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BACKGROUND: Percutaneous coronary intervention (PCI) is increasingly used in revascularisation of patients with left main coronary artery disease in place of the standard treatment, coronary artery bypass grafting (CABG). The NOBLE trial aimed to evaluate whether PCI was non-inferior to CABG in the treatment of left main coronary artery disease and reported outcomes after a median follow-up of 3·1 years. We now report updated 5-year outcomes of the trial.METHODS: The prospective, randomised, open-label, non-inferiority NOBLE trial was done at 36 hospitals in nine northern European countries. Patients with left main coronary artery disease requiring revascularisation were enrolled and randomly assigned (1:1) to receive PCI or CABG. The primary endpoint was major adverse cardiac or cerebrovascular events (MACCE), a composite of all-cause mortality, non-procedural myocardial infarction, repeat revascularisation, and stroke. Non-inferiority of PCI to CABG was defined as the upper limit of the 95% CI of the hazard ratio (HR) not exceeding 1·35 after 275 MACCE had occurred. Secondary endpoints included all-cause mortality, non-procedural myocardial infarction, and repeat revascularisation. Outcomes were analysed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT01496651.FINDINGS: Between Dec 9, 2008, and Jan 21, 2015, 1201 patients were enrolled and allocated to PCI (n=598) or CABG (n=603), with 17 subsequently lost to early follow-up. 592 patients in each group were included in this analysis. At a median of 4·9 years of follow-up, the predefined number of events was reached for adequate power to assess the primary endpoint. Kaplan-Meier 5-year estimates of MACCE were 28% (165 events) for PCI and 19% (110 events) for CABG (HR 1·58 [95% CI 1·24-2·01]); the HR exceeded the limit for non-inferiority of PCI compared to CABG. CABG was found to be superior to PCI for the primary composite endpoint (p=0·0002). All-cause mortality was estimated in 9% after PCI versus 9% after CABG (HR 1·08 [95% CI 0·74-1·59]; p=0·68); non-procedural myocardial infarction was estimated in 8% after PCI versus 3% after CABG (HR 2·99 [95% CI 1·66-5·39]; p=0·0002); and repeat revascularisation was estimated in 17% after PCI versus 10% after CABG (HR 1·73 [95% CI 1·25-2·40]; p=0·0009).INTERPRETATION: In revascularisation of left main coronary artery disease, PCI was associated with an inferior clinical outcome at 5 years compared with CABG. Mortality was similar after the two procedures but patients treated with PCI had higher rates of non-procedural myocardial infarction and repeat revascularisation.FUNDING: Biosensors.

We have entered an era of renewed interest in novel approaches to surgical intervention and minimally invasive and transcatheter technique. With an aging population, isolated tricuspid valve regurgitation incidence is rising; however, referral for surgical intervention remains low. We undertook this retrospective review to assess outcomes and challenges associated with tricuspid valve intervention. A comprehensive retrospective review of all patients undergoing tricuspid valve intervention in our institution between 2004 and 2018 was carried out. A total of 259 patients who underwent a tricuspid intervention between 2004 and 2018 were identified. Of those, 229 underwent a repair and 30 underwent a replacement. Median survival for repair was 3124 days, and replacement was 2294 days. In-patient mortality was 12% for those undergoing repair and 7% for the replacement patients. Of those undergoing redo tricuspid valve intervention, eight patients (61.5%) were alive at most recent follow-up. Eight patients required intraoperative pacemakers, 2 required postoperative pacemakers. Of those who had intraoperative epicardial pacing systems placed, 5 of the 8 remained pacing dependent on most recent follow up. Beyond technical challenges, decision making regarding pacemaker requirement requires further exploration. Redo tricuspid valve surgery carries a significant mortality risk and consideration should be given to earlier intervention in this context.

