Episodic fevers and vasodilatory shock mimicking urosepsis in a patient with HIV-associated multicentric Castleman's Disease: a case report

Background

Multicentric Castleman’s disease (MCD) is a pre-malignancy that presents with lymphadenopathy and features of systemic inflammation. Human immunodeficiency virus (HIV)-associated MCD is associated with human herpesvirus-8 (HHV-8) infection. If untreated MCD has a relapsing and remitting course that is eventually fatal.

Case presentation

A 67-year-old man had six hospital admissions over 20 months characterised by fever, urinary frequency and CRP >100 mg/L. The final admission was complicated by hypotension requiring intensive care unit admission and ionotropic support. His history included HIV and Hepatitis B virus (HBV) co-infection on suppressive therapy. Each presentation was managed as presumed urosepsis with use of empirical antibiotics, however numerous blood and urine cultures failed to identify a pathogen. A bone-marrow aspirate and trephine found no evidence of haematological malignancy. A positron emission tomography scan found active lymph nodes, one of which was biopsied and found to contain the plasma-cell variant of Castleman’s disease. Ultimately the cause for the recurrent presentations was attributed to progressive MCD. The patient received rituximab monotherapy and has had no further related admissions.

Conclusions

MCD should be considered in patients with chronic HIV infection presenting with recurrent sepsis-like episodes and/or vasodilatory shock, particularly if no pathogen is identified or lymphadenopathy is evident.

The measurement of adult blood pressure and management of hypertension before elective surgery: Joint Guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society

This guideline aims to ensure that patients admitted to hospital for elective surgery are known to have blood pressures below 160 mmHg systolic and 100 mmHg diastolic in primary care. The objective for primary care is to fulfil this criterion before referral to secondary care for elective surgery. The objective for secondary care is to avoid spurious hypertensive measurements. Secondary care should not attempt to diagnose hypertension in patients who are normotensive in primary care. Patients who present to pre-operative assessment clinics without documented primary care blood pressures should proceed to elective surgery if clinic blood pressures are below 180 mmHg systolic and 110 mmHg diastolic.

Implementing a community bullying awareness intervention in an adolescent psychiatric unit: a feasibility study

PROBLEM

Adolescents with a mental health diagnosis are at risk of involvement in bullying. We tested the feasibility of a bullying awareness group intervention in an established inpatient psychiatric unit milieu.

METHODS

Adolescents admitted to an urban inpatient adolescent psychiatric unit were eligible to attend two sequential 1-hour Bullying Awareness intervention group sessions. Data were collected before the first session (T1), post-both sessions (T2), and following discharge from the unit (T3).

FINDINGS

A total of 65 adolescents were enrolled; most were female (66.2%), African-American (60%), and in grades 10 to 12 (57%). Intervention feasibility was achieved as >80% of participants completed all components of the intervention and 100% completed all study questionnaires at T1 and T2. Feasibility of the follow-up (T3) was not achieved. Bullying knowledge scores improved significantly from T1 to T2.

CONCLUSIONS

The intervention is feasible to implement in an inpatient adolescent psychiatry unit and can improve adolescents' bullying knowledge.

Genetic Diversity and Protective Efficacy of the RTS,S/AS01 Malaria Vaccine

BACKGROUND

The RTS,S/AS01 vaccine targets the circumsporozoite protein of Plasmodium falciparum and has partial protective efficacy against clinical and severe malaria disease in infants and children. We investigated whether the vaccine efficacy was specific to certain parasite genotypes at the circumsporozoite protein locus.

METHODS

We used polymerase chain reaction-based next-generation sequencing of DNA extracted from samples from 4985 participants to survey circumsporozoite protein polymorphisms. We evaluated the effect that polymorphic positions and haplotypic regions within the circumsporozoite protein had on vaccine efficacy against first episodes of clinical malaria within 1 year after vaccination.

RESULTS

In the per-protocol group of 4577 RTS,S/AS01-vaccinated participants and 2335 control-vaccinated participants who were 5 to 17 months of age, the 1-year cumulative vaccine efficacy was 50.3% (95% confidence interval [CI], 34.6 to 62.3) against clinical malaria in which parasites matched the vaccine in the entire circumsporozoite protein C-terminal (139 infections), as compared with 33.4% (95% CI, 29.3 to 37.2) against mismatched malaria (1951 infections) (P=0.04 for differential vaccine efficacy). The vaccine efficacy based on the hazard ratio was 62.7% (95% CI, 51.6 to 71.3) against matched infections versus 54.2% (95% CI, 49.9 to 58.1) against mismatched infections (P=0.06). In the group of infants 6 to 12 weeks of age, there was no evidence of differential allele-specific vaccine efficacy.

CONCLUSIONS

These results suggest that among children 5 to 17 months of age, the RTS,S vaccine has greater activity against malaria parasites with the matched circumsporozoite protein allele than against mismatched malaria. The overall vaccine efficacy in this age category will depend on the proportion of matched alleles in the local parasite population; in this trial, less than 10% of parasites had matched alleles. (Funded by the National Institutes of Health and others.).

Combined effect of photobiomodulation with a matrix metalloproteinase inhibitor on the rate of relapse in rats

OBJECTIVE

To investigate combined effect of photobiomodulation with a matrix metalloproteinase (MMP) inhibitor on the relapse rate in relation to MMP expression in rats.

