Osteosarcoma metastatic to adrenal gland diagnosed by fine-needle aspiration

Osteosarcoma, a primary malignant tumor of the long bones, frequently metastasizes to the lungs. We report an unusual case of osteosarcoma metastatic to the right adrenal gland in a 37-yr-old male who presented 8 yr after remission with an adrenal mass. A preoperative diagnosis was made by fine-needle aspiration (FNA) biopsy. FNA biopsy revealed pleomorphic oval cells with prominent nucleoli, spindle cells, and giant tumor cells. Diagnostic osteoid was readily seen on smears and was also detected by polarization of cell-block section. Immunocytochemical stains revealed positivity of tumor cells for vimentin and osteonectin. Cytokeratin stains were negative. The cytologic diagnosis of metastatic Osteosarcoma was made, which was later confirmed upon resection of tumor by histology. Although the role of FNA in the diagnosis of primary bone tumors, including osteogenic sarcoma (OGS), remains controversial, this case, however, demonstrates the value of FNA biopsy combined with immunocytochemistry performed on the aspirated material in diagnosing osteosarcoma from an unusual location such as the adrenal gland.     

Epidemiological study of epilepsy from a tertiary care hospital in kingdom of Saudi Arabia

Objectives:To identify the types of seizures and describe the clinical features, EEG and radiological findings among patients with epilepsy.Methods:In this retrospective epidemiological study, we analyzed the medical records of the patients with the diagnosis of epilepsy during the study period (January 1st 2016- December 2016)Results:The study included 184 patients, 91 (49.5%) were males and 93 (50.5%) females. Age ranged between 12 and 85 years (mean 35.4±19.5 SD years). Most of the patients 150 (82%) had Generalized tonic clonic seizures followed by focal onset in 27 (14%) of the patients. Main EEG abnormality was focal to bilateral was recorded in 53 (41%), idiopathic/ cryptogenic epilepsy was diagnosed in 61% of the patients. The most common abnormalities on brain imaging were temporal/hippocampal atrophy/stroke. The most common cause of symptomatic epilepsy was stroke found in 20(11%) followed by post infectious epilepsy and head trauma.Conclusion:Seizure types, EEG characteristics and etiologies of symptomatic epilepsy in our cohort of patients are in accordance with the current literature. Slight discrepancy observed in gender distribution and etiologies for symptomatic epilepsy compared with other studies from Saudi Arabia need to be studied further by prospective and population base studies.

Epilepsy is one of the most common neurological diseases and is a serious neurological disorder that is associated with social stigma.1 Epilepsy can be defined as a brain disorder that is characterized by episodes of vigorous shaking and disturbed brain activity (seizures) that can affect the patient’s attention and behavior.2 According to World Health Organization 2010 Global burden of Disease Study, it is the second most neurological disorder around the world in terms of disability adjusted life years.3 According to one of the prevalence study available from the kingdom of Saudi Arabia in 2001, the prevalence of epilepsy was found to be 6.54 per 10004 and in other Arab countries (Sudan, Libya and Tunisia) was about 2.3/1000.5 The incidence of epilepsy has been found to be substantially greater in developing countries compared with developed countries.6 Epidemiological studies about epilepsy from Arab countries especially Saudi Arabia are lacking. We were able to find only few studies about the prevalence of seizure disorder in an Arab population5,7 and even sparser from Saudi Arabia.4,8 we were unable to find any study regarding epidemiology of Epilepsy from our hospital. This study therefore was aimed to review and present the data of patients with epilepsy from our hospital, King Fahd Hospital of the University (KFHU), Alkhobar, Kingdom of Saudi Arabia.     