Background: In the treatment of left main coronary artery (LMCA) disease, patients’ age may affect the clinical outcome after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). This study stratified the clinical outcome according to the age of patients treated for LMCA stenosis with PCI or CABG in the Nordic-Baltic-British Left Main Revascularization (NOBLE) study. Methods: Patients with LMCA disease were enrolled in 36 centers in northern Europe and randomized 1:1 to treatment by PCI or CABG. Eligible patients had stable angina pectoris, unstable angina pectoris, or non-ST elevation myocardial infarction. The primary endpoint was major adverse cardiac or cerebrovascular events (MACCEs), a composite of all-cause mortality, nonprocedural myocardial infarction, any repeat coronary revascularization, and stroke. Age-stratified analysis was performed for the groups younger and older than 67 years and for patients older than 80 years. Results: For patients ≥67 years, the 5-year MACCEs were 35.7 versus 22.3% (hazard ratio [HR] 1.72 [95% confidence interval [CI] 1.27–2.33], p = 0.0004) for PCI versus CABG. The difference in MACCEs was driven by more myocardial infarctions (10.8 vs. 3.8% HR 3.01 [95% CI 1.52–5.96], p = 0.0009) and more repeat revascularizations (19.5 vs. 10.0% HR 2.01 [95% CI 1.29–3.12], p = 0.002). In patients younger than 67 years, MACCE was 20.5 versus 15.3% (HR 1.38 [95% CI 0.93–2.06], p = 0.11 for PCI versus CABG. All-cause mortality was similar after PCI and CABG in both age-groups. On multivariate analysis, age was a predictor of MACCE, along with PCI, diabetes, and SYNTAX score. Conclusions: As the overall NOBLE results show revascularization of LMCA disease, age of 67 years or older was associated with lower 5-year MACCE after CABG compared to PCI. Clinical outcomes were not significantly different in the subgroup younger than 67 years, although no significant interaction was present between age and treatment. Mortality was similar for all subgroups (ClinicalTrials.gov identifier: NCT01496651).

BACKGROUND: Coronary artery bypass grafting (CABG) is the standard treatment for revascularisation in patients with left main coronary artery disease, but use of percutaneous coronary intervention (PCI) for this indication is increasing. We aimed to compare PCI and CABG for treatment of left main coronary artery disease.METHODS: In this prospective, randomised, open-label, non-inferiority trial, patients with left main coronary artery disease were enrolled in 36 centres in northern Europe and randomised 1:1 to treatment with PCI or CABG. Eligible patients had stable angina pectoris, unstable angina pectoris, or non-ST-elevation myocardial infarction. Exclusion criteria were ST-elevation myocardial infarction within 24 h, being considered too high risk for CABG or PCI, or expected survival of less than 1 year. The primary endpoint was major adverse cardiac or cerebrovascular events (MACCE), a composite of all-cause mortality, non-procedural myocardial infarction, any repeat coronary revascularisation, and stroke. Non-inferiority of PCI to CABG required the lower end of the 95% CI not to exceed a hazard ratio (HR) of 1·35 after up to 5 years of follow-up. The intention-to-treat principle was used in the analysis if not specified otherwise. This trial is registered with ClinicalTrials.gov identifier, number NCT01496651.FINDINGS: Between Dec 9, 2008, and Jan 21, 2015, 1201 patients were randomly assigned, 598 to PCI and 603 to CABG, and 592 in each group entered analysis by intention to treat. Kaplan-Meier 5 year estimates of MACCE were 29% for PCI (121 events) and 19% for CABG (81 events), HR 1·48 (95% CI 1·11-1·96), exceeding the limit for non-inferiority, and CABG was significantly better than PCI (p=0·0066). As-treated estimates were 28% versus 19% (1·55, 1·18-2·04, p=0·0015). Comparing PCI with CABG, 5 year estimates were 12% versus 9% (1·07, 0·67-1·72, p=0·77) for all-cause mortality, 7% versus 2% (2·88, 1·40-5·90, p=0·0040) for non-procedural myocardial infarction, 16% versus 10% (1·50, 1·04-2·17, p=0·032) for any revascularisation, and 5% versus 2% (2·25, 0·93-5·48, p=0·073) for stroke.INTERPRETATION: The findings of this study suggest that CABG might be better than PCI for treatment of left main stem coronary artery disease.FUNDING: Biosensors, Aarhus University Hospital, and participating sites.

