Triple synchronous gastrointestinal malignancies: a rare occurrence

Gastrointestinal cancer is common, and is a significant cause of morbidity and mortality. The synchronous occurrence of two different malignancies is not uncommon, but that of more than two malignancies is extremely rare. Such occurrences often pose diagnostic and therapeutic challenges. We report the case of an elderly man who was previously treated for gastric cancer 13 years ago, and who was later diagnosed with synchronous triple gastrointestinal malignancies consisting of hepatocellular carcinoma, a gastric collision tumour with adenocarcinoma and a large B cell lymphoma. The patient's condition progressed rapidly, and he died four weeks after the diagnosis.     

Long-term follow-up of primary glaucoma surgery with Ahmed glaucoma valve implant versus trabeculectomy

PURPOSE: To compare the long-term results of trabeculectomy and Ahmed glaucoma valve implant in the initial surgical management of primary open- and closed-angle glaucoma. DESIGN: Randomized controlled clinical trial. METHODS: One eye each of consecutive patients with primary glaucoma and without prior intraocular surgery was randomized to receive either trabeculectomy or the Ahmed implant.Large university-affiliated eye hospital in Columbo, Sri Lanka. RESULTS: Of 123 patients, 64 were randomized to trabeculectomy and 59 to the Ahmed implant. With a mean follow-up of 31 months, the trabeculectomy group had statistically lower intraocular pressures (IOP) during the first postoperative year. After the first year, the IOPs were comparable. No statistically significant differences between groups were noted for postoperative visual acuity, visual field, anterior chamber depth, and short-term or long-term complications. Adjunctive medication requirement was comparable for both groups. The cumulative probabilities of success (IOP <21 mm Hg and at least 15% reduction in IOP from preoperative levels) at the final follow-up period (months, 41-52) were 68.1% for trabeculectomy and 69.8% for Ahmed implant (P =.86). CONCLUSIONS: Lower IOPs were noted for the trabeculectomy group during the first year. With longer follow-up, the IOPs and the cumulative probabilities of success were comparable between the two groups.     

Is age at diagnosis an independent prognostic factor for survival following breast cancer?

BACKGROUND: Previous studies of patients with breast cancer have examined age at diagnosis as a prognostic factor for survival with contradictory results. The current study examines the effect of age in conjunction with pathological tumour size, lymph node status and histological grade to clarify whether age at diagnosis is an independent factor for overall survival. METHODS: This is a population-based study that examines the survival of 393 women with a first diagnosis of breast cancer in 1992 in the Greater Western region of Sydney in New South Wales, Australia. Survival analysis was conducted using the Kaplan-Meier method. Relative risks associated with age at diagnosis, pathological tumour size, and number of positive lymph nodes and histological grade and adjusted for each other were computed using Cox proportional hazard regression. Patients' ages were categorized as 'younger' (<40 years of age at diagnosis), 'middle-aged' (40-69 years) or 'older age' (>69 years). RESULTS: The 10-year survival of women <40 years was 49%, which was significantly lower than 'middle-aged' women (73%). For women with node-negative breast cancer, younger women had a significantly (P = 0.011) poorer survival rate (68%) than middle-aged (90%) or older women (80%). After adjusting for the effects of the pathological tumour size, the lymph node status and histological grade, women <40 years showed a higher risk of dying than older women. However, young women detected with a small (<20 mm) node-negative tumour have a good prognosis. CONCLUSIONS: Age at diagnosis, tumour size and lymph node status were independent prognostic indicators for survival. Age at diagnosis should be considered as an important factor in making decisions about adjuvant therapy, irrespective of nodal status.     

Papillary cystic carcinoma of the pancreas and present status of pancreatic malignancies in Brunei

During the 10-year period from January 1986 to December 1995, a total of six cases of pancreatic carcinoma were documented in Brunei. Among them was a case of papillary cystic carcinoma of the pancreas, in which the patient, a 22-year-old woman, presented with a painless upper abdominal mass that had been increasing in size over a 6-year period. Ultrasonography showed a well circumscribed solid and cystic pancreatic mass. The tumor was excised locally and the patient remained disease-free at 8 months' follow-up. This papillary cystic carcinoma of the pancreas deserves special mention as it has a low-grade malignant potential, is amenable to local resection, and has a good long-term survival rate after excision.     

Predictors of primary care referrals to a vascular disease prevention lifestyle program among participants in a cluster randomised trial

Background

Cardiovascular disease accounts for a large burden of disease, but is amenable to prevention through lifestyle modification. This paper examines patient and practice predictors of referral to a lifestyle modification program (LMP) offered as part of a cluster randomised controlled trial (RCT) of prevention of vascular disease in primary care.

Methods

Data from the intervention arm of a cluster RCT which recruited 36 practices through two rural and three urban primary care organisations were used. In each practice, 160 eligible high risk patients were invited to participate. Practices were randomly allocated to intervention or control groups. Intervention practice staff were trained in screening, motivational interviewing and counselling and encouraged to refer high risk patients to a LMP involving individual and group sessions. Data include patient surveys; clinical audit; practice survey on capacity for preventive care; referral records from the LMP. Predictors of referral were examined using multi-level logistic regression modelling after adjustment for confounding factors.

Results

Of 301 eligible patients, 190 (63.1%) were referred to the LMP. Independent predictors of referral were baseline BMI ≥ 25 (OR 2.87 95%CI:1.10, 7.47), physical inactivity (OR 2.90 95%CI:1.36,6.14), contemplation/preparation/action stage of change for physical activity (OR 2.75 95%CI:1.07, 7.03), rural location (OR 12.50 95%CI:1.43, 109.7) and smaller practice size (1–3 GPs) (OR 16.05 95%CI:2.74, 94.24).

Conclusions

Providing a well-structured evidence-based lifestyle intervention, free of charge to patients, with coordination and support for referral processes resulted in over 60% of participating high risk patients being referred for disease prevention. Contrary to expectations, referrals were more frequent from rural and smaller practices suggesting that these practices may be more ready to engage with these programs.

Trial registration

ACTRN12607000423415

     

Persistence of pneumolysin in the cerebrospinal fluid of patients with pneumococcal meningitis is associated with mortality

Poor prognosis in Pneumococcal meningitis may be associated with high pneumolysin levels in cerebrospinal fluid (CSF). In patient samples we showed that pneumolysin levels in CSF remained high after 48 hours in nonsurvivors of meningitis compared with survivors. Selective antipneumolysin treatment may present a novel therapeutic option.