Primary stroke prevention: a paradigm shift focusing on silent paroxysmal atrial fibrillation.

We review the prevalence, predictability, prognosis and preventability of atrial fibrillation and associated cardiogenic brain embolism, focusing on 'silent' sub-clinical atrial fibrillation (SCAF) which is very common in the elderly and associated with significantly increased risk of stroke and cardiovascular mortality. The current paradigm treats atrial fibrillation once discovered by its symptoms, complications (stroke) or by chance and screening recommendations are limited to opportunistic pulse palpation. We argue that the marked incidence of SCAF in patients over 65 justifies a much more active approach to identify patients at a particularly high-risk by routine evaluation of readily-available clinical, electrocardiographic, echocardiographic and laboratory markers. Elderly patients at high-risk need further monitoring by suitable devices (occasionally, long-term) and treatment with direct oral anti-coagulants once SCAF is revealed. This approach can already be adopted during clinical encounters at the general practitioner and consultant level, to decrease the substantial SCAF-associated morbidity and mortality.

Hypocalcaemia of malignancy.

BACKGROUND: Hypercalcaemia of malignancy is well recognised, but hypocalcaemia in cancer patients is not, although it is increasingly encountered. METHODS: Analysis of an exemplary case and a narrative review of the literature based on the search terms cancer and hypocalcaemia. RESULTS: Hypocalcaemia may affect as many as 10% of hospitalised cancer patients. We identified 12 different potential mechanisms of hypocalcaemia of malignancy. Identifying the pathogenesis is essential for the correct treatment and can usually be performed at the bedside, based on serum parathyroid hormone (PTH) levels, creatinine, phosphate, magnesium, creatine kinase, liver enzymes and 25(OH)D. Essentially, decreased or normal PTH hypocalcaemia is seen after removal or destruction of its source, hypomagnesaemia, or cinacalcet treatment. In all other cancer-associated hypocalcaemia, PTH is elevated, including significant renal impairment, critically ill patients, extensive cell destruction (rhabdomyolysis, tumour lysis, haemolysis), acute pancreatitis, adverse drug reactions, cancer or cancer treatment-related malabsorption syndromes, vitamin D deficiency, or osteoblastic metastases. Different mechanisms may often operate in tandem. Pathogenesis determines treatment and affects prognosis. However, hypocalcaemia of malignancy as such did not imply a worse prognosis, in contrast with hypercalcaemia. CONCLUSION: Hypocalcaemia in cancer patients is commonly encountered, particularly in hospitalised patients, may be mediated by diverse mechanisms and should be better recognised.

Primary effusion lymphoma in the absence of HIV infection--clinical presentation and management.

Primary Effusion Lymphoma (PEL) is a rare type of Non-Hodgkin's Lymphoma caused by human herpesvirus type 8, also termed Kaposi's sarcoma-associated herpesvirus. It usually occurs in human immunodeficiency virus (HIV)-infected patients. A subset of patients is not infected with HIV and their treatment remains poorly defined. To clarify treatment issues in HIV-negative PEL patients, we report on two such patients who represent two opposing ends in the spectrum of treatment and review the literature regarding treatment options and patient outcomes. Either repeated cycles of chemotherapy or, surprisingly, drainage of the malignant effusions alone, proved very effective in our patients. The literature reveals additional treatment options which may be effective including immunochemotherapy, stem cell transplantation, antiviral treatment and immunomodulatory and targeted biological therapy. However, no controlled trials were found due to the rarity of the condition. In the absence of controlled trials, treatment decisions in PEL not associated with HIV must remain individual and patient-tailored.

Unsuspected serious abdominal trauma after falls among community-dwelling older adults.

