Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

The RSNA Image Sharing Network

In the era of health information exchanges, there are trade-offs to consider when sharing a patient's medical record among all providers that a patient might choose. Exchange among in-network partners on the same electronic medical records (EMR) and other integrated information systems is trivial. The patient identifier is common, as are the relevant departmental systems, to all providers. Difficulties arise when patient records including images (and reports) must be shared among different networks and even with the patients themselves. The National Institutes of Health (NIH) challenged Radiological Society of North America (RSNA) to develop a transport method that could supersede the need for physical media (for patients or other providers), replace point-to-point private networks among providers, and enable image exchange on an ad hoc basis between arbitrary health networks without long legal delays. In concert with the evolving US health care paradigm, patient engagement was to be fundamental. With Integrating Healthcare Enterprise's (IHE's) help, the challenge has been met with an operational system.

Thrombostatin FM compounds: direct thrombin inhibitors - mechanism of action in vitro and in vivo

BACKGROUND

Novel pentapeptides called Thrombostatin FM compounds consisting mostly of D-isomers and unusual amino acids were prepared based upon the stable angiotensin converting enzyme breakdown product of bradykinin - RPPGF.

METHODS AND RESULTS

These peptides are direct thrombin inhibitors prolonging the thrombin clotting time, activated partial thromboplastin time, and prothrombin time at >or=0.78, 1.6, and 1.6 microm, respectively. They competitively inhibit alpha-thrombin-induced cleavage of a chromogenic substrate at 4.4-8.2 microm. They do not significantly inhibit plasma kallikrein, factor (F) XIIa, FXIa, FIXa, FVIIa-TF, FXa, plasmin or cathepsin G. One form, FM19 [rOicPaF(p-Me)], blocks alpha-thrombin-induced calcium flux in fibroblasts with an IC(50) of 6.9 +/- 1.2 microm. FM19 achieved 100% inhibition of threshold alpha- or gamma-thrombin-induced platelet aggregation at 8.4 +/- 4.7 microm and 16 +/- 4 microm, respectively. The crystal structure of thrombin in complex with FM19 shows that the N-terminal D-Arg retrobinds into the S1 pocket, its second residue Oic interacts with His-57, Tyr-60a and Trp-60d, and its C-terminal p-methyl Phe engages thrombin's aryl binding site composed of Ile-174, Trp-215, and Leu-99. When administered intraperitoneal, intraduodenal, or orally to mice, FM19 prolongs thrombin clotting times and delays carotid artery thrombosis.

CONCLUSION

FM19, a low affinity reversible direct thrombin inhibitor, might be useful as an add-on agent to address an unmet need in platelet inhibition in acute coronary syndromes in diabetics and others who with all current antiplatelet therapy still have reactive platelets.

Proactively monitoring departmental clinical IT systems with an open source availability system

The goal of all radiology information technology (IT) support organizations is excellent customer service through the availability of critical clinical information services, such as picture archiving communication systems and radiology information systems. Despite these goals, IT support personnel often act like firefighters, reacting to each problem, but unable to prevent or predict other problems. Proactive support is always more desirable than reactive support. Warning signs may exist well before a technical issue becomes system wide or the user is affected. The objective for IT support organizations in health care should be to maximize system uptime by using proactive monitoring systems for failures and to automatically detect failures through systems management tools. We report on the implementation of Nagios, an open source monitoring tool, as an availability management system in a diagnostic imaging department and on customized applications and protocols specific to radiology needs.

