of cardiac failure and, if present, a baseline transthoracic echocardiogram should be performed. In the presence of cardiac impairment these patients should be managed by an experienced cardiologist.

[Progress of Rehabilitation for Cardiac Patients Depending on the Degree of Self-Sufficiency at Admission]

INTRODUCTION

There are hardly any publications about the outcome of cardiac rehabilitation considering patients with an increased need for medical, nursing and therapeutic care. The aim of this study, which consecutively included n=387 statutory health insurance inpatients over a period of 2 years, was to find out differences in outcome in self-care patients (Barthel index>70) as compared to patients with a need for complex care (Barthel index≤70).

METHODS

Rehabilitation outcomes concerning physical capacity, emotional status and activities of daily living as measured by Barthel index, FIM index, HADS, clinical complications, exercise test, duration of rehabilitation and form of dismission were analyzed and compared between both groups.

RESULTS

The inpatients with a Barthel index ≤70 at admission were older, had a longer stay in hospital and in rehabilitation, developed more complications and more often suffered from concomitant diseases. They were readmitted to hospital more often. They showed a comparatively higher increase in indices of self-care and a significant increase in physical performance tests.

CONCLUSION

Higher medical care expenses of multimorbid cardiac inpatients are no contraindication against rehabilitation, because even in this group the specific rehabilitation aims of the healthcare payers can be reached.

Agreement on urgency assessment between secretaries and general practitioners: an observational study in out-of-hours general practice service in Belgium

BACKGROUND

In some European countries telephone triage (TT) during out-of-hours primary care showed to be safe and effective. Other countries, such as Belgium, may not have trained auxiliary personnel while their national health services want to establish TT.

OBJECTIVES

To compare urgency levels assessed by secretaries and general practitioners in one general practice cooperative in Belgium.

METHODS

Percentage of correct-, under-, and over-triage were calculated in total and per reason for encounter. Inter-rater agreement was investigated.

RESULTS

The secretaries correctly triaged (same urgency level) 77% of the telephone calls, under-triaged 10% and over-triaged 13%.'Shortness of breath', 'skin cuts', 'chest pain', 'feeling unwell' and 'syncope' were often under-triaged.

CONCLUSION

Before introducing TT, auxiliary staff should be trained and protocols should be used.

Accessibility and use of Primary Health Care: how conclusive is the social-economical situation in Antwerp?

BACKGROUND

The percentage of households that delays medical assistance due to financial reasons is slowly increasing. Moreover, some groups of the population do not ever find their way to primary health care and end up unnecessarily in the emergency department or with specialists. This study wants to examine how primary health care can be made accessible to these groups.

AIM

In this study, we aim to discover whether in a city such as Antwerp primary health care is accessible to everyone.

METHOD

The statistics were collected from the Health Care Survey done by the Welfare Services Antwerp in cooperation with the City of Antwerp. The questions were asked in three different ways: a postal questionnaire, a telephone questionnaire and a face-to-face interview.

RESULTS

We determined that people who live on social welfare delay medical help due to financial reasons more frequently than the global Antwerp population. They often do not have a regular general practitioner (GP). Especially single parents, house-wives and house-husbands, job-seekers, incapacitated people unable to work, unskilled workers and foreigners are among the vulnerable groups where accessibility to primary health care is a concern.

CONCLUSION

If we hope to improve the accessibility of primary health care, we must first and foremost inform the above-mentioned groups of the insurability and how this is applied. When this is fulfilled, it will be easier for the GP to receive this vulnerable group within the primary care system, so that the help of specialized care, which is often unnecessary, can be reduced.

Use of out-of-hours services: the patient's point of view on co-payment a mixed methods approach

INTRODUCTION

In many countries out of hours (OOH) care is offered by different health care services. General practitioners (GP) tend to offer services in competition with emergency departments (ED). Patients behaviour depends on a number of factors. In this study, we highlight the knowledge and ideas of patients concerning the co-payment system.

METHODS

We used a mixed methods design, combining quantitative and qualitative research. During two weekends in January 2005, all patients using the ED or the GP OOH service, were invited for an interview with a structured questionnaire. A stratified random sample of patients participated in a semi-structured interview. Both methods add complementary data to answer the research questions.

RESULTS

Most mentioned reasons for seeking help at the ED are: accessibility (15.0%), proximity (6.4%) and competence of the staff (5.6%). Reasons for choosing the GP are: GP is easy to find, minor medical problem or anxiety and confidence in the GP. The odds of not knowing the co-payment system are significantly higher in patients visiting the ED (OR 1.783; 95% CI: 1.493-2.129). Mostly GP users recognize the problem of ED overuse. They suggested especially to provide clear information about the tasks of the different services and about the payment system, to reduce ED overuse.

