Testing for t(3;8) in MYC/BCL6 re-arranged large B cell lymphoma identifies a high risk subgroup with inferior survival.

A reciprocal t(3;8) BCL6::MYC fusion is common in large B cell lymphoma (LBCL) with MYC and BCL6 disruption. These pseudo-double hit cases are not adverse, whereas t(3;8) negative MYC/BCL6 lymphoma has an inferior prognosis relative to other MYC-rearranged LBCL.

Systematic review and meta-analysis of female lifestyle factors and risk of recurrent pregnancy loss.

It is known that lifestyle factors affect sporadic miscarriage, but the extent of this on RPL (recurrent pregnancy loss) is less well known. A systematic review and meta-analysis was performed to assess the associations between lifestyle factors and RPL. Studies that analysed RPL in the context of BMI, smoking, alcohol and caffeine intake were included. The primary and secondary outcomes were odds of having RPL in the general population and odds of further miscarriage, respectively. Underweight and women with BMI > 25 are at higher odds of RPL in the general population (OR 1.2, 95% CI 1.12-1.28 and OR 1.21, 95% CI 1.06-1.38, respectively). In women with RPL, having BMI > 30 and BMI > 25 has increased odds of further miscarriages (OR 1.77, 95% CI 1.25-2.50 and OR 1.35, 95% CI 1.07-1.72, respectively). The quality of the evidence for our findings was low or very low. Being underweight and BMI > 25 contributes significantly to increased risk of RPL (general population). BMI > 25 or BMI > 30 increases the risk of further miscarriages (RPL population). Larger studies addressing the effects of alcohol, cigarette smoking and caffeine on the risk of RPL with optimisation of BMI in this cohort of women are now needed.

Coronary artery dimensions in normal Indians.

BACKGROUND: Diameter of coronary artery is an important predictor of outcome after percutaneous coronary interventions and coronary artery bypass graft surgery. There is very limited data available about coronary artery dimensions in an Indian population. AIMS: To study the normal dimensions of the coronary artery segments in Indians without coronary artery disease by using quantitative coronary angiography and also to compare the dimensions in Indians with Western. MATERIAL AND METHOD: 229 patients who have undergone coronary angiography with entirely normal coronary angiogram were included in our study. RESULTS: This study showed the diameter of vessels in males and females when taken together the left main was larger in size followed by proximal LAD, proximal RCA & proximal LCX respectively (4.08±0.44mm, 3.27±0.23mm, 3.20±0.37mm, 2.97±0.37mm).When the vessel diameter was indexed to body surface area there was no statistical difference between male and female (p value>0.05). The computed value of proximal coronary artery diameter unadjusted for individual body surface area, when compared to Caucasians showed that Caucasians have larger coronary artery dimensions than Indians. But when the proximal vessel diameter was indexed to body surface area there was no statistical significant difference between Indians and Caucasians (p value>0.05). CONCLUSIONS: We found that coronary artery size when indexed to body surface area is not statistically different in Indian males and females and compared to Caucasians. However with a smaller body habitus Indians have smaller coronary arteries.

Normalization of Testosterone Levels After Testosterone Replacement Therapy Is Not Associated With Reduced Myocardial Infarction in Smokers.

OBJECTIVE: To examine the effect of cigarette smoking (CS) status and total testosterone (TT) levels after testosterone replacement therapy (TRT) on all-cause mortality, myocardial infarction (MI), and stroke in male smokers and nonsmokers without history of MI and stroke. PARTICIPANTS AND METHODS: Data from 18,055 males with known CS status and low TT levels who received TRT at the Veterans Health Administration between December 1, 1999, and May 31, 2014, were grouped into (1) current smokers with normalized TT, (2) current smokers with nonnormalized TT, (3) nonsmokers with normalized TT, and (4) nonsmokers with nonnormalized TT. Combined effect of CS status and TT level normalization after TRT on all-cause mortality, MI, and stroke was compared using propensity score-weighted Cox proportional hazard models. RESULTS: Normalization of serum TT levels in nonsmokers was associated with a significant decrease in all-cause mortality (hazard ratio [HR]=0.526; 95% CI, 0.477-0.581; P<.001) and MI (HR=0.717; 95% CI, 0.522-0.986; P<.001). Among current smokers, normalization of serum TT levels was associated with a significant decrease in only all-cause mortality (HR=0.563; 95% CI, 0.488-0.649; P<.001) without benefit in MI (HR=1.096; 95% CI, 0.698-1.720; P=.69). Importantly, compared with nonsmokers with normalized TT, all-cause mortality (HR=1.242; 95% CI, 1.104-1.396; P<.001), MI (HR=1.706; 95% CI, 1.242-2.342; P=.001), and stroke (HR=1.590; 95% CI, 1.013-2.495; P=.04) were significantly higher in current smokers with normalized TT. CONCLUSION: We conclude that active CS may negate the protective effect of testosterone level normalization on all-cause mortality and MI after TRT.