Immunohistochemical studies using epithelial markers have recently been published which identified micrometastases in lymph nodes that had not been found on routine pathological assessment, therefore increasing the accuracy of staging of non-small cell lung cancers. The presence of these micrometastases was associated with reduced survival. We have therefore performed a retrospective immunohistochemical study on all the lymphoid tissue from five lymph node stations (2 hilar, 3 mediastinal) from 49 patients with T1–2, N0 disease. Before immunohistochemistry was undertaken, all slides were reviewed, with the lymph nodes confirmed as negative. In total, 1447 lymph node slices (average 30 per case, 5.9 per lymph node station) were examined, these figures reflecting sectioning of lymph nodes at approximately 3 mm intervals before processing. MNF116, a broad spectrum anti-keratin antibody was then used to look for occult metastases, with adjacent serial sections being examined to ensure that any positively staining cells were detected solely by immunohistochemistry and not through deeper sectioning. In five cases, lymph nodes contained positively staining cells. Two cases proved to be false positives, further immunohistochemistry identifying the cells as benign mesothelial inclusions. In the remaining three cases, positive staining correlated with tumour cells in the adjacent serial sections. Follow-up on 46 of 49 patients revealed recurrence in 27% (actual survival 68%); however all three cases containing tumour cells on immunohistochemistry were free from recurrence. These results suggest that the use of immunohistochemistry adds little useful information above that of thorough routine examination of lymph nodes. They also document that benign mesothelial inclusions within lymph nodes are more frequent than previously reported.

Amyloidosis is a rare systemic disease that is notoriously difficult to diagnose early. Cardiac involvement is associated with a poor prognosis. We present the case of a 72-year-old gentleman who underwent elective coronary artery bypass grafting and mitral valve repair. While initially making a good post-operative recovery, a sudden deterioration on post-operative day 3 led to an unexpected mortality. Post-mortem examination demonstrated previously undiagnosed severe systemic amyloidosis, which particularly affected his heart, due to underlying multiple myeloma. It is important to emphasise that due to the absence of the typical findings on routine pre-operative investigations suggestive of cardiac amyloidosis in this patient, cardiac surgeons should be aware that symptoms inconsistent with angiography findings should prompt consideration of amyloidosis. Diagnostic tools including cardiac MRI and ultimately endomyocardial biopsy could then facilitate earlier recognition of this enigmatic disease process.

A 50 year old man presented with sudden abdominal pain, abdominal distension and shock. At emergency laparotomy a large amount of blood was found in the peritoneal cavity. There was micronodular cirrhosis of the liver and the spleen was enlarged. The bleeding was traced to distended veins in the right paracolic gutter which were oversewn and the abdomen closed. A coagulopathy was diagnosed and treatment including high dose aprotinin commenced. However, he continued to bleed and at a second laparotomy the area of previous haemorrhage was packed. Further deterioration continued until death 12 hours later. Intraperitoneal haemorrhage from ectopic varices is a rare occurrence. There is a high mortality rate usually due to an advanced coagulopathy. This is the first report of aprotinin being used in an attempt to treat this. On the basis of this report aprotinin would not seem to be of benefit for this condition.

The surgical management of 50 false aneurysms caused by transfemoral arterial catheterization was reviewed to document the incidence and effects of rupture before repair. Twelve false aneurysms ruptured, leading to shock in six patients, distal ischaemia in three and stroke in one. The mean(s.d.) time, from catheterization to rupture was 2.8(1.7) (range 1-6) days. Postoperative complications occurred in seven patients with ruptured and eight with non-ruptured aneurysms (P < 0.04). The mean(s.d.) age of patients with ruptured aneurysms was 67.2(6.3) (95 per cent confidence interval 63.5–70.8) years and those without 58.5(9.1) (95 per cent confidence interval 55.3–61.7) years (P < 0.008). On multiple regression analysis, age, peripheral vascular disease and raised plasma liver enzyme levels on admission were found to be significant independent predictive variables for rupture (all P < 0.05). It is recommended that patients with these risk factors undergo urgent operative correction of femoral false aneurysm.

It would be of benefit to the dairy industry to have sires evaluated for the net economic value of their genetic potential for milk-production traits. Economic weights and selection indexes were derived for a variety of production circumstances, taking into account all returns and costs of dairy production and allowing for the existence of quotas. A single index designed for the average farmer in Ontario under a multiple-component pricing system was highly efficient (>98% of maximum gains) for most situations. Changes in pricing of milk caused the largest changes in the index. An index based on the current volume payment with fat correction would cause a 24% loss in efficiency of selection if protein eventually becomes twice the price of fat. A single index was proposed as highly efficient for farmers across Canada irrespective of their production circumstances, provided payment for milk is based on a multiple-component pricing system giving roughly equal value to fat and protein and low value to milk volume. Key words: Selection indexes, economics, milk production, sire selection

