Efficacy, side effects and route of administration are more important than frequency of dosing of anti-osteoporosis treatments in determining patient adherence: a critical review of published articles from 1970 to 2009

The purposes of the study were to review available published literature on magnitude of non-adherence with osteoporosis regimens and to determine the association between frequency and modality of medication administration with patient preference and adherence. We searched peer-reviewed journal databases—MEDLINE, EMBASE, Biosis and Derwent Drug File for publications (January 1979 to January 2009) including MeSH terms—“patient preference”, “adherence” and “compliance” based on “dosing frequency” and “modality”. Since adherence was difficult to accurately quantify, preference, compliance and persistence were evaluated. Patients’ preference and adherence at 12 months were higher with weekly over daily bisphosphonates (≥84% preference for weekly, medication possession ratios (MPR) 60–76% vs 46–64%; persistence 43.6–69.7% vs 31.7–55.7%). MPR reported for oral bisphosphonates were 68–71% at 12 months. At 2 years, only 43% of patients had MPR ≥80% for daily and weekly bisphosphonates. Observational studies (6–12 months) reported discontinuation rates of 18–22% for daily and 7% for weekly bisphosphonates. Data on monthly bisphosphonates are conflicting and confounded by cost differences, patient support programmes and definition of persistence. Studies suggest patient preference for annual zoledronic acid infusions over weekly bisphosphonates (66.4–78.8% vs 9.0–19.7%, respectively), but no data on compliance or persistence are available. Drug effectiveness, side effects and route of administration were more important than frequency. Although less frequent dosing is preferred, other factors such as perceived efficacy, side effects, medication cost, availability of patient support programmes and route of delivery are equally important. Adherence is complex and difficult to quantify and may not be exclusively influenced by frequency of medication administration.     

Chronic daily headache

The therapy of chronic daily headache (CDH) is complex and involves a combination of drugs, supportive psychotherapy, nondrug therapy, “tender-loving care,” and “tough love.” CDH is a chronic problem with exacerbations and remissions. Patients with CDH often manifest mood disorders, and recognition and treatment of these problems is a key component of success. The use of preventative antimigraine therapy is a major component of treatment of this condition. Patients with exacerbations may need judicious short courses of medications that can produce medication-overuse headache. Patients may switch to another physician to get opiates or other pain relief medications. The patient may later realize this mistake and return to the physician. Use of patient “contracts,” in which the patient agrees not to take more than a prescribed amount of restricted medication or seek it elsewhere, may be helpful. In this area, there is no standard patient or standard therapeutic regimen. The treatment plan must be individualized for each patient. Taking a little extra time to talk with patients and discuss medications, procedures, and goals and objectives may pay bigger dividends in the therapeutic relationship later in the course of treatment.     

Chronic daily headache

Opinion statement The therapy of chronic daily headache (CDH) is complex and involves a combination of drugs, supportive psychotherapy, nondrug therapy, “tender-loving care,” and “tough love.” CDH is a chronic problem with exacerbations and remissions. Patients with CDH often manifest mood disorders, and recognition and treatment of these problems is a key component of success. The use of preventative antimigraine therapy is a major component of treatment of this condition. Patients with exacerbations may need judicious short courses of medications that can produce medication-overuse headache. Patients may switch to another physician to get opiates or other pain relief medications. The patient may later realize this mistake and return to the physician. Use of patient “contracts,” in which the patient agrees not to take more than a prescribed amount of restricted medication or seek it elsewhere, may be helpful. In this area, there is no standard patient or standard therapeutic regimen. The treatment plan must be individualized for each patient. Taking a little extra time to talk with patients and discuss medications, procedures, and goals and objectives may pay bigger dividends in the therapeutic relationship later in the course of treatment.     

Patient delay from onset of chest pain suggesting acute coronary syndrome to hospital admission

Objective --The aim of the study was to examine patient delay (time from onset of chest pain to patient seeking medical care) among patients who were admitted to hospital with suspected acute coronary syndrome (ACS). Design and results --For 337 patients acutely admitted to the Cardiology Department, Odense University Hospital, during a 3-month period in 1998 with suspected ACS, patient delay and the total pre-hospital delay were registered. In addition, information on patient characteristics, patient behaviour and symptom perception was obtained. The median patient delay was 2.85 &#114 h (range 0.2-91 &#114 h), of this the "silent" patient delay represented 1 &#114 h (range 1 &#114 min-11.3 &#114 h). The total pre-hospital delay was median 3.88 &#114 h. Thirty-one per cent of the patients had confirmed acute myocardial infarction (AMI), and this patient group had a significantly shorter patient delay compared with the group without AMI, 2.05 &#114 h vs 3.12 &#114 h, p &#114 = &#114 0.01. Patient delay of more than 2 &#114 h was associated with the factors "self-medication" and "wanted to wait and see if the symptoms went away". A smaller than average risk of patient delay was found in the case of "suspicion of heart attack" and "suspicion of a serious condition". Conclusion --Patient