Idelalisib and Rituximab in 17p Deletion-Positive Splenic Marginal Zone Lymphoma.

Splenic marginal zone lymphoma (SMZL) is a rare indolent B-cell malignancy involving the spleen and bone marrow. Various cytogenetic abnormalities with prognostic value have been identified in SMZL. Complexity of karyotype, 14q aberrations, and TP53 deletions have been found to be poor prognostic indicators. We report an unusual case of SMZL with a complex karyotype including 17p deletion, primarily refractory to 2 chemoimmunotherapy regimens, that responded well to treatment with phosphatidylinositol-3-kinase delta (PI3Kδ) inhibitors idelalisib and rituximab.

Association between Helicobacter pylori infection and pancreatic cancer. A cumulative meta-analysis.

CONTEXT: Infection with Helicobacter pylori (H. pylori) has been implicated in the etiopathogenesis of various malignant conditions. Notwithstanding, its etiological association with pancreatic cancer remains inconclusive. Studies focusing on the relationship between H. pylori infection and pancreatic cancer risk have yielded conflicting results. OBJECTIVE: The aim of this study was to obtain a reliable estimate of the risk of H. pylori infection in causing pancreatic cancer, by performing a meta-analysis of the existing observational studies evaluating the association. METHODS/STATISTICS: Observational studies comparing the prevalence of H. pylori infection in patients with pancreatic cancer and healthy controls, conducted in adult populations and published in all languages, were identified through systematic search in the MEDLINE and EMBASE up to April 2010. H. pylori infection was confirmed by serological testing using an antigen-specific enzyme-linked immunosorbent assay. Pooled adjusted odds ratios (AOR) and associated 95% confidence intervals (CI) were obtained by using a DerSimonian and Laird random-effects model. RESULTS: Six studies involving a total of 2,335 patients met our eligibility criteria. A significant association between H. pylori seropositivity and development of pancreatic cancer (AOR 1.38, 95% CI: 1.08-1.75; P=0.009) was seen. No significant association was seen on pooled analysis of the three studies assessing the relationship between cytotoxin-associated gene A (CagA) positivity and pancreatic cancer. A cumulative meta-analysis suggested a reducing, albeit statistically significant association as the evidence was accumulated. CONCLUSIONS: The pooled data suggests an association between infection with H. pylori and the development of pancreatic cancer. Further research is needed to confirm our findings.

Research into practice: 10 years of international public health partnership between the UK and Swaziland.

BACKGROUND: There is increasing interest in global health partnerships. However, evidence of benefit remains weak. We report on the impact of a 10-year public health partnership between the UK and Swaziland. Swaziland has the highest rates of TB and HIV in the world. Health services are being overwhelmed and patients suffer the cost and inconvenience of centralized services. Our international health partnership was set up to promote the translation of public health research into practice. METHODS: The partnership is based on six principles: sustainability; robust measurement; evidence-based practice; patient-centred improvement; systems approach and researchers as implementers. Based on rigorous health needs assessments and informed by international evidence, we have achieved a number of successful changes. RESULTS: The partnership has been successful in the development of a community TB service; a chronic disease programme for epilepsy; implementation of guidelines; implementation of ART programmes; nurse-led community ART clinics; innovations to improve follow-up and expert patients. CONCLUSION: Global inequalities are increasing rapidly and international partnership has an important role in tackling this threat. Partnerships should be based on sustainable, long-term links with a strong foundation of trust and mutual support. Effective leadership, good communication, clinical engagement and interagency collaboration are pre-requisites for the successful implementation of success.

Nurse led, primary care based antiretroviral treatment versus hospital care: a controlled prospective study in Swaziland.

BACKGROUND: Antiretroviral treatment services delivered in hospital settings in Africa increasingly lack capacity to meet demand and are difficult to access by patients. We evaluate the effectiveness of nurse led primary care based antiretroviral treatment by comparison with usual hospital care in a typical rural sub Saharan African setting. METHODS: We undertook a prospective, controlled evaluation of planned service change in Lubombo, Swaziland. Clinically stable adults with a CD4 count > 100 and on antiretroviral treatment for at least four weeks at the district hospital were assigned to either nurse led primary care based antiretroviral treatment care or usual hospital care. Assignment depended on the location of the nearest primary care clinic. The main outcome measures were clinic attendance and patient experience. RESULTS: Those receiving primary care based treatment were less likely to miss an appointment compared with those continuing to receive hospital care (RR 0.37, p < 0.0001). Average travel cost was half that of those receiving hospital care (p = 0.001). Those receiving primary care based, nurse led care were more likely to be satisfied in the ability of staff to manage their condition (RR 1.23, p = 0.003). There was no significant difference in loss to follow-up or other health related outcomes in modified intention to treat analysis. Multilevel, multivariable regression identified little inter-cluster variation. CONCLUSIONS: Clinic attendance and patient experience are better with nurse led primary care based antiretroviral treatment care than with hospital care; health related outcomes appear equally good. This evidence supports efforts of the WHO to scale-up universal access to antiretroviral treatment in sub Saharan Africa.

Intrathoracic lymphadenopathy: sarcoidosis or metastatic seminoma? The diagnostic dilemma revisited.

There exists a rare enigmatic relation between testicular germ cell tumors (particularly seminoma) and granulomatous inflammation of lymph nodes and organs akin to sarcoidosis. We report a young patient with stage I testicular seminoma followed by close surveillance after radical orchidectomy, who developed hilar and subcarinal lymphadenopathy more than two years after the original diagnosis. A mediastinal biopsy was consistent with noncaseating granuloma with no evidence of tumor. Our case highlights the importance of histologic confirmation of the etiology of lymphadenopathy in these cases. We reiterate that histological examination remains the cornerstone for establishing a definite and accurate diagnosis of testicular seminoma relapse.

Late recurrence of gastric cancer with isolated brain metastasis.

A 70-year-old woman presented to our clinic in 2007 after an evaluation for dysphagia revealed a poorly differentiated adenocarcinoma of the gastroesophogeal junction. Workup for metastatic disease was negative at presentation. She had a complete response to treatment, which was completed in November 2007. She continued to follow up regularly until 2011 when she presented again with neurologic symptoms and was found to have an isolated brain metastasis. She underwent resection of the lesion, and pathology was consistent with her originally diagnosed gastric cancer. The patient received adjuvant radiation therapy, however, unfortunately had rapid progression of disease 1 month later and was transitioned to hospice. Here, we report a rare case of late recurrence of gastric cancer with isolated brain metastasis with a review of literature.

Direct observation of treatment for tuberculosis: a randomized controlled trial of community health workers versus family members.

We implemented community-based direct observation of treatment, short course (DOTS), including a randomized controlled trial of direct observation either by community health workers (CHWs) or family members, under operational conditions in a region of Swaziland. There was a high death rate of 15%, due to the high HIV rates in the region. There was no significant difference in the cure and completion rate between direct observation of treatment by CHWs and family members [2% difference (95% CI -3% to 7%), exact P = 0.52]. A before-and-after comparison of outcomes demonstrated that the cure and treatment completion rate improved from a baseline of 27-67% following implementation of community-based DOTS. We conclude that community-based tuberculosis DOTS can improve successful outcomes of treatment. However, direct observation can be undertaken effectively using either daily family or CHW supervision. The choice of treatment supporter should be based on access, patient preference and availability of CHW resource.