CONCLUSION AND DISCUSSION

When intending to shift from ED to GP services for minor medical problems, aiming at just one measure is no option. Information campaigns aiming to address the entire population, can clarify the role of each player in out-of-hours care.

Experience: the most critical factor in choosing after-hours medical care

INTRODUCTION

In many countries, a reassessment of after-hours primary care has become necessary. In particular, centralised general practitioner deputizing services (GPDS) have emerged. In this study, consumers' preferences for after-hours medical care were obtained and the use of the new GPDS was predicted.

METHOD

On the basis of the Theory of Reasoned Action, a survey was developed that was used at the Free Newborn and Child health care services in Antwerp. Consumers were asked about their knowledge, experience and perceptions concerning the performance of different medical services.

RESULTS

350 questionnaires were used for analysis. 98.6% of the respondents knew about the existence of the emergency department, whereas the GPDS was known by 81.7% of the respondents. The main reasons for preferring emergency department over the other services were an easy access, good explanation by the doctor and a late due time of the payment. Respondents preferred the GPDS mainly because of an expected shorter waiting time. Experience had a strong positive influence on choosing a particular after-hours medical service.

CONCLUSION

In our study, the consumers' preferences concerning after-hours medical care were assessed. The following items are crucial for choosing after-hours care: experience with the services, easy access to the service, explanation by the doctor about the illness and the treatment and waiting time.

Phase II study of gemcitabine and cisplatin in locally advanced/metastatic oesophageal cancer

Palliative chemotherapy for inoperable/metastatic oesophageal cancer has limited activity. This study assesses the feasibility and activity of gemcitabine and cisplatin in this group of patients. In total, 42 patients with locally advanced/metastatic squamous or adenocarcinoma of the oesophagus were treated with gemcitabine 1250 mg m⁻² days 1 and 8 and cisplatin 75 mg m⁻² day 1 in a 21-day cycle. Interim safety analysis was carried out after the first 19 patients suggested significant toxicity. The dose of gemcitabine was subsequently reduced to 1000 mg m⁻². Patients were assessed for toxicity and response. The median number of treatment cycles per patient was 4 (range 1–6). Grade 3–4 neutropenia occurred in 37% of cycles; however, there was only one episode of neutropenic fever. Nonhaematological toxicities included fatigue, nausea and vomiting. Among 32 patients eligible for response, there were three complete responses and 16 partial responses (overall response rate of 45%); nine patients had stable disease. Median survival was 11 months. The response rate appears to be greatest in those with squamous carcinoma compared to adenocarcinoma (71 vs 33%, P=0.036). The combination of gemcitabine and cisplatin in this schedule has manageable toxicity and significant activity in patients with locally advanced/metastatic oesophageal cancer and is worthy of further study.

Localisation of alpha, mu and pi class glutathione S-transferases in kidney: comparison with CuZn superoxide dismutase

We describe studies in whole kidney, cortical and medullary homogenates and, glomerular cells in culture to determine the relative levels of expression of alpha (Ya, Yc, Yk), mu (Yb1/Yb2), pi (Yf) glutathione S-transferases (GST) and CuZn superoxide dismutase (CuZn SOD) in different regions of the nephron. Immunoblotting and immunohistochemistry were used to demonstrate relatively weak expression of alpha, mu GST and, CuZn SOD in the glomerulus compared to that in particularly distal tubules. Whilst expression of Ya was found within glomerular cells, Yc, Yk and Yf were not detected. Immunofluorescence showed that Ya and Yb1/Yb2 but not Yf were expressed in cultured epithelial and mesangial cells studied between passages 1 and 3. While Ya was distributed in cytosol, Yb1/Yb2 was primarily located in nuclei.

The influence of 2-acetoxy-1, 3-di(nitroimidazolyl)propane derivatives on human red blood cell membrane ATP-ase activity

The effect of two nitroimidazoles, 2-acetoxyl-1,3-bis-(2'-methyl-4'-nitro-1'-imidazolyl)propane (Rs-029) and 2-acetoxy-1-(2'-methyl-4'-nitro-1'-imidazolyl)-3-(2''-methyl-5''-nitro- 1- nitroimidazolyl)propane (Rs-034) on ATP level and erythrocyte membrane ATP-ase activity was studied. The action of these compounds on erythrocyte membrane ATP-ase activity differed depending on the structure of nitroimidazoles. Only Rs-029 significantly inhibited (Na+K+) ATP-ase activity and activated Mg2+ ATP-ase. Both, Rs-029 and Rs-034 decreased ATP content in red blood cells after three hours incubation in the presence of plasma.