The authors retrospectively reviewed computed tomographic (CT) scans of 18 patients who developed 21 episodes of intrathoracic complications after allogeneic bone marrow transplantation (BMT). Pathologic and/or microbiologic diagnoses were available for all patients. All patients were immunocompromised due to either graft-versus-host disease (GVHD), neutropenia, or recurrent malignancy after BMT. CT demonstrated diagnostically relevant findings that were not apparent at radiography in 12 of the 21 cases (57%). These included a ground-glass pattern in early pneumonia (n = 5); a peripheral distribution in GVHD, bronchiolitis obliterans organizing pneumonia, and eosinophilic drug reaction (n = 4); cavitating lesions in Pneumocystis carinii pneumonia (n = 1); hemorrhagic infarcts in aspergillosis (n = 1); and mediastinal adenopathy in recurrent Hodgkin disease (n = 1). The authors conclude that chest CT is superior to radiography in demonstrating the presence, distribution, and extent of intrathoracic complications developing in patients after allogeneic BMT. CT is useful in guiding procedures for tissue diagnosis.

Sixty-five first lactation Holstein heifers, 31 sired by one of 19 top Canadian AI proven sires and 34 sired by one of 19 top New Zealand AI proven sires were compared for production, feed intake, energetic efficiency, body weight and condition. Heifers were fed free choice a high-, medium- and low-energy complete feed for the first 140 d, 141–240 d and 241–305 d of lactation, respectively. The Canadian-sired heifers averaged 6097 ± 177 kg, 231 ± 6 kg, 226 ± 6 kg and 310 ± 9 kg of milk, fat protein, and lactose while the New Zealand sired heifers produced 5469 ± 169 kg, 226 ± 6 kg, 189 ± 6 kg and 273 ± 9 kg. Net energy consumption and gross energy production of the Canadian-sired heifers was 7783 Mcal and 4515 Mcal, and for New Zealand-sired heifers was 7310 Mcal and 4248 Mcal, resulting in feed efficiencies of 0.59 ± 0.01 and 0.58 ± 0.01 for Canadian- and New Zealand-sired heifers. Feed efficiencies, body weight gain and change in body condition score from week 2 of lactation to the end of lactation did not differ significantly between the Canadian- and New Zealand-sired heifers. Canadian-sired heifers had a lower body condition score (P

The difficulties in detecting vascular injuries associated with penetrating limb trauma are greater than generally appreciated, and any delay in diagnosis will compromise management and potentially may lead to amputation. Established lessons regarding the mode of presentation and early management of these injuries have to be relearned and are illustrated by three recent case reports of clinically unrecognized lower limb vascular injuries later discovered to be arteriovenous fistulas and false aneurysms. The diagnosis of these lesions may depend on the identification of subtle clinical signs followed by early preoperative angiography, the potential value of which is entirely dependent on the surgeon's acumen and level of awareness.

Milk production data collected from 1980 to 1986 for Holsteins in Canada were examined for evidence of preferential treatment of cows. Herds were split by milk-recording organization and within organization into Embryo Transfer herds, Bulldam herds, and other herds. Cows were classified as registered or grade within herds. Within-herd coefficients of variation were calculated for all herd-years and were generally higher for Bulldam herds. Cow estimated transmitting abilities (ETA) for milk yield were regressed on dam ETA and sire ETA to compare the regression coefficients with the theoretical regression coefficients and to examine the residuals. Residual variances increased with predicted ETA in all the sets of other herds and in ET herds located in Ontario. There was little evidence of effects due to preferential treatment. Frequency distributions of deviations from herd-year-season mean were calculated separately for grade and purebred cattle within lactation number and herd type. All distributions except for grades in Bulldam herds were significantly lepto-kurtotic (P

Right atrial myxoma arising from the Eustachian valve is rare, with only two reported cases; moreover, any association with colonic polyps is uncommon, with only one such case documented. A case is described of a 68-year-old male who presented with chronic anemia; an initial investigation revealed colonic polyps, but anemia persisted after polypectomy. Further investigation revealed a right atrial myxoma arising from the Eustachian valve and prolapsing into the right ventricle through the tricuspid valve. After successful removal of the lesion, hematological indices returned to normal. In cases of persisting anemia, other rare causes such as atrial myxoma should be sought.