Clinical & radiological evaluation of atherosclerotic changes in carotid & coronary arteries in asymptomatic & clinically symptomatic individuals as a tool for pre-symptomatic diagnosis of cardiovascular disease.

BACKGROUND & OBJECTIVES: An increase in prevalence of atherosclerosis has been noted worldwide with reports of higher incidence of atherosclerotic vascular changes in Asian Indians. There is a need to measure vascular atherosclerotic changes and provide objective parameter to predict cardiac and cerebrovascular adverse events. Atherosclerotic changes in carotids and coronaries are generally accepted as an association. We attempted in this study to relate intimal-luminal changes in carotid arteries to luminal changes in coronary arteries. Our study presents results of high resolution ultra sonographic (HRUS) evaluation of intimal-medial-thickness (IMT) in carotid with luminal changes in coronaries on multidetector-CT (MDCT) in clinically asymptomatic and symptomatic individuals. METHODS: In this prospective study, HRUS examination of the carotid bifurcation was performed in 151 individuals to measure IMT in asymptomatic and symptomatic groups. Assessments of coronary arteries of the same group of patients were evaluated by MDCT within a week interval. IMT changes were associated with age, sex, predisposing factors, calcium burden of coronaries and structural atherosclerotic changes in coronary arteries. RESULTS: A linear association of IMT was observed with increasing age. IMT of 0.5-0.69 mm was noted in 50 per cent of patients between 51-56 yr with higher number of symptomatic patients in this group. Linear increases in coronary vascular changes were noted with increasing IMT thickness. Changes were more prevalent in diabetic, hypertensive, treadmill test (TMT) positive and clinically symptomatic patients. INTERPRETATION & CONCLUSIONS: Age-related progression of atherosclerosis was evident in internal carotid arteries. Significant association was observed in the IMT thickness of right common carotid (RCC) and coronary disease in symptomatic group; whereas IMT of left common carotid and internal carotid arteries did not show any association. RCC IMT between 0.5-0.7mm showed maximal association with significant symptomatic narrowing of coronary arteries. Patients with IMT beyond 0.7mm had no association with symptoms.

Comparison of testicular dose delivered by intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT) in patients with prostate cancer.

A small decrease in testosterone level has been documented after prostate irradiation, possibly owing to the incidental dose to the testes. Testicular doses from prostate external beam radiation plans with either intensity-modulated radiation therapy (IMRT) or volumetric-modulated arc therapy (VMAT) were calculated to investigate any difference. Testicles were contoured for 16 patients being treated for localized prostate cancer. For each patient, 2 plans were created: 1 with IMRT and 1 with VMAT. No specific attempt was made to reduce testicular dose. Minimum, maximum, and mean doses to the testicles were recorded for each plan. Of the 16 patients, 4 received a total dose of 7800 cGy to the prostate alone, 7 received 8000 cGy to the prostate alone, and 5 received 8000 cGy to the prostate and pelvic lymph nodes. The mean (range) of testicular dose with an IMRT plan was 54.7 cGy (21.1 to 91.9) and 59.0 cGy (25.1 to 93.4) with a VMAT plan. In 12 cases, the mean VMAT dose was higher than the mean IMRT dose, with a mean difference of 4.3 cGy (p = 0.019). There was a small but statistically significant increase in mean testicular dose delivered by VMAT compared with IMRT. Despite this, it unlikely that there is a clinically meaningful difference in testicular doses from either modality.