BACKGROUND: In elderly community-dwelling patients who experience ground-level falls, fractures or brain injury are the major concern. Serious abdominal injury is seldom contemplated. AIM: Identify all such patients presenting after a simple fall and admitted with serious blunt abdominal trauma to a single academic medical centre. DESIGN: Retrospective chart analysis. METHOD: All patients with both diagnoses aged 65 years or more admitted over 1 year to the department of medicine, geriatrics, surgery or urology were identified. RESULTS: Out of 546 patients screened, three cases of ground-level falls leading to splenic rupture, isolated gallbladder rupture with gallstone ileus and perinephric hematoma were found (0.55%) and are reported. CONCLUSIONS: Falls in elderly patients are exceedingly common mandating recognition of even rare complications. Physicians should be more aware of the possibility of occult and serious consequences of blunt abdominal trauma after falls among older adults, albeit rare.

Evaluating the impact of age and disease on survival of chronic lymphocytic leukaemia patients by a new method.

BACKGROUND: The impact of chronic lymphocytic leukaemia (CLL) on survival may be different in younger patients, but this remains controversial. OBJECTIVES: The aim of the study was to examine the effect of age on survival in CLL using an original method. METHODS: Clinical, laboratory and survival data of 87 CLL patients treated in our institute were analysed. The survival of patients in different age groups was determined and compared, as related to the expected survival of age- and gender-matched general population obtained from national statistical data. RESULTS: The mean age in the younger (< or = 65 years, n = 37) and older (> 65 years) age groups was 56 and 74 years (p < 0.001). The younger group had more unfavourable presentation, with advanced stage (Rai 2-4) in 46% vs. 16% (p = 0.002), and diffuse involvement of bone marrow in 60% vs. 18% (p = 0.03), compared with the older group, and were more likely to require treatment (p = 0.02). The Kaplan-Meyer curve showed a more favourable survival for the younger group. However, the loss of expected survival exposed a reversed pattern: while the older patients lost only 13%, the survival loss in the younger patients was 44% (p < 0.001). CONCLUSIONS: Chronic lymphocytic leukaemia had a more unfavourable presentation and a more severe clinical course in the younger patients. Our method of evaluating the negative impact of disease on expected survival reveals that their survival also is significantly more affected than that of older patients. We suggest calculating the loss of expected survival as a new criterion for assessing disease impact.

Adding fresh frozen plasma to rituximab for the treatment of patients with refractory advanced CLL.

BACKGROUND: Many patients with chronic lymphocytic leukaemia (CLL) develop progressive, treatment-resistant disease. Rituximab (RTX), a monoclonal antibody targeting CD20 on B lymphocytes and widely used in other indolent B cell neoplasms is less efficacious in CLL, possibly due to associated complement deficiencies. OBJECTIVE: To examine in open trial whether providing complement by concurrent administration of fresh frozen plasma (FFP) will enhance the effect of RTX in CLL. SETTING: Outpatient haematology clinics in Israel and Greece. PATIENTS: Five patients with severe treatment-resistant CLL. All had been previously treated with fludarabine and three also failed treatment with RTX. INTERVENTION: Two units of FFP followed with RTX 375 mg/m(2) as a single agent, repeated every 1-2 weeks, as needed. RESULTS: A rapid and dramatic clinical and laboratory response was achieved in all patients. Lymphocyte counts dropped markedly followed by shrinkage of lymph nodes and spleen and improvement of the anaemia and thrombocytopenia. This could be maintained over 8 months (median) with additional cycles if necessary. Treatment was well tolerated in all cases. CONCLUSION: Adding FFP to RTX may provide a useful therapeutic option in patients with advanced CLL resistant to treatment.

The unbearable lightness of diagnostic testing: time to contain inappropriate test ordering.

The numbers of tests, imaging and diagnostic procedures ordered by doctors in primary care and hospital settings alike are rising. According to established guidelines, many of these tests may be unnecessary. Various non-clinical factors often underlie test ordering, and multiple prevalent problems associated with tests and their interpretation are often under-appreciated. These include the significant potential for cascades of further testing and patient harm. Multifaceted strategies may improve test-ordering behaviour. Brief reconsideration of several points by the clinician before ordering the test is advisable.