Aims: In vitro transfection experiments show that the nm23 gene suppresses metastasis, although the evidence from clinical studies is contradictory. The purpose of this study was to investigate whether nm23 selectively influences systemic, pleural, and lymphatic metastasis in non-small cell lung cancer (NSCLC). Methods: Forty two patients undergoing resection of NSCLC and lymph node sampling were enrolled prospectively. In each case, a bone marrow aspirate, pleural lavage, and lymph nodes were assessed using immunohistochemistry for epithelial antigens and morphology. The intensity of nm23-H1 immunoreactivity of the primary tumour was compared with the internal control of normal bronchial epithelium in 32 cases where available. The microvessel count (MVC) of each tumour was determined using immunohistochemistry for the endothelial cell marker CD34. Results: Tumour cell dissemination was detected in the bone marrow in 18 patients, in the pleura in seven, and in the lymph nodes in 21. Increased immunoreactivity for nm23 was found in the primary tumour in six patients, with none having tumour cells in the bone marrow, compared with 12 of 26 patients who showed nm23 immunoreactivity equal to or less than the control (Fisher's exact test: p = 0.043). This effect was confirmed to be independent of the MVC on multivariate analysis. There was no significant difference in the incidence of pleural or lymphatic tumour cell dissemination between the two groups. Conclusions: nm23 appears to be a suppresser of systemic, but not lymphatic, metastasis in primary NSCLC.

This is the second in a series of short reviews of internet-based radiological educational resources, and will focus on neuroradiology. Most of the sites cater for medical students and trainee or non-specialist radiologists, but may also be of interest to specialists, especially for use in teaching. Hyperlinks are available in the electronic version of this article and were all active at the time of going to press (August 2005). If your computer has high-level internet security settings or does not accept cookies, you may not be able to access all of the sites listed; this may be the case on some hospital-based systems. All websites should be fully accessible from other computers with less stringent security settings, e.g. a PC at home.

A wealth of cardiothoracic websites exist on the internet. What follows is a list of the higher quality resources currently available which should save you time searching them out for yourself. Many of the sites listed cater for undergraduates and trainee or non-specialist radiologists, nevertheless these may also be of interest to specialists in thoracic radiology, particularly for use in teaching. Hyperlinks are available in the electronic version of this article and were all active at the time of going to press (April 2005).

Osteosarcoma develops only rarely in patients under 6 years of age. The authors describe a 19-month-old girl who presented with proximal humeral metaphyseal osteosarcoma. To the authors' knowledge, this report represents the youngest patient with this bone lesion.

A 48-year old Caucasian woman presented with chest pain on exertion and was diagnosed with an anomalous origin of dominant right coronary artery, it then ran a short intramural course in the wall of the aorta. Right coronary artery (RCA) was reimplanted on cardiac bypass at normal exit point on the aortic root. The heart was adequately protected with antegrade cold blood cardioplegia via the aortic root and regular direct cardioplegia via the coronary ostia. The patient could not come off cardiopulmonary bypass after surgery and required right ventricular assist device support to be weaned from cardiopulmonary bypass. The patient ultimately recovered well and her right heart function is normalising. We believe that antegrade cardioplegia via the aortic root caused increased pressure in the aorta and squashed RCA in the wall of the aorta causing failure of myocardial protection and stunning of the right ventricle. This could be prevented with alternative myocardial protection strategies like direct cardioplegia via the coronary ostium.

Based on three haematological indices, this model can predict operability with an accuracy of 82%. Neoadjuvant chemotherapy could be considered for those predicted to be inoperable. This model may aid the clinician in the selection of patients for curative surgery.

TPS327 Background: This phase I study evaluates the tolerability of clofarabine with liposomal daunorubicin in patients with refractory or relapsed AML. The UK front line study (AML17) is currently investigating clofarabine and daunorubicin for a high- risk subgroup of AML patients >16 yrs old. Patients

Intrinsic disorders of the diaphragm are uncommon. However, the diaphragm is a useful radiographic landmark for detecting adjacent pulmonary, pleural and abdominal abnormalities, which may lead to the elevation of one or both hemidiaphragms or to focal irregularities in the diaphragmatic contour. In this review the authors summarize the most common diaphragmatic abnormalities and suggest the optimal approach for each to allow a specific diagnosis.