Etanercept in the treatment of active refractory Crohn's disease: a single-center pilot trial

OBJECTIVES: Etanercept, an injectable tumor necrosis factor (TNF) receptor fusion protein, binds and inactivates human TNF and is used in active rheumatoid arthritis. Blocking TNF with monoclonal antibodies has also been beneficial in Crohn's disease. We attempted to determine the efficacy and safety of etanercept for induction of clinical, endoscopic, and histological improvement in patients with moderate to severe Crohn's disease despite standard treatment. METHODS: Ten patients with active Crohn's disease were treated with etanercept (25 mg s.c.) twice per week for 12 wk. Background therapy was kept stable during the trial. Crohn's disease activity index (CDAI), Inflammatory Bowel Disease Questionnaire, and C-reactive protein levels were measured at weeks 0, 2, 4, 8, and 12. Colonoscopies were performed before and after therapy in responders; endoscopic biopsies were scored for inflammation. RESULTS: At week 2 after the start, a clinical response (deltaCDAI > or = 70) was observed in 6/10 patients (median = 305 [294-418] to 166 [107-392]), with reduction in serum C-reactive protein levels (median = 17.2 [6.8-67.2] to 9.1 [0.9-17.2] mg/dl). Colonoscopies showed a reduction in inflammatory lesions in the four patients who attained remission (CDAI < 150), whereas the inflammatory score of the biopsies did not decrease significantly. No moderate or severe adverse events were observed. CONCLUSIONS: Etanercept may be effective in Crohn's disease refractory to standard therapy.     

Magnetic resonance imaging of the effects of infliximab on perianal fistulizing Crohn's disease

OBJECTIVES: Although the clinical efficacy of infliximab as measured by closure of fistulas in Crohn's disease has been demonstrated, its influence on the inflammatory changes in the fistula tracks is less clear. The aim of the present study was to assess the behavior of perianal fistulas before and after infliximab treatment. METHODS: Magnetic resonance imaging (MRI) and clinical evaluation were performed in a total of 18 patients before and after treatment with infliximab. An MRI-based score of perianal Crohn's disease severity was developed using both criteria of local extension of fistulas (complexity, supralavetoric extension, relation to the sphincters and of active inflammation (T2 hyperintensity, presence of cavities/abscesses, and rectal wall involvement). RESULTS: The MRI score was reliable in assessing the fistula tracks, with a good interobserver concordance (p < 0.001). Fistula tracks with signs of active inflammation were found in all 18 patients at baseline and collections in seven. After short-term infliximab treatment, active tracks persisted in eight of 11 patients who had clinically responded to infliximab. After long-term (46 wk) infliximab therapy, MRI signs of active track inflammation had resolved in three of six patients. CONCLUSIONS: We have developed an MRI-based score of perianal Crohn's disease severity to assess the anatomical evolution of Crohn's fistulas. Our study demonstrates that despite closure of draining external orifices after infliximab therapy, fistula tracks persist with varying degrees of residual inflammation, which may cause recurrent fistulas and pelvic abscesses. Whether complete fistula fibrosis occurs over time with repeated infliximab infusions needs further study.     

Infliximab administered with shortened infusion times in a specialized IBD infusion unit: A prospective cohort study

Background and aimsBiological therapy with anti TNF agents requires parenteral administration and in the case of infliximab this involves in hospital treatment. We aimed to prospectively assess the safety and tolerance of infliximab infusion in patients with IBD in a specialized unit adhering to strict standard operation procedures including switch to accelerated 1 h infusions.MethodsA prospective audit of a referral center IBD infusion unit was performed. We recorded infusion times and all adverse events including hypersensitivity reactions. Patients were also polled about the impact of the treatment on quality of life (QOL).ResultsOn 20 consecutive days 177 patients were treated with infliximab and all participated. Of those infliximab 117 received 1 h infusions and 4 (2.2%) had an immediate infusion reaction. Median time on unit was optimal for those with 1 h infusions [1:35 h (IQR: 1:25–1:50)] without an increased risk of infusion reactions. Prophylactic therapy significantly increased the time on unit [3:20 h (IQR: 2:50–3:45), p < 0.001]. Patients reported a high global satisfaction and a good tolerability of the infusions with a considerable or strong impact on studies, work or QOL in one third.ConclusionsA dedicated IBD infusion unit can achieve high quality of care and shortened 1 h infliximab infusions are well tolerated in patients with scheduled maintenance therapy.     

