Takotsubo cardiomyopathy presenting as postoperative atrial fibrillation.

Takotsubo cardiomyopathy (TC) is a condition which was first acknowledged in Japan and is characterized by a reversible systolic dysfunction of the apical or mid segments of the left ventricle. Typically affecting women in the post-menopausal population, it is triggered by intense emotional, physical or medical stress. Also known as apical ballooning syndrome or stress cardiomyopathy, TC derives its name from the left ventricular angiographic appearance of a 'Takotsubo', literally translated as an 'octopus fishing trap' in Japanese. Patients often describe chest pain, have ischemic electrocardiogram (ECG) changes and positive cardiac enzymes mimicking an acute coronary syndrome. Obstructive coronary artery disease is excluded with prompt cardiac catheterization. We present the case of a 78-year-old lady, post gynecological surgery, presenting with palpitations and ECG confirming fast atrial fibrillation. Despite spontaneous cardioversion, she went on to develop ECG changes and cardiac enzyme elevations suggestive of an acute myocardial infarction. Cardiac catheterization was performed and confirmed the diagnosis of TC. It highlights an atypical presentation of TC, which can present initially as an arrhythmia in the postoperative phase as a consequence of the supraphysiological effects of elevated circulating plasma catecholamines. It reiterates the importance of prompt diagnosis and treatment to prevent cardiac decompensation in a condition poorly understood.

Myasthenia gravis with thymoma is more common in the Maori and Pacific Island populations in New Zealand.

BACKGROUND: The association of myasthenia gravis (MG) with thymoma is well recognized. Our clinical impression has been that MG associated with thymoma may be more common in patients of Polynesian descent than in other races. AIM: To determine the influence of ethnicity on the association of MG with thymoma in our population. METHOD: Review of all cases of thymectomy performed at Greenlane Hospital in Auckland for the 20-year period from June 1978 to June 1998. RESULTS: There were 103 thymectomies performed in the study period. Fifty-five thymomas were identified, 15 in subjects of Maori or Pacific Island ethnicity and 40 in subjects of other races, predominantly Caucasian. Ten of 15 Maori or Pacific Island subjects with thymoma had MG (67%), compared with 15 of 40 subjects of other races (37.5%, P = 0.05). The mean age of Maori or Pacific Island subjects with thymoma and MG was 42.5 years, compared with 56.3 years in subjects from other races (P = 0.06). All five Maori and Pacific Island subjects with invasive thymoma had MG, whereas only four of 15 subjects (27%) from other races with invasive tumours had MG (P < 0.01). The overall incidence of thymoma and the proportion of thymomas that were invasive did not differ between the ethnic groups. CONCLUSIONS: Myasthenia gravis with thymoma occurs more frequently among Maori or Pacific Island people than in other racial groups in our population. This is due to an increase in the proportion of cases with thymoma who have MG in this group, while the overall frequency of cases of thymoma is similar between groups. MG with thymoma in the Maori or Pacific Island populations also presents at a younger age and is more often associated with tumour invasion.

Biologic agents and immunotherapy in rheumatoid arthritis. Progress and perspective.

Advances in our understanding of rheumatoid synovitis have been coupled with increasingly refined methods from biotechnology to produce promising therapeutic agents. Monoclonal antibodies (MoAbs), recombinant cytokines, cytokine receptor fusion proteins and other biologics have been elevated from the status of novel reagents applied in phase I toxicity trials to, in some cases, substantially evaluated and validated tools awaiting federal regulatory approval. Biologic agents will soon be released for the treatment of patients with RA. We review some of the most promising preclinical work that supports a position of optimism regarding the future of RA. We also speculate on the potential role for biologics in future management of patients with RA.

The relationship of oral contraceptive use to rheumatoid arthritis.

Current use of oral contraceptives among 71 women aged 17 to 45 diagnosed for the first time as having definite or probable rheumatoid arthritis at Group Health Cooperative of Puget Sound was compared with oral contraceptive use among matched controls. Twenty-three percent of cases and 13% of controls were current users of oral contraceptives at the index date (relative risk estimate = 2.0, 95% CI = 0.97-4.21). We conclude that current oral contraceptive use was not protective against the development of rheumatoid arthritis in this population.

PIP: A possible association between oral contraceptive (OC) use and rheumatoid arthritis was investigated in the 71 women aged 17-45 years of age enrolled at Washington's Group Health Cooperative who were newly diagnosed with this condition in the period 1977-86. 280 matched controls were randomly selected for the Cooperative's file of pharmacy users. Among women with rheumatoid arthritis, 16 (23%) were current OC users, 10 (14%) were past users, and 45 (63%) were never-users. Among controls, 37 (13%) were current users, 44 (16%) were past users, and 203 (71%) were never-users. The relative risk of rheumatoid arthritis was 2.0 (95% confidence interval, 0.97-4.2) in current OC users compared with never-users. The relative risk for past use compared with never-use was 1.0 (0.4-2.2). The duration of OC use or the OC's estrogen content did not have a significant impact on the risk of rheumatoid arthritis. These findings suggest that there is no association between OC use and rheumatoid arthritis and contradict earlier studies that found OC use to exert a protective effect on the development of rheumatoid arthritis. The only factor identified as predictive of a new diagnosis of rheumatoid arthritis was pregnancy completion within the past 24 months (relative risk, 4.1; 95% confidence interval, 1.5-11.2).

Head injury unmasking other brain diseases.

Sixteen patients previously free of neurological complaints sustained minor head injuries and subsequently presented acutely with a wide range of unexpected, serious brain diseases. These included brain tumours, berry aneurysms, arteriovenous malformations and brain abscess. The possible, responsible mechanisms include direct mechanical trauma to the asymptomatic brain lesion, hydrocephalus and brain oedema. This unusual complication of head injury should be suspected when a florid neurological syndrome follows a minor head injury. CAT scanning usually identifies the responsible disease. Because of its therapeutic implications, this complication deserves recognition in the differential diagnosis and management of head injuries.