A multispecialty consensus-based approach to carotid artery revascularization is feasible in routine clinical practice and results in excellent clinical outcomes.

BACKGROUND: Carotid artery stenting (CAS) and endarterectomy (CEA) are considered competing rather than complementary carotid artery revascularization (CAR) strategies. However, patient characteristics that increase procedural risk are quite different for CAS or CEA. We hypothesized that selecting a CAR strategy based on individual patient characteristics using a multispecialty consensus based (MSCB) approach will result in superior outcomes in the overall CAR group. We evaluated the feasibility of an MSCB approach to CAR in routine clinical practice. METHODS: We performed a retrospective review of patients undergoing CEA or CAS at the Kansas City Veterans hospital over a 2-year period. As routine clinical practice, each case was discussed in a weekly "vascular conference" by vascular surgery, radiology, and interventional cardiology physicians and a revascularization strategy was chosen. Thirty-day and 1-year incidences of stroke, transient ischemic attack, myocardial infarction, and death were recorded. RESULTS: Eighty CAR procedures were performed (45 CEAs and 35 CASs). The CAS group had an average of 1.9 surgical high-risk features, while the CEA group had 0.5 (P<.05). The CAS group had significantly more common carotid stenosis, stenoses considered too high or low for CEA, and more long internal carotid artery lesions. For the overall CAR group, 30-day incidence of stroke/transient ischemic attack, myocardial infarction, and death was 2.5% and 1-year incidence of stroke and death was 5%. CONCLUSION: An MSCB approach allows the choice of an optimal CAR strategy with excellent clinical outcomes. Reporting outcomes for the overall CAR may be a better way of assessing and comparing outcomes of CAR across healthcare systems rather than CEA or CAS outcomes separately.

Hepatopulmonary Syndrome, Severe Cyanosis and Marfanoid Habitus.

We report the case of a 17-year-old male with Marfanoid habitus who presented with deep cyanosis, haematemesis, dyspnoea and platypnoea. He had oesophageal varices, indicating portal hypertension, with mildly deranged liver function. His arterial blood gas (ABG) revealed hypoxia and orthodeoxia. Contrast-enhanced echocardiography with agitated saline and a 99m Technetium macro-aggregated albumin perfusion lung scan confirmed intrapulmonary shunting. Pulmonary angiogram showed multiple, small diffuse pulmonary arteriovenous fistulae scattered all over the lungs and predominantly in the bases of the lungs. Based on these results and the clinical background a diagnosis of hepatopulmonary syndrome with Marfanoid habitus was made. Patient was treated conservatively as he was not prepared for liver transplantation.

Small cell osteosarcoma of the mandible: Case report and review of its diagnostic aspects.

Small cell osteosarcoma, a rare histological subtype, has very infrequently been reported in the mandible. We present a case of a 28-year-old female who had classic signs, symptoms, and radiographic features of the lesion. The histology showed sheets of small round cells and osteoid. The absence of the latter would have made it difficult to distinguish from other small round cell tumors of bone, especially Ewing's sarcoma. We have reviewed the clinical and radiographic features, cytologic and histologic characteristics, as well as the immunohistochemistry and molecular genetics of small cell osteosarcoma.

Molecular basis of protective effect by crocetin on survival and liver tissue damage following hemorrhagic shock.

Hemorrhagic shock (HS) causes reduction of cellular energy stores, as measured by levels of ATP and ADP. Furthermore, energy depletion may cause mitochondrial damage, which in turn leads to cell death by apoptosis. The hypothesis of the present study is that by enhancing the recovery of cellular ATP and ADP and mitochondrial damage can be reduced, and the extent of apoptosis minimized. Crocetin, a carotenoid compound, appears to enhance the diffusion of oxygen in aqueous solution, and hence may improve energy stores both to the cell and within it. HS was produced in Sprague-Dawley rats by withdrawing blood from the carotid cannula until a mean arterial pressure of 35-40 mm Hg was reached, and then maintained by further withdrawals of blood for 30 and 60 min. Crocetin was administered 2-4 mg/kg in resuscitation fluid through venus cannula and the animals survived for 24-48 h after HS. Experiments designed to promote tissue reconstitution of ATP using crocetin indicate that these approaches are successful in increasing ATP post-hemorrhage and survival. Crocetin treatment also inhibited cellular damage as indicated by increase of Bcl-2 following decrease in cytosolic cytochrome c and caspase-3 after resuscitation. The prolonged energy deficit seen after hemorrhagic shock can produce late damage and rapid restoration of ATP levels to baseline can reduce apoptosis. In conclusions, crocetin can minimize the cellular damage as evidenced by apoptosis and increased the survival of rats.

