‘Double hit’ from streptococcal pneumonia and hypersensitivity pneumonitis associated with anagrelide

We report a case of unresolved streptococcal pneumonia in a patient taking anagrelide for essential thrombocythaemia. Resolution only occurred after discontinuing anagrelide and the institution of corticosteroid therapy, which resulted in dramatic improvement. There has been only one previous case report of anagrelide causing hypersensitivity pneumonia. We postulate this patient suffered a ‘double hit’ from streptococcal infection and anagrelide.     

Influenza surveillance on ‘foie gras’ duck farms in Bulgaria, 2008–2012

Objectives

Ducks can shed and spread influenza A viruses (IAVs) while showing no disease signs. Our objective was to clarify the role of ‘foie gras’ ducks in the circulation of IAVs in Bulgaria.

Methods

Monthly avian influenza surveillance was conducted on 63 ‘foie gras’ duck farms, 52 of which were surveyed throughout the study between November 2008 and April 2012. Virologic and serologic samples were collected and tested. During this time, wild bird samples were collected at major wild bird‐resting areas near the Black Sea coast and Danube River.

Results

The study showed high isolation frequency of low‐pathogenicity avian influenza viruses. In the raising population (<75 days old), subtypes H3, H4, and H6 were detected monthly and H5 LPAIV, sporadically. Different subtypes (H1, H10, H11) were isolated from the fattening premises (75‐ to 100‐day‐old ducks), suggesting different routes of introduction. Only 6 of the 52 farms that were surveyed both virologically and serologically were influenza‐free throughout the study, possibly due to higher biosecurity measures implemented. No evidence of direct transmission of IAV from wild birds was found. Wild bird surveillance showed low isolation frequency of IAV. IAV prevalence of 0·55% for migratory ducks and 0·53% for migratory geese was estimated in November–December 2011 and January–February 2012, respectively, at two ornithologically important locations near the Black Sea coast.

Conclusions

The ‘foie gras’ duck farms in Bulgaria are an optimal niche where Eurasian‐like IAVs are maintained and reassorted unapparent to farmers and veterinarians.     

The changes in blood pressure after acute stroke: abolishing the ‘white coat effect’ with 24-h ambulatory monitoring

Objectives . To assess the changes in 24-h and casual blood pressure (BP) levels following hospitalization for acute stroke. Design . Prospective study of patients admitted with acute hemispheric stroke and hospitalized controls using casual and 24-h BP monitoring. Setting . Medical wards in a large teaching hospital. Subjects . Thirty-three patients (median age 77 years, 17 male) and 21 control subjects admitted non-acutely. Interventions . All subjects underwent 24-h BP monitoring within 24 h of stroke onset (patients) or admission (controls) and again at 1 week. Casual BPs were recorded over the same period. Main outcome measures . The change in BP over the first week in each group. Eleven stroke subjects had 24-h BP monitoring repeated at 6 months. Results . In the stroke group, 24-h systolic BP (SBP) fell by 7 mmHg (95% CI, 0 to 14 mmHg; P < 0.05) and diastolic BP (DBP) by 3 mmHg (95% CI, 0 to 6 mmHg; P < 0.02) over the first week. Mean 24-h BP levels in the control group did not change during this period. However, casual BP recordings fell in both stroke (18/12 mmHg) and control (19/9 mmHg) groups. Stroke subjects followed to 6 months showed no further change in 24-h BP (day 7: 137±17/79±13 mmHg; month 6: 138 ± 16/78 ± 11 mmHg). Conclusions . Although there was a large fall in causal BPs seen in both groups there, was only a small, but a significant fall in mean 24-h BP over the first week following hemispheric stroke that was not seen in control subjects. Although the ‘white coat effect’ and admission to hospital play an important part in the high casual BP observed in the days following acute stroke they are unlikely to be the sole factors.     

‘Double‐Hit’ cytogenetic status may not be predicted by baseline clinicopathological characteristics and is highly associated with overall survival in B cell lymphoma patients

‘Double‐Hit’ (DH) B cell non‐Hodgkin lymphomas are characterized by the presence of a MYC rearrangement and additional rearrangement(s) most commonly involving BCL2 and/or BCL6. Patients with DH lymphomas are unlikely to achieve long‐term survival when treated with standard immunochemotherapy alone. DH gene rearrangements can be identified through metaphase karyotyping or more sensitive fluorescence in situ hybridization (FISH), although the latter is not routinely performed. We report 53 cases of B cell lymphoma that underwent diagnostic metaphase karyotying or FISH for MYC rearrangements. DH lymphoma was detected in 17 cases. No baseline factor, including age, serum lactate dehydrogenase, stage, International Prognostic Index or histology predicted for DH status. The median overall survival was significantly shorter for DH compared to non‐DH lymphoma patients (8·2 vs. 56·8 months, P < 0·001). DH status retained the most statistically significant association with overall survival on multivariate Cox regression analysis. DH status could not be inferred by baseline disease‐ or patient‐related characteristics and was most predictive of overall survival in this cohort of B cell lymphoma patients. These findings support the practice of routine performance of FISH for DH gene rearrangements on B cell lymphoma specimens in order to effectively identify DH patients who may benefit from risk‐adapted therapy.     