MATERIALS AND METHODS

Fifty-two rats were divided into four groups according to the treatment modality: control group, irradiation group, doxycycline group, and irradiation with doxycycline group. During a relapse period of 5 days after orthodontic movement, maxillary central incisors were treated by low-level laser therapy (LLLT) as a photobiomodulation and/or doxycycline as a synthetic MMP inhibitor. Relapse rate was evaluated in association with MMP expression at the gene and protein levels.

RESULTS

Relapse rates were increased by LLLT (1.57-fold) and decreased by doxycycline (0.83-fold) compared with the control, showing positive correlation with the levels of expression for all MMPs in the periodontal ligament (PDL). LLLT concomitant with doxycycline administration resulted in no significant differences of relapse rate and MMP expression from the control.

CONCLUSIONS

The combined effect of photobiomodulation with an MMP inhibitor around the relapsing teeth proved to be antagonistic to PDL remodeling activity during relapse. This study suggests a basis for developing a novel biologic procedure targeting the MMP-dependent PDL remodeling to control the relapse rate.

A survey of dental school's emergency departments in Ireland and the UK: provision of undergraduate teaching and emergency care

Outlines various aspects of emergency departments in dental schools.

Outlines current curriculum details, teaching methods and undergraduate experience in emergency dental care across dental schools.

Discusses the use of various triage systems in emergency departments in dental schools.

Outlines the GDC's stance on emergency dental care education.

Aim Emergency dental care is a vital service that new graduates should be prepared to offer. There are few published data relating to emergency dental care education. To assess this, and to gain a profile of accident and emergency departments (A&E) in dental schools, an online survey was sent to all of the dental schools in the Republic of Ireland and the UK.

Setting The survey addressed the school's A&E curriculum, teaching methods, undergraduate exposure and departmental details.

Results The majority of A&E departments operated during normal working hours with a minority offering an out-of-hours service. Teaching of A&E topics, and undergraduate experience, vary significantly between schools. A&E departments were diversely named and exhibited significant regional variation. Approximately half employed a triage system. It is unclear what represents an adequate level of undergraduate exposure, and more research is required in this area.

Conclusions Assessment of undergraduates following time in clinic is an important component of any A&E module. We consider a reflective portfolio to represent a suitable form of assessment, and would recommend their introduction. In addition, we recommend that dental hospitals consider a nurse-led triage system.

Successful treatment of severe atenolol overdose with calcium chloride

Atenolol, a selective β1-adrenergic antagonist, is commonly used to treat hypertension, ischemic heart disease and cardiac dysrhythmias. Few cases of severe atenolol intoxication have been described, and only one of these reports discussed the use of calcium chloride as a treatment. We present a case of atenolol overdose associated with shock and first-degree heart block, in which administration of calcium chloride led to dramatic improvement after failure of conventional treatment. In addition, we discuss the pharmacokinetics, toxicology and management of β-blocker overdose, focusing on the possible role of calcium chloride.

Investigating an outbreak of Clostridium perfringens gastroenteritis in a school using smartphone technology, London, March 2013

Binary file ES_Abstracts_Final_ECDC.txt matches

Abstract S4-07: Effects of bisphosphonate treatment on recurrence and cause-specific mortality in women with early breast cancer: A meta-analysis of individual patient data from randomised trials

Background: Disseminated tumour cells can remain dormant in the bone marrow for years prior to subsequent activation and the development of overt metastases. Bisphosphonates (BP) have profound effects on bone physiology and could potentially modify the metastatic disease process. Variable outcomes in terms of disease recurrence have been reported, with efficacy apparently influenced by menopausal status.

Methods: We sought individual patient data for meta-analysis from 41 randomised trials that compared BP to no BP (placebo or open control). Primary outcomes were time to recurrence, time to first distant recurrence and breast cancer mortality. Predefined subgroup comparisons were of type of BP (amino-/non-amino), duration and schedule of BP treatment, menopausal status, age, ER status, concomitant chemotherapy and site of distant recurrence (bone/other).

Results: Data on 17,751 women (75% of 23,573 randomised in relevant trials) have so far been received, with around 3,300 breast cancer recurrences and 2,500 deaths. Effects on breast cancer mortality, recurrence and bone metastases for 17,016 women in the locked database and for 10,540 who were postmenopausal are shown below.

No. eventsRate Ratio (SE)10 year gain2p valueAll women (n = 17,016)Breast cancer mortality2,0490.91 (0.04)1.7%0.04Breast cancer recurrence3,2840.94 (0.04)1.0%0.13Distant recurrence2,7510.92 (0.04)1.3%0.05Bone recurrence8250.79 (0.07)1.4%0.002Other distant recurrence1,9260.99 (0.05)0.1%0.8Postmenopausal women (n = 10,540)Breast cancer mortality1,1070.83 (0.06)3.1%0.004Breast cancer recurrence1,8090.86 (0.05)3.0%0.002Distant recurrence1,5030.83 (0.05)3.3%0.0007Bone recurrence4450.65 (0.08)2.9%0.00001Other distant recurrence1,0580.93 (0.06)0.7%0.26

Reductions in bone recurrence for postmenopausal women were similar irrespective of bisphosphonate type, treatment schedule, ER status, nodal involvement or use of concomitant chemotherapy. There were no improvements in bone (RR = 1.00, 2p = 0.97) or other recurrence for premenopausal women. Adjuvant bisphosphonates also reduced bone fractures (RR = 0.83, 2p = 0.009).

Conclusion: Adjuvant bisphosphonates reduce bone recurrences and improve breast cancer survival in postmenopausal but not premenopausal women.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr S4-07.