Atraumatic splenic rupture following IVIg for parvovirus B19 pure red cell aplasia post renal transplant

Parvovirus B19 (PB19) associated pure red cell aplasia (PRCA) is an uncommon but well described complication of immunosuppression post solid organ transplantation. We report a unique case of a renal transplant patient with PB19 associated PRCA who developed a spontaneous splenic rupture after receiving IVIg for persistent anemia. He subsequently required splenectomy. Within the spleen we subsequently identified PB19 affected cells.     

Timing and detection of metachronous colorectal cancer

Background: Surveillance following surgery for colorectal cancer aims to detect treatable disease relapse or metachronous neoplasia. Metachronous cancers have been reported within a short duration of follow‐up, and may be due to missed lesions, seeding into polypectomy wounds or accelerated tumorigenesis related to genetic instability. The purpose of this study was to establish the timing and method of detection of metachronous cancers in a large population of patients in a surveillance database. Methods: This retrospective clinical study used patients with an elevated risk of colorectal neoplasia included in a colonoscopy‐based surveillance programme to identify those with two or more colorectal cancers, as well as the timing and method of detection of the tumours. Colonoscopy reports and histopathology results were reviewed to determine quality of bowel preparation, tumour location, and polypectomy data. Results: Fourteen (2.5%) of 569 patients with colorectal cancer developed metachronous malignant tumours, nearly half of which were identified within 3 years of follow‐up by surveillance colonoscopy or an interval faecal immunochemical test for globin. None of these had a previous polypectomy at the site of the second tumour, bowel preparation at the original colonoscopy was good in most cases, and no metachronous tumour occurred at a colonic flexure. Conclusion: Metachronous cancers can occur early during follow‐up after curative intent resection, and early colonoscopic surveillance may be warranted.     

Endocrine problems in pregnancy

This paper aims to describe the pathophysiology and management of the main endocrine complications of pregnancy. For each endocrine dysfunction, the issues with the fetus, the mother, obstetric complications, and the long term prognosis for the disease itself need to be considered. Key management issues are highlighted with each condition. Thyroid dysfunction and goitre are common while management is relatively straightforward. Adrenal, pituitary, and parathyroid diseases present less commonly in pregnancy. Early recognition of endocrine disease in pregnancy and appropriate management has the potential to improve outcome for the mother and fetus in the short and long term.     

Increased left atrial volume index is an independent predictor of raised serum natriuretic peptide in patients with suspected heart failure but normal left ventricular ejection fraction: Implication for diagnosis of diastolic heart failure

BACKGROUND: Left atrial volume index (LAVI) is increasingly recognised as a relatively load-independent marker of left ventricular (LV) filling pressures. We assessed the capacity of LAVI to predict LV diastolic dysfunction in comparison with N-terminal pro B-type natriuretic peptide (NTproBNP) in patients with suspected heart failure and a normal ejection fraction (EF). METHODS: 137 patients with suspected heart failure (HF), referred from the community for echocardiography, prospectively underwent Doppler echocardiography, LAVI and NTproBNP estimation. Raised LAVI and reduced LV systolic function were defined as >26 ml/m2 and LV EF <50% respectively. RESULTS: Of 137 patients, 21 were excluded (2 with significant mitral valve disease and 19 with atrial fibrillation). Of the remaining 116 subjects, 92 showed normal LV systolic function. The univariate predictors of serum log NTproBNP were age (p < 0.001), LA dimension (p = 0.001), LAVI (p < 0.001), A wave (p = 0.001), E:A (p = 0.07) and septal wall thickness (p = 0.004). However on multivariate analysis, LAVI was found to be the most consistent and significant predictor of NTproBNP. The area under the curve of the receiver operating characteristic (ROC) curve for NTproBNP in detecting patients with LVEF > or = 50% and LAVI >26 ml/m2 was 0.81 (p < 0.0001) and for patients with LAVI > 26 ml/m2 with and without LVEF > or = 50% was 0.82 (p < 0.0001). CONCLUSION: This data confirms that LAVI on resting echocardiography, specifically in patients with suspected HF and normal LV systolic function is a powerful independent predictor of LV diastolic dysfunction as predicted by serum NTproBNP. In a population with a high suspicion of diastolic heart failure, LAVI may significantly contribute to diagnostic precision.     

Multiple joint effusions associated with high-dose imatinib therapy in a patient with chronic myelogenous leukaemia

Imatinib mesylate is a small molecule tyrosine kinase inhibitor that has significant efficacy in the treatment of chronic myelogenous leukaemia (CML). However, it is likely that patients with CML will require prolonged and perhaps life-long therapy. In general, the side-effects of imatinib therapy have been mild to moderate, with the large majority of patients tolerating prolonged periods of therapy. However, a minority of patients are completely intolerant of therapy, while others are able to remain on therapy despite significant side-effects. Here, we describe a novel form of fluid retention presenting as multiple joint effusions in a patient with advanced phase CML on high-dose imatinib, as well as successful measures that were undertaken to control this adverse event. Although fluid retention, including periorbital oedema, pleural and pericardial effusions, as well as life-threatening cerebral oedema have been previously described and attributed to imatinib, this is the first case of imatinib-associated polyarticular effusions that we are aware of. Further work will be required to confirm a casual relationship between imatinib therapy and this novel side-effect, as well as to determine the underlying pathophysiologic mechanisms.     