Hyporesponsiveness to augmentation of murine natural killer cell activity in different anatomical compartments by multiple injections of various immunomodulators including recombinant interferons and interleukin 2

Augmentation of natural killer (NK) cell activity has been observed after the single administration of a wide variety of biological response modifiers (BRM); however, multiple injections of BRM have resulted in hyporesponsiveness to NK augmentation in both preclinical and clinical studies. In these studies, hyporesponsiveness to augmentation of NK cell activity occurred after multiple injections of interferon (IFN recombinant human IFN-alpha A/D and recombinant IFN-gamma) and interleukin 2 and was found to be systemic (lungs, liver, blood, and spleen). In contrast, hyporesponsiveness to augmentation by multiple injections of maleicanhydride divinyl ether (MVE-2) or Propionibacterium acnes was limited to the spleen and peripheral blood lymphocytes, with continued augmentation of NK cell activity in the peritoneum, lungs, and liver. Despite the hyporesponsiveness to augmentation of NK activity by multiple IFN injections, NK activity could still be augmented by a single injection of another BRM. The NK cell hyporesponsiveness induced in the spleen by MVE-2 was also reversed by a single administration of IFN or polyinosinic-polycytidylic and poly-L-lysine solubilized by carboxymethyl cellulose but not by OK-432 or P. acnes. These results demonstrate that the nature of the hyporesponsiveness to NK augmentation, which is induced by multiple treatments with BRM, varies with the type of agent. The noncytokine BRM that were studied induced hyporesponsiveness only in specific lymphoid compartments but not in major nonlymphoid organs, whereas cytokine BRM induced a systemic hyporesponsiveness. The hyporesponsive state induced by the different types of BRM, also varied in regard to the pattern of susceptibility to augmentation of NK activity by unrelated BRM.

Hyporesponsiveness to augmentation of murine natural killer cell activity in different anatomical compartments by multiple injections of various immunomodulators including recombinant interferons and interleukin 2

Augmentation of natural killer (NK) cell activity has been observed after the single administration of a wide variety of biological response modifiers (BRM); however, multiple injections of BRM have resulted in hyporesponsiveness to NK augmentation in both preclinical and clinical studies. In these studies, hyporesponsiveness to augmentation of NK cell activity occurred after multiple injections of interferon (IFN recombinant human IFN-alpha A/D and recombinant IFN-gamma) and interleukin 2 and was found to be systemic (lungs, liver, blood, and spleen). In contrast, hyporesponsiveness to augmentation by multiple injections of maleicanhydride divinyl ether (MVE-2) or Propionibacterium acnes was limited to the spleen and peripheral blood lymphocytes, with continued augmentation of NK cell activity in the peritoneum, lungs, and liver. Despite the hyporesponsiveness to augmentation of NK activity by multiple IFN injections, NK activity could still be augmented by a single injection of another BRM. The NK cell hyporesponsiveness induced in the spleen by MVE-2 was also reversed by a single administration of IFN or polyinosinic-polycytidylic and poly-L-lysine solubilized by carboxymethyl cellulose but not by OK-432 or P. acnes. These results demonstrate that the nature of the hyporesponsiveness to NK augmentation, which is induced by multiple treatments with BRM, varies with the type of agent. The noncytokine BRM that were studied induced hyporesponsiveness only in specific lymphoid compartments but not in major nonlymphoid organs, whereas cytokine BRM induced a systemic hyporesponsiveness. The hyporesponsive state induced by the different types of BRM, also varied in regard to the pattern of susceptibility to augmentation of NK activity by unrelated BRM.

Effects of nitroheterocyclic sensitizers on erythrocyte membranes ATP-ase activity

The effect of two nitroimidazoles, 1(2'-hydroxy-3'-chloropropyl)-2-methyl-4-nitroimidazol and 1(2'-hydroxy-3'-chloropropyl)-2-methyl-5-nitroimidazol and irradiation on erythrocyte membrane ATP-ase activity was studied. The action of nitroimidazole derivatives on the erythrocyte membrane ATP-ase activity differed depending on the nitro group position. 5-Nitroimidazole derivative in the concentration of 300 micrograms/mg protein inhibited significantly the non-irradiated erythrocyte membrane (Na+, K+) ATP-ase activity, while 4-NO2 in the concentration of 3 micrograms/mg protein influenced this activity, but only after an exposure at dose of 60 Krad. In the concentration of 300 micrograms/mg membrane protein it activated this ATP-ase.