Analyzing Health-Related Quality of Life Data to Estimate Parameters for Cost-Effectiveness Models: An Example Using Longitudinal EQ-5D Data from the SHIFT Randomized Controlled Trial

Introduction

The aim of this article is to discuss methods used to analyze health-related quality of life (HRQoL) data from randomized controlled trials (RCTs) for decision analytic models. The analysis presented in this paper was used to provide HRQoL data for the ivabradine health technology assessment (HTA) submission in chronic heart failure.

Methods

We have used a large, longitudinal EuroQol five-dimension questionnaire (EQ-5D) dataset from the Systolic Heart Failure Treatment with the I _f Inhibitor Ivabradine Trial (SHIFT) (clinicaltrials.gov: NCT02441218) to illustrate issues and methods. HRQoL weights (utility values) were estimated from a mixed regression model developed using SHIFT EQ-5D data (n = 5313 patients). The regression model was used to predict HRQoL outcomes according to treatment, patient characteristics, and key clinical outcomes for patients with a heart rate ≥75 bpm.

Results

Ivabradine was associated with an HRQoL weight gain of 0.01. HRQoL weights differed according to New York Heart Association (NYHA) class (NYHA I–IV, no hospitalization: standard care 0.82–0.46; ivabradine 0.84–0.47). A reduction in HRQoL weight was associated with hospitalizations within 30 days of an HRQoL assessment visit, with this reduction varying by NYHA class [?0.07 (NYHA I) to ?0.21 (NYHA IV)].

Conclusion

The mixed model explained variation in EQ-5D data according to key clinical outcomes and patient characteristics, providing essential information for long-term predictions of patient HRQoL in the cost-effectiveness model. This model was also used to estimate the loss in HRQoL associated with hospitalizations. In SHIFT many hospitalizations did not occur close to EQ-5D visits; hence, any temporary changes in HRQoL associated with such events would not be captured fully in observed RCT evidence, but could be predicted in our cost-effectiveness analysis using the mixed model. Given the large reduction in hospitalizations associated with ivabradine this was an important feature of the analysis. Funding: The Servier Research Group.

     

Detecting genetic variability among different Mycobacterium tuberculosis strains using DNA microarrays technology

Recent advances in functional and comparative genomics have improved our understanding of genetic diversity among the Mycobacterium tuberculosis complex. In this study, we investigated the genetic polymorphism of M. tuberculosis using whole-genome microarray analysis. Amplified fragments of 15 M. tuberculosis strains (from two different geographical origins) and the reference strain H37Rv were produced by random amplification of polymorphic DNA (RAPD) using three different primers. The RAPD products were labeled with fluorescent dyes (Cy3 and Cy5) and hybridized to a TB DNA microarray representing nearly all open reading frames (ORFs) of H37Rv. The final results were analyzed using bioinformatic tools. Some genetic variability was found among the 16 M. tuberculosis strains. The majority of the highly polymorphic DNA sequences were observed in ORFs representing non-essential genes of the bacterium. The future use of comparative genomics based on DNA microarray technology should prove a powerful tool for understanding phenotypic variability among M. tuberculosis isolates of similar genetic composition. It is also a promising approach to provide important insights into evolution, virulence and pathogenesis of M. tuberculosis.     