Therapeutic Development in Cardiac Syndrome X: A Need to Target the Underlying Pathophysiology

Morbidity of patients with cardiac syndrome X (typical anginal‐like chest pain and normal coronary arteriogram) is high with continuing episodes of chest pain and frequent hospital readmissions. Management of this syndrome represents a major challenge for the treating physician. Conventional therapies with antianginal agents such as nitrates, calcium channel antagonists, classic β‐adrenoceptor blockers and nicorandil have been tried, with variable success. However, this might be related to a failure to target the underlying pathophysiology and, clearly, more effective therapies are needed. Supporting evidence for the important role of endothelial dysfunction and oxidative stress in the pathogenesis of cardiac syndrome X has come from the recent observation that basal superoxide production predicts future cardiovascular events in this patient group. This review will discuss the pathophysiology, current medical management and potential new pharmacological treatment for patients with cardiac syndrome X which target endothelial dysfunction and oxidative stress. What's already known about this topic? ?Morbidity of patients with cardiac syndrome X is high. ?The important role of endothelial dysfunction and oxidative stress in the pathogenesis of cardiac syndrome X. What does this article add? ?This review will discuss the pathophysiology, current medical management and potential new pharmacological treatment for patients with cardiac syndrome X which target endothelial dysfunction and oxidative stress.     

Quantification of angiogenesis by CT perfusion imaging in liver tumor of rabbit

BACKGROUND:Tumor angiogenesis is essential for primary and metastatic tumor growth.Computed tomography perfusion(CTP)is a new imaging method,made possible by the recent development of fast CT scanners and improved data analysis techniques,which allows measurement of the physiologic and hemodynamic properties of tissue vasculature.This study aimed to evaluate CTP in the quantification of angiogenesis and to assess the relationship between tissue perfusion parameters and microvascular density(MVD)and vascular...     

Is fine-needle aspiration (FNA) of multiple thyroid nodules justified?

Background: The clinical management of patients with solitary thyroid nodule is well established; however, the evaluation of patients with multiple thyroid nodules is controversial. The aim of this study was to assess if there is a correlation between the risk of malignancy and number of thyroid nodules. Design: The study cohort included 2884 patients (2410 females and 474 males) with 3274 thyroid nodules that underwent FNA under ultrasound guidance between November 1997 and April 2004. Multiple thyroid nodules were aspirated in 360 patients; 2 in 332 (291 females, 41 males), 3 nodules in 26 (23 females, 3 males), and 4 nodules in 2 patients (1 female, 1 male). Subsequent information regarding the histological diagnosis was obtained in the cases that underwent surgical excision. Results: The average age for patients with single or multiple nodules was the same (51 yr). The FNA specimens were diagnosed as benign (n=1663, 51%), neoplasm (n=880, 27%), suspicious for neoplasm or papillary carcinoma (n=234, 7%), malignant (n=187, 6%), and non-diagnostic (n=310, 9%). Surgical excision was performed in 1135 patients: 993 patients with single nodules and 142 patients with multiple nodules. The surgical pathology diagnosis was benign in 656 nodules (52%) and malignant in 596 nodules (48%). In the malignant category 153 tumors were papillary microcarcinoma (<1 cm). Excluding these cases, the malignancy rate was 39% in patients with single nodules, 41% with two nodules, and 21% with three nodules. Conclusions: The cancer risk is similar for patients with one or two nodules over 1 cm and decreases with three or more thyroid nodules.     

Two sisters with IMAGe syndrome: cytomegalic adrenal histopathology, support for autosomal recessive inheritance and literature review

Adrenal hypoplasia congenita (AHC) is a rare condition and causes primary adrenal insufficiency. X-linked (OMIM 300200) and autosomal recessive (OMIM 240200) forms are recognized. Recently, an association between Intrauterine growth restriction, Metaphyseal dysplasia, Adrenal hypoplasia congenita, and Genital abnormalities (IMAGe syndrome; OMIM 300290) has been described. We present the clinical features of two sisters with intrauterine growth restriction, AHC, and dysmorphic features. Interesting histopathologic findings of one sister are also presented. We suggest that IMAGe syndrome is the most plausible diagnosis and that autosomal recessive inheritance is likely. We analyzed genes that were postulated candidates for IMAGe syndrome (SF1, DAX-1, and STAR), and no mutations were found. Other cases of IMAGe syndrome are reviewed.