Cardioembolic stroke is an important cause of stroke in young people. Cardioembolism classically causes infarcts in multiple vascular territories. In the case described here a young woman developed cardioembolic stroke secondary to atrial myxoma. The presentation was atypical in that the woman had no systemic manifestations of her myxoma.

OncoVEXGM-CSF is a second generation oncolytic HSV expressing GM-CSF. Deletion of ICP34.5 provides tumour selectivity, a modification extensively studied elsewhere. Compared to previous oncolytic HSV, oncolytic potency is increased using a clinical virus strain with greater lytic capabilities than previous laboratory strains, and by expressing US11 as an IE rather than an L gene. Immune stimulation is improved by deleting ICP47, which blocks antigen presentation, and expression of GM-CSF. Following intra-tumoral injection, OncoVEXGM-CSF is, therefore, intended to stimulate a GM-CSF-enhanced immune response to tumour antigens released by oncolysis. This aims to treat metastatic disease and reduce tumor recurrence.

Kushner and Thomasma have assembled a distinguished group of contributors who are almost all practising clinicians with an interest in medical ethics. The book is well laid out and is divided into two main parts: part one “On caring for patients” and part two “On becoming a `team player’: searching for esprit de corps and conflicts of socialization”. This is a convenient way to think about medical ethics. Part one covers the ethical dilemmas of doctors caring for patients and the many practical problems that arise; this area of medical ethics is what most doctors would consider to be “true” medical ethics. Many doctors would not consider part two to be medical ethics at …

EDITOR—Partridge provides no evidence to support his claims that cardiothoracic surgeons are less likely than thoracic surgeons to stage the extent of lung cancer objectively and assess the patients' fitness; he points out that they have “competing demands from a waiting list for coronary artery surgery.”1 He also says that relying on cardiothoracic surgeons to do lung resections may mean that some do too few to maintain competence. …

BACKGROUND: Problems in the management of thoracic trauma have stimulated the search for an alternative to underwater seals for drainage of the pleural cavity. A chest drainage bag incorporating a one way flutter valve has been compared with underwater seal drains in a randomised clinical trial. METHODS: During June-December 1989 119 patients undergoing elective thoracotomy were randomised to receive postoperative chest drainage by drainage bags (56 patients, 87 drains) or by underwater seal drains (63 patients, 98 drains). Daily drainage volumes, the requirement for pleural suction, mobility, and complications were recorded prospectively. RESULTS: There was no significant difference between the two groups in the mean volume drained, the requirements for pleural suction, or the occurrence of complications. Patients with drainage bags were fully mobile 23 hours (95% confidence interval 0-47 hours) earlier than the others. CONCLUSIONS: When used after elective thoracotomy drainage bags are safe and effective and permit earlier mobility than underwater seal drains.

We present the case of 56-year-old woman who required complex coronary artery bypass grafting for high-risk anomalous left main coronary artery (LMCA) originating from right coronary cusp including conventional reimplantation of the LMCA plus left internal mammary artery (LIMA) graft to the left anterior descending (LAD) and saphenous vein graft (SVG) to the left circumflex (LCx). On subsequent cardiac computed tomography screening and cardiac catheterization, the LIMA graft was occluded after just a few centimeters, but the SVG graft was patent with good run-off into the native LCx and also filled the LAD retrogradely. The reimplanted left main stem demonstrated at least moderate ostial stenosis although pressure wire assessment of this was not significant (fractional flow reserve 0.89), probably due to good retrograde filling of the LAD from the SVG to LCx, therefore, we did not proceed with ostial LMCA stenting. She remains on yearly review with a low threshold for further revascularization should the SVG to LCx develop progressive stenosis. This case illustrates how patients with anomalous LMCA may sometimes benefit from grafting in addition to conventional reimplantation. Electronic supplementary material The online version of this article (doi:10.1007/s40119-015-0039-x) contains supplementary material, which is available to authorized users.

proliferative and cytotoxic capacity in vitro against cultured lymphoma cells7. This immature or abnormally developed immune system may predispose to the development of malignant change, as has been found in diseases of postulated immunological aetiology such as thyroiditis. Another suggestion is that the immunological disturbances in coeliac disease may activate oncogenic viruses6. T cell lymphoma most often presents as tumour masses in the small bowel, and neurological presentation with lymphomatous meningitis has not previously been reported. The possibility of lymphoma should be considered in coeliac patients who deteriorate neurologically for no apparent reason.