Maximal γ-globin expression in the compound heterozygous state for –175 Gγ HPFH and β°39 nonsense thalassaemia: a case study

The –175 (T→C) ^Gγ hereditary persistence of fetal haemoglobin is a very rare promoter mutation occurring in Caucasians as well as in African-Americans. Heterozygotes for this non-deletional HPFH show 20% HbF, mostly of ^Gγ type. We describe here a healthy Sardinian man who coinherited –175 (T→C) ^Gγ HPFH with the β-thalassaemia codon 39 nonsense mutation in trans; he showed 64% HbF, 100% of ^Gγ type. Although the β-globin haplotype pattern (II/II) was indicative of the presence of the ^Aγ^T allele on both chromosomes, the ^Aγ^T expression was undetectable by HPLC even in red cell populations separated by age. The proband was, moreover, homozygous for the –4 bp deletion at position -225 to -222 of ^Aγ promoter which has recently been associated with decreased ^Aγ^T globin expression. These findings suggest that this maximal overexpression of ^Gγ-globin probably reflects intensified stimulation of the mutated ^Gγ promoter in this hitherto undescribed genetic condition.     

Clinical outcomes and the impact of prior oral anticoagulant use in patients with coronavirus disease 2019 admitted to hospitals in the UK — a multicentre observational study

Coagulation dysfunction and thrombosis are major complications in patients with coronavirus disease 2019 (COVID-19). Patients on oral anticoagulants (OAC) prior to diagnosis of COVID-19 may therefore have better outcomes. In this multicentre observational study of 5 883 patients (≥18 years) admitted to 26 UK hospitals between 1 April 2020 and 31 July 2020, overall mortality was 29·2%. Incidences of thrombosis, major bleeding (MB) and multiorgan failure (MOF) were 5·4%, 1·7% and 3·3% respectively. The presence of thrombosis, MB, or MOF was associated with a 1·8, 4·5 or 5·9-fold increased risk of dying, respectively. Of the 5 883 patients studied, 83·6% (n = 4 920) were not on OAC and 16·4% (n = 963) were taking OAC at the time of admission. There was no difference in mortality between patients on OAC vs no OAC prior to admission when compared in an adjusted multivariate analysis [hazard ratio (HR) 1·05, 95% confidence interval (CI) 0·93–1·19; P = 0·15] or in an adjusted propensity score analysis (HR 0·92 95% CI 0·58–1·450; P = 0·18). In multivariate and adjusted propensity score analyses, the only significant association of no anticoagulation prior to diagnosis of COVID-19 was admission to the Intensive-Care Unit (ICU) (HR 1·98, 95% CI 1·37–2·85). Thrombosis, MB, and MOF were associated with higher mortality. Our results indicate that patients may have benefit from prior OAC use, especially reduced admission to ICU, without any increase in bleeding.     

‘You have to learn to live with it’: a qualitative and quantitative study of older people with asthma

Introduction: Asthma mortality has declined overall because of a range of public health initiatives. In western countries, the majority of asthma deaths now occur in people over the age of 50. The reasons for the poorer response of older age groups to public health asthma initiatives are not known. Objectives: We undertook a study to investigate the disease perspectives of older people with asthma and barriers which may exist and prevent optimal asthma care. Methods: Fifty‐five participants (16 male and 39 female) aged over 50 from an inner city, suburban area and a rural region were recruited. Lung function was measured, and questionnaire data on asthma symptoms, knowledge and control, medication use and respiratory health were collected. Participants were also interviewed in‐depth, and the quantitative and qualitative data were triangulated. Results: Participants with a duration of asthma for >30 years reported significantly fewer symptoms and better quality of life irrespective of asthma severity, indicating less appreciation of symptoms in those with a long asthma duration. Interviews revealed this was related to previous asthma management strategies when treatment options were limited. Participants with a recent diagnosis sought understanding of asthma and the reason for their illness. Initiatives to improve asthma care in older people need to reflect these findings. Conclusions: Self‐management strategies for older people need to be tailored according to the time of disease onset and the duration of disease. Please cite this paper as: Goeman DP, O’Hehir RE, Jenkins C, Scharf SL and Douglass JA. ‘You have to learn to live with it’: a qualitative and quantitative study of older people with asthma. The Clinical Respiratory Journal 2007; 1:99–105.