Developing peptide inhibitors to thrombin activation of platelets from bradykinin analogs

Investigations identified peptide, platelet-selective thrombin inhibitors. Three peptides (MAP4-RPPGF, RGKWC and RGDWC) were relatively selective inhibitors of thrombin-induced platelet activation and calcium mobilization. MAP4-RPPGF at 35.5+/-0.03 microM inhibits gamma-thrombin-induced platelet aggregation 100% and alpha-thrombin-induced calcium mobilization in fibroblasts 84%. RGKWC at 800+/-400 microM inhibits gamma-thrombin-induced platelet aggregation 100% and calcium mobilization 63%. RGDWC at 140+/-100 microM inhibits gamma-thrombin-induced platelet aggregation 100% and calcium mobilization 32%. RGDWC also inhibits ADP-induced platelet aggregation, whereas MAP4-RPPGF and RGKWC do not. RGKWC prolongs the activated partial thromboplastin time (APTT) but not the prothrombin time (PT) or thrombin clotting time (TCT). RGKWC uniquely inhibits alpha-thrombin activation of human factor XI. Single amino acid substitutions in peptide pentamers result in differences in potency and mechanism(s) of inhibition of platelet and fibroblast activation by thrombin.

Thrombostatin inhibits cyclic flow variations in stenosed canine coronary arteries

Thrombostatins are a group of compounds based upon a breakdown product of bradykinin, RPPGF. They inhibit alpha-thrombin-induced platelet activation by binding to protease activated receptor 1 and, at a lower affinity, by interacting with thrombin's active site. After a single intravenous infusion of MAP4-RPPGF (11.58 mg/kg), its t1/2alpha was 4.5 min with a clearance of 2.0 ml/min. MAP4-RPPGF administration had a sustained antiplatelet effect, preventing gamma-thrombin-induced (12.5 nM) platelet activation for 4 h. Its antiplatelet effect summated with that of aspirin and/or clopidogrel. MAP4-RPPGF was compared with aspirin and clopidogrel in the Folts model of coronary artery thrombosis. Dogs were randomized to 3 treatment groups: aspirin 1.14 mg/kg i.v., clopidogrel 0.5 mg/kg i.v., or MAP4-RPPGF 0.77 mg/kg i.v. Cyclic flow variations (CFV) were recorded in 5 untreated dogs hourly for 3 successive hours and for 1 h before (all groups >11 CFV/h), and for 2 h after drug infusion in each of the 3 treatment groups. After 1 h drug treatment, all groups of animals had <6 CFV/h; after 2 h treatment, all had <1 CFV/h. All agents significantly reduced CFV from control at each hour, but none was significantly better than any other. Thrombostatin was as effective as aspirin or clopidogrel in inhibiting coronary artery thrombosis in this canine model.

Il-13 and IFN-gamma: interactions in lung inflammation

Chronic inflammatory diseases of the lungs, such as asthma, are frequently associated with mixed (Th2 and Th1) T cell responses. We examined the impact of critical Th1 and Th2 cytokines, IFN-gamma and IL-13, on the responses in the lungs. In a mouse model of airway inflammation induced by mixed T cell responses, the number of Th1 (IFN-gamma-positive) cells was found to be negatively correlated with airway hyperreactivity. In these mice, blockade of IL-13 partially inhibited airway hyperreactivity and goblet cell hyperplasia but not inflammation. In contrast, in mice that responded with a polarized Th2 response to the same Ag, blockade of IL-13 inhibited airway hyperreactivity, goblet cell hyperplasia, and airway inflammation. These results indicated that the presence of IFN-gamma would modulate the effects of IL-13 in the lungs. To test this hypothesis, wild-type mice were given recombinant cytokines intranasally. IFN-gamma inhibited IL-13-induced goblet cell hyperplasia and airway eosinophilia. At the same time, IFN-gamma and IL-13 potentiated each other's effects. In the airways of mice given IL-13 and IFN-gamma, levels of IL-6 were increased as well as numbers of NK cells and of CD11c-positive cells expressing MHC class II and high levels of CD86. In conclusion, IFN-gamma has double-sided effects (inhibiting some, potentiating others) on IL-13-induced changes in the lungs. This may be the reason for the ambiguous role of Th1 responses on Th2 response-induced lung injury.