Application of the percutaneuos thrombin injection in treatment of iatrogenic femoral pseudoaneurysms

Pseudoaneurysms are not a common complication of the endovascular procedures but can present a serious therapeutic problem. Both, the application of compression therapy and surgical operation can lead to the development of subsequent complications. The aim of this study was analysis of the treatment results of iatrogenic pseudoaneurysms managed with percutaneous thrombin injection. Treated group consisted of 69 patients diagnosed with iatrogenic femoral pseudoaneurysms. The indication for injection technique was ineffective compression therapy as well as necrotic changes or bacterial skin infection in the groin area or a large diameter of pseudoanurysm's chambers. Thrombin was injected percutaneously during 1-3 sessions in the dose of 100-1200 U into the centre of the chamber under ultrasound control. Primary and secondary success rate was 88% and 94% respectively. The following factors significantly decreased effectiveness of the method: complex pseudoaneurysms (with treatment efficacy 82% and 88% respectively vs 90% and 96% for simple pseudoaneurysms), and large chamber volume. Early and late recanalization of the thrombotic changes appeared in 7% and 3% of treated cases. The most frequent complication was appearance of non-elastic tumor (71%) or pain (64%) in the groin area. The most serious complication was acute lower limb ischemia detected in one case (2%) as a result of femoral artery compression by the thrombosed pseudoaneurysm. Percutaneous thrombin injection should be a preferred method of pseudoaneurysms treatment, especially in cases of ineffective compression therapy or its contraindications due to low cost of the therapy, simplicity of the technique and relatively low percentage of the complications.     

Risk Factors Associated with Clinical Malaria Episodes in Bangladesh: A Longitudinal Study

Malaria is endemic to Bangladesh. In this longitudinal study, we used hydrologic, topographic, and socioeconomic risk factors to explain single and multiple malaria infections at individual and household levels. Malaria incidence was determined for 1,634 households in 54 villages in 2009 and 2010. During the entire study period 21.8% of households accounted for all (n = 497) malaria cases detected; 15.4% of households had 1 case and 6.4% had ≥ 2 cases. The greatest risk factors for malaria infection were low bed net ratio per household, house construction materials (wall), and high density of houses. Hydrologic and topographic factors were not significantly associated with malaria risk. This study identifies stable malaria hotspots and risk factors that should be considered for cost-effective targeting of malaria interventions that may contribute to potential elimination of malaria in Bangladesh.     

Effects of Exercise Training on Heart Rate Variability in Chagas Heart Disease

Background:

Heart rate variability (HRV) is a marker of autonomic dysfunction severity. The effects of physical training on HRV indexes in Chagas heart disease (CHD) are not well established.

Objective:

To evaluate the changes in HRV indexes in response to physical training in CHD.

Methods:

Patients with CHD and left ventricular (LV) dysfunction, physically inactive, were randomized either to the intervention (IG, N = 18) or control group (CG, N = 19). The IG participated in a 12-week exercise program consisting of 3 sessions/week.

Results:

Mean age was 49.5 ± 8 years, 59% males, mean LVEF was 36.3 ± 7.8%. Baseline HRV indexes were similar between groups. From baseline to follow-up, total power (TP): 1653 (IQ 625 - 3418) to 2794 (1617 - 4452) ms, p = 0.02) and very low frequency power: 586 (290 - 1565) to 815 (610 - 1425) ms, p = 0.047) increased in the IG, but not in the CG. The delta (post - pre) HRV indexes were similar: SDNN 11.5 ± 30.0 vs. 3.7 ± 25.1 ms. p = 0.10; rMSSD 2 (6 - 17) vs. 1 (21 - 9) ms. p = 0.43; TP 943 (731 - 3130) vs. 1780 (921 - 2743) Hz. p = 0.46; low frequency power (LFP) 1.0 (150 - 197) vs. 60 (111 - 146) Hz. p = 0.85; except for high frequency power, which tended to increase in the IG: 42 (133 - 92) vs. 79 (61 - 328) Hz. p = 0.08).

Conclusion:

In the studied population, the variation of HRV indexes was similar between the active and inactive groups. Clinical improvement with physical activity seems to be independent from autonomic dysfunction markers in CHD.