Pneumocystis Jirovecii Pneumonia after Initiation of Tofacitinib Therapy in Rheumatoid Arthritis: Case-Based Review.

The use of biologic and targeted synthetic disease-modifying anti-rheumatic drugs (tsDMARDs) in rheumatic diseases is constantly increasing during the last decade. Tofacitinib is a new oral Janus Kinase (JAK) inhibitor, approved for rheumatoid arthritis (RA), psoriatic arthritis and ulcerative colitis. Safety data of tofacitinib derived from randomized controlled trials and long-term extension studies has demonstrated a moderate increase in the risk for common serious infections. We describe a case of Pneumocystis jirovecii pneumonia (PJP) in a woman on tofacitinib therapy for RA. Although tofacitinib use has been associated with the development of opportunistic infections, PJP has been rarely reported. PJP should be included in the differential diagnosis of patients with autoimmune disorders under newer oral JAK inhibitors therapy who present with fever, hypoxia and pulmonary infiltrates.

Primary choriocarcinoma of the renal pelvis presenting as intracerebral hemorrhage: a case report and review of the literature.

INTRODUCTION: A choriocarcinoma is a malignant neoplasm normally arising in the gestational trophoblast, gonads and, less frequently, the retroperitoneum, mediastinum and pineal gland. Primary choriocarcinomas of the renal pelvis are extremely rare. CASE PRESENTATION: We report a case of primary choriocarcinoma of the renal pelvis in a 38-year-old Greek woman of reproductive age, presenting with a sudden development of intracerebral hemorrhage due to metastatic lesions. The diagnosis was established with a renal biopsy, along with an elevated serum level of beta-human chorionic gonadotropin. An extensive diagnostic work up confirmed the origin of the choriocarcinoma to be the renal pelvis. CONCLUSION: Extragonadal choriocarcinomas are rare neoplasms that require extensive laboratory and imaging studies to exclude a gonadal origin. Moreover, this is the first case of severe intracerebral hemorrhage as the initial presentation of primary choriocarcinoma of the renal pelvis. Nonetheless, choriocarcinomas should be considered in the differential diagnosis of women of reproductive age.

Relationship between individual cardiovascular risk factors and localization of coronary atherosclerotic lesions.

OBJECTIVE: The localization of coronary atherosclerotic lesions in patients with coronary artery disease is important. We investigated the relationship between individual cardiovascular risk factors and lesion localization in the coronary arteries. METHODS: We studied 200 consecutive patients with suspected or known coronary artery disease who were referred for coronary angiography because of chest pain. We assessed the following cardiovascular risk factors: male gender, hypercholesterolemia, smoking, arterial hypertension, positive family history, and diabetes. We evaluated atherosclerotic lesions creating a stenosis ≥ 50% in the 3 coronary arteries and lesions creating a stenosis ≥ 30% in the left main stem. RESULTS: Of the 200 study patients, 155 (78%) showed at least 1 coronary artery lesion with a luminal stenosis ≥ 50%. With an increasing number of risk factors, there was a significant progressive increase of diseased arteries (P < .001). There was a differential association between individual risk factors and lesions in the 3 coronary arteries. Male gender, hypercholesterolemia, and diabetes were predictors of lesions in the left anterior descending artery (odds ratios 2.365, 2.510, and 1.998, respectively). Predictors of left circumflex artery lesions were male gender, smoking, and diabetes (odds ratios 2.581, 1.913, and 2.280, respectively), whereas the only independent predictor of right coronary artery lesions was male gender (odds ratio 2.995). Diabetes was also significantly associated with lesions in the diagonal branches of the left anterior descending artery and the marginal branches of the left circumflex artery. CONCLUSION: Individual cardiovascular risk factors are associated with the localization of atherosclerotic lesions in the coronary circulation.

Residents' resuscitation training and theoretical knowledge in a Greek General Hospital.

The objective of this paper was to assess the resuscitation training and knowledge status of medical and surgical residents (SRs). A questionnaire of 23 questions was answered by medical and SRs in an Athens General Hospital. The questionnaire was designed based on the 2005 resuscitation guidelines. The questionnaire was answered by 137 residents (53.3% medical and 46.7% surgical). With regard to the knowledge questions, the mean score, on a maximum scale of 10, was 5.39±1.93 for the medical residents and 5.27±2.33 for the SRs. Their resuscitation knowledge was positively influenced by their attendance of Basic Life Support (P=0.005) and Advanced Life Support/Advanced Cardiac Life Support courses (P=0.013). Residents in this tertiary general hospital in Athens had inadequate knowledge of resuscitation guidelines and the majority of them were not currently certified in any of these courses.

Somatic mutations of adenomatous polyposis coli gene and nuclear b-catenin accumulation have prognostic significance in invasive urothelial carcinomas: evidence for Wnt pathway implication.

Wnt pathway signaling is crucial in many cancers and data indicate crosstalk with other key cancer pathways, however in urothelial carcinogenesis it has not been extensively studied. We searched for mutations in adenomatous polyposis coli (APC), a key regulator of the pathway, and studied b-catenin expression and interactions with the expression of other markers of apoptosis, angiogenesis, and proliferation in patients with invasive urothelial cancer. The mutation cluster region of APC was directly sequenced in 70 patients with muscle invasive disease who were treated with surgery and adjuvant chemotherapy. COX-2, p53, Ki67, and b-catenin were studied immunohistochemically and micro vessel density was quantified by CD105 expression. Single somatic amino-acid substitutions (missense) were found in 9 (13%) and frameshift deletions in 2 (3%) tumors, all located in regions adjacent to b-catenin binding sites. Patients having either APC missense mutations or b-catenin nuclear accumulation had less frequent COX-2 overexpression (24% vs. 76%, p = 0.043) and more frequent lymph node involvement (75% vs. 38%, p = 0.023). Patients with either APC mutations or b-catenin accumulation had shorter disease-free interval (13.4 vs. 28 months, p = 0.07), whereas in multivariate analysis they had shorter disease-specific survival (60.5 vs. 20.6 months, p = 0.048). Somatic APC missense mutations are not rare in advanced urothelial neoplasms. Either APC mutations and/or aberrant expression of b-catenin are associated with worse outcome. Further study of the role of the Wnt pathway, potential crosstalk with other pathways and potential candidate therapeutic targets in urothelial cancer is needed.