Centrilobular opacities in the lung on high-resolution CT: diagnostic considerations and pathologic correlation

Accurate assessment of high-resolution CT scans of the lung requires a knowledge of secondary lobular anatomy. Opacity that localizes to the centrilobular region implies the presence of a disease process that primarily involves centrilobular bronchioles, lymphatics, or pulmonary arterial branches. We illustrate the high-resolution CT findings of many of these processes and provide pathologic correlation for cases in which it was available.

Mechanisms of somatostatin action in RINm5F cells in culture: Preliminary evidence for possible altered G protein function

Octreotide (SMS), a somatostatin analogue, is an established antigrowth peptide, but it does not effectively inhibit the growth of insulinoma cells. In order to study the mechanisms that underlie this apparent lack of an antiproliferative effect on insulinoma tumor cells we established the rat insulinoma cell line, RINm5F, in culture. Cells in culture were tested by incubation in media with and without SMS. To study tritiated [3H]-thymidine incorporation into extracted DNA (TTID), 2 muCi/well of 3H was added for 24 hr, and cells were harvested and assayed for TTID (cpm/microgram DNA). Insulin (IRI) and intracellular cAMP (cAMPi) were measured by RIA. To study the effects of SMS on insulin secretion, conditioned media were sampled after 24 hr. To study the effects of cAMPi, conditioned medium was used to extract cAMPi following incubation with SMS for 15 min. Increasing concentrations of SMS had no significant effect on TTID in the presence of 1% FBS. Trypan blue exclusion tests showed > 90% viable cells throughout all stages of these experiments. There were no significant differences in cell numbers and protein content in the presence of SMS. There was a significant decrease in the secretion of insulin and intracellular cAMP levels in response to 50 nM SMS. However, SMS significantly inhibited TTID in RINm5F cells following a 4-hr pretreatment with pertussis toxin (PT) (23553 +/- 1747 vs 20635 [cpm/microgram DNA] +/- 1983 [SEM], P < 0.01). We conclude that the inhibition of insulin secretion by SMS is associated with an attenuation of cAMP formation.(ABSTRACT TRUNCATED AT 250 WORDS)

Green College Lecture. Ethical challenges in embryo manipulation

Images

Microgranulomatous aspergillosis after shoveling wood chips: report of a fatal outcome in a patient with chronic granulomatous disease

Chronic granulomatous disease is characterized by recurrent infections that result from an inability of phagocytes to kill organisms effectively. We describe a patient with this disease who developed aspergillus pneumonia after shoveling moldy cedar wood chips. Despite aggressive therapy, the patient's condition deteriorated and he died. At autopsy, the lungs revealed diffuse granulomas, all of the same age, with aspergillus organisms confined to the granulomas. We propose the term "microgranulomatous aspergillosis" for this response, which does not conform to the commonly described aspergillus syndromes. We conclude that susceptible immunosuppressed patients should be advised to avoid occupational situations where high spore concentrations are generated.

Ethics committees

Three kinds of ethics committees should be distinguished, the mandatory local hospital or clinic-based committee, the statutory national committee set up to issue licences, or survey issues highlighted by local committees, or in the national press, reporting to Parliament, and publishing annual reports; and the committee established either temporarily or on a permanent basis to examine outstanding and general problems in the morals of medical practice and research, and to advise Ministers as to possible changes in the law. At all levels, such committees will be concerned with moral problems, and can never, therefore, be expected to come up with uniquely 'correct' solutions. Nevertheless they are essential both to reassure the public and to give guidance to the medical profession, both in clinical practice and research. Such committees should, at all levels, have a non-medical chairman, and a high proportion of 'lay' members. They must have regard to common moral sentiments, and to what will be morally acceptable in the country as a whole (though they can never hope for total agreement with their conclusions). Their recommendations, being in the sphere of public rather than private morality will be as far as possible the outcome of consensus, without which legislation is not possible.