Tuberculous pericardial effusion: features, tamponade, and computed tomography.

The clinical features with particular reference to tamponade and mediastinal adenopathy were studied in tuberculous pericardial effusion. Tamponade is a frequent complication and the recognition of tuberculous etiology can be difficult. Involvement of the pericardium is mostly from mediastinal lymph nodes that have not been studied. This was a prospective cohort study. All patients had large effusions, and underwent pericardiocentesis and chest computed tomography. Patients with tuberculosis had specific therapy. Others with viral/idiopathic effusion served as controls for the computed tomography studies. There were 26 patients with tuberculosis: 18 had tamponade on echocardiography. All had symptoms. Fever (n = 23) and dyspnea (n = 20) were the most frequent presenting symptoms. Pericardial rub was heard in 14, and 3 had enlarged cervical or axillary nodes. Pulmonary tuberculosis was present in 6. Tuberculin skin test measured 17 +/- 3.3 mm. The biopsy specimen showed a granuloma in 22 of 24. All 26 had mediastinal lymph nodes > 10 mm with a mean size of 19.5 +/- 8.6 mm that disappeared (81%) or regressed (19%) on treatment (p < 0.001). Aortopulmonary nodes were most frequently enlarged (65.4%) and hilar the least. Three required pericardiectomy. At follow-up all were doing well. None with viral/idiopathic effusion had lymph node enlargement. Fever, dyspnea, and tamponade were frequent with tuberculosis. The prognosis was good with specific therapy. Mediastinal nodes were enlarged in all and only with tuberculosis and not with viral/idiopathic effusion. Nodes disappeared or regressed with treatment. In the appropriate clinical context, mediastinal lymph node enlargement on chest computed tomography along with a strongly positive skin test results could help in the diagnosis of a tuberculous etiology of pericardial effusion.

The electrocardiogram in large pericardial effusion: the forgotten "P" wave and the influence of tamponade, size, etiology, and pericardial thickness on QRS voltage.

There are varying reports on the electrocardiogram in pericardial effusions. Some correlate low QRS voltage with tamponade and the size of the effusion while others do not. Low voltage also appears to vary with the etiology. There are no reports on the influence of pericardial thickness or changes in the P voltage. The authors studied 43 patients with large effusions of whom 26 had tuberculosis and the remaining had viral/idiopathic etiology. Pericardial thickness was measured at chest computed tomography. They found no correlation between the low QRS voltage and tamponade, size of the effusion, etiology, or pericardial thickness. Low voltage of the P wave and T-wave changes were more frequent than low QRS voltage.

Tuberculous pericardial effusion--mediastinal lymph glands: the cause and clue to the etiology.

BACKGROUND: Tuberculous pericardial effusion is most often due to the spread of tuberculosis from the mediastinal lymph glands; however, no attempt has yet been made to study these glands. We studied the mediastinal glands in proven tuberculous pericardial effusion patients and hypothesized that the findings may be of use in the etiological diagnosis of pericardial effusion. METHODS AND RESULTS: We studied 45 patients with large pericardial effusion or tamponade. All underwent chest computed tomographic studies that were reviewed by radiologists blinded to the diagnosis. Of these 45 patients, 27 had tuberculosis and 18 had viral or idiopathic effusion. Pericardial biopsy was done in 25/27 and tuberculin skin test in 22/27 patients with tuberculosis, and all received specific treatment. In patients with tuberculosis the skin test measured 17+/-3.3 mm. All 27 had mediastinal lymph glands > or = 10 mm in size. The mean size of the mediastinal glands was 19.5+/-8.6 mm and the mean number was 2.5+/-1.2. The aortopulmonary glands were the most frequently enlarged (63%), and hilar the least often (14.8%). The glands showed a hypodense center in 52% of the patients. On follow-up of 15.8+/-10.4 months, glands were not seen in 80.9%, and were smaller in size in 19%; none had a hypodense center. Marked lymphadenopathy was not seen in any patient with viral/idiopathic pericardial effusion. Two had glands < or = 5 mm in size. CONCLUSIONS: Only patients with tuberculosis had substantial mediastinal lymph gland enlargement and not those with viral or idiopathic pericardial effusion. Such glands disappeared or regressed on treatment. In the appropriate clinical context, marked nonhilar mediastinal lymphadenopathy on chest computed tomographic studies along with a strongly positive tuberculin skin test could be of value in the noninvasive diagnosis of pericardial effusion due to tuberculosis.

Disease of proximal part of vertebral artery in patients with coronary artery disease.

Recognition of coincidence of cerebral vascular disease is of importance in patients with coronary artery disease. One hundred and seventy-three patients who underwent coronary angiography were also studied by angiography of subclavian arteries and abdominal aorta. The majority of the patients (128/173; 74%) were men. Risk factors of hypertension, diabetes, and hypercholesterolemia were present in a high percentage of patients. Disease of the proximal part of the vertebral artery was seen in 41.6% (72/173). Presence of vertebral artery disease was significantly correlated with diabetes (p = 0.02), renal artery stenosis (p = 0.003), coronary artery disease (p = 0.05), and iliac artery disease (p = 0.05). The proximal part of the vertebral artery was found to be affected in a high percentage (41.6%) of patients undergoing coronary angiography.

Extent and severity of atherosclerotic vascular disease in patients undergoing coronary angiography--the Kuwait Vascular Study.

Only a few angiographic studies have correlated the presence and severity of coronary artery disease with atherosclerosis in other arteries. The presence of disease in more than 1 area clearly has important implications on management. One hundred and seventy eight patients had angiographic evaluation of their peripheral arteries and abdominal aorta after routine diagnostic coronary angiography. The extent and severity of vascular disease was correlated with those of coronary artery disease. Of the 178 patients, 73.6% were men (mean age +/- sd was 52.93 +/- 10.12 years). Hypercholesterolemia (59%), systemic hypertension (56.7%) and diabetes mellitus (50.6%) were the major risk factors. Triple-vessel coronary artery disease was present in 48.9%, and 13.5% had normal coronaries. A new atherosclerotic vascular disease score, which reflects the presence and severity of atherosclerotic vascular disease elsewhere, was seen to correlate significantly with the extent of coronary artery disease. Of particular interest was the involvement of the first part of the vertebral artery in 41.6% of patients. The combined involvement of the abdominal aorta, renal artery, and iliac artery segments (together referred to as the lower body segment) was seen almost exclusively in those with 2- or 3-vessel coronary artery disease. Also there was a direct correlation between the extent of coronary artery disease and the score in the lower body segment as opposed to the upper body segment (subclavian, vertebral, and internal mammary arteries). The presence of atherosclerotic vascular disease correlated with the severity of coronary artery disease, particularly in respect to disease in the lower body segment. Thus early detection of such disease in the iliac or femoral arteries has a potential for early diagnosis of significant coronary artery disease.

Angiographic comparison of coronary artery disease in Arab women with and without type II diabetes mellitus.

OBJECTIVE: To compare angiographic features in women with and without type II diabetes mellitus. SUBJECTS AND METHODS: One hundred and six consecutive women who underwent diagnostic coronary angiography in the Chest Diseases Hospital, Kuwait, were chosen for the study. Quantitative coronary angiography was performed and the angiographic features were assessed. RESULTS: Eighty-two patients had coronary artery disease. Of these, 59 (72%) had type II diabetes mellitus and 23 (28%) were non-diabetics. Segmental disease involving the mid and distal left anterior descending artery was more common in diabetics than non-diabetics. Diabetics had a greater number of long lesions and more distal coronary artery disease. However, the caliber and suitability of the distal vessels for grafting was similar. CONCLUSION: Angiographic severity of coronary artery disease in this selective group of mostly Arab women was more in those with type II diabetes mellitus than non-diabetics. However, the distal luminal diameter was similar in both groups.