Sweet's syndrome with lung involvement

Severe dyspnea and pulmonary infiltrates were associated with recurrent episodes of Sweet's syndrome (acute febrile neutrophilic dermatosis) in a 54-yr-old woman with myelodysplasia. Lung and skin biopsies revealed a sterile infiltration of the interstitial tissues by mature neutrophils. Corticosteroid therapy resulted in rapid clinical improvement; however, recurrent episodes were increasingly resistant to therapy, and she ultimately died from respiratory failure. Sweet's syndrome involving the lung is rare, with only two previously reported cases documented by lung biopsy. Prompt recognition of Sweet's syndrome with lung involvement is important because of the potential for severe respiratory compromise.

Use of the polymerase chain reaction in the diagnosis of unsuspected herpes simplex viral pneumonia: report of a case

A 30-year-old apparently immunocompetent woman presented with acute respiratory failure (acute respiratory distress syndrome). No etiologic agent was found, and she died 2 weeks later despite antibiotic therapy. Postmortem examination of the lungs showed diffuse organizing alveolar damage with superimposed focal necrotizing peribronchiolar pneumonia. Cultures obtained from lung tissue were negative for virus, fungi, and bacteria. Histopathologic and electron microscopic studies showed that the necrotizing changes were consistent with herpesvirus infection. With the use of a new diagnostic tool, the polymerase chain reaction, a specific diagnosis of herpes simplex virus pneumonia was made, and other viral agents were excluded. The polymerase chain reaction is a sensitive, specific, and rapid technique that may greatly facilitate establishing an infectious etiology in cases of pneumonia.

Acquisition of peroxidase activity by rat alveolar macrophages during pulmonary inflammation

The authors investigated the ability of rat alveolar macrophages to acquire peroxidase activity in the course of pulmonary inflammation. Granulomatous pulmonary inflammation was induced in bacille Calmette-Guérin (BCG)-immunized rats by intravenous injection of BCG in mineral oil. In contrast to normal alveolar macrophages, which are peroxidase-negative, alveolar macrophages lavaged from the BCG-treated rats showed significant peroxidase activity in large cytoplasmic inclusions compatible with internalized exogenous material. Alveolar macrophage uptake of intact peroxidase-positive neutrophils was also observed. Maximal numbers of peroxidase-positive alveolar macrophages were observed after the initial influx of neutrophils into the lungs, and peroxidase activity could be demonstrated in cell-free lavage fluid during the acute phase of lung injury. Normal alveolar macrophages acquired peroxidase activity after incubation with peritoneal exudate neutrophils, with purified soluble human myeloperoxidase, and with opsonized erythrocytes. It is concluded that alveolar macrophages acquire peroxidase activity from multiple sources during pulmonary inflammation. Internalization of peroxidase by the alveolar macrophage may serve to clear a potentially toxic enzyme(s) from the alveolar space and contribute to the resolution of pulmonary inflammation.

Nucleotide sequences of a feline leukemia virus subgroup A envelope gene and long terminal repeat and evidence for the recombinational origin of subgroup B viruses

Molecular clones of the subgroup A feline leukemia virus FeLV-A/Glasgow-1 have been obtained. Nucleotide sequence analysis of the 3' end of the proviral genome and comparison with the published sequence of FeLV-B/Gardner-Arnstein showed that the most extensive differences are located within the 5' domain of the env gene. Within this domain, several divergent regions of env are separated by more conserved segments. The 3' end of env is highly conserved, with only a single amino acid coding difference in p15env. The proviral long terminal repeats are also highly conserved, differing by only eight base substitutions and one base insertion. Specific probes constructed from the FeLV-A or FeLV-B env genes were used to compare the env genes of various exogenous FeLV isolates and the endogenous FeLV-related proviruses of normal cat DNA. An FeLV-A-derived env probe showed no hybridization to normal cat DNA but detected all FeLV-A and FeLV-C isolates tested. In contrast, an FeLV-B env probe detected independent FeLV-B isolates and a family of endogenous FeLV-related proviruses. Our observations provide strong evidence to support the hypothesis that FeLV-B viruses have arisen by recombination between FeLV-A and endogenous proviral elements in cat DNA.

Another ten years in education

Opening remarks by the President, Sir John Walton: The Lloyd Roberts Lecture is one of the major events of the Society year. It is given in rotation at the invitation of the Royal College of Physicians of London, the Medical Society of London and the Royal Society of Medicine, and this year it is our turn. For those of you who do not know who Lloyd Roberts was — he died in 1920, at which time he was the Consulting Obstetric Physician, a very modern term indeed, to Manchester Royal Infirmary because, although he practised throughout his professional life as an obstetrician and gynaecologist, he was also a Fellow of the Royal College of Physicians of London and was particularly interested in medical aspects of obstetrics and gynaecology. He was one of that long line of medical polymaths who distinguished British medical affairs in the last century and in the early part of this century in that he had a major interest in literary matters. Quite apart from publishing his very well known Students' Guide to the Practice of Midwifery, he also published a revised edition of Sir Thomas Browne's Religio Medici, and was responsible for writing a major work on The Scientific Knowledge of Dante. A great collector of art treasures, including a specially fine collection of mezzotints, glass and books, he was in many, many ways a man of outstanding breadth of interest and culture. One of the most interesting things that was said about Lloyd Roberts in a very long obituary after he died was that, even if he had died thirty years earlier, his biography would have had a very large sale.

Hospital work done, he was to be found by midday standing, always standing, compact, alert, close cropped, by his consulting room fire with a glass of milk warming in the fender and, amongst the instruments on the mantelpiece, there were walnuts, which he cracked at intervals with explosive violence. These served for lunch.

One of his most famous quotes, which apparently has always been remembered, was that he used to say he was not a consultant but ‘a general specialist, with a leaning towards women’, and his definition of gynaecology was ‘anything either curable or lucrative’. But everyone said that he was a born healer and it did people good merely to see him, so that he was clearly one of the most notable members of our profession of the day. Now, who could we have chosen better than Baroness Warnock to deliver this year's Lloyd Roberts Lecture?

Educated at Lady Margaret Hall, subsequently Fellow and Tutor of Philosophy at St Hugh's College and then later Headmistress of Oxford High School for six years, she has chaired many special enquiries of particular interest to this profession, such as the Committee of Enquiry into Special Education. She served on the Advisory Committee on Animal Experiments as Chairman until recently and we know very well of her work in chairing the Committee of Enquiry into Human Fertilization and Embryology. She has also found the time to write widely on Existentialism, Imagination and Education, and other topics. Now, if there has been an occasion when simultaneously a husband and wife have been respectively Head of House, one in Oxford and the other in Cambridge, then as a very new boy at Oxford it is not something which I personally have been aware. Interest in education makes it particularly fitting that she should have chosen tonight, following upon the lecture given in this series some fifteen years ago by Lord James of Rusholme, to talk about ‘Another ten years in education’.

Pulmonary veno-occlusive disease after chemotherapy

A case of pulmonary veno-occlusive disease (PVOD) in a 41-year-old woman who had received chemotherapy (bleomycin, mitomycin-C, and cis-platinum) for metastatic cervical carcinoma is reported. Before her death, pulmonary hypertension and right ventricular heart failure had been attributed to lung toxicity induced by chemotherapy, but the postmortem findings were characteristic of PVOD. The authors support the view that PVOD is a syndrome, not a distinct entity, and present the case as a further example of the many situations in which PVOD can arise. Whether the lesions of the pulmonary veins developed as a result of the chemotherapy or whether the two conditions were associated by chance must remain, for now, a subject of speculation. Pathologists are urged to devote special attention to the examination of the pulmonary vessels in patients who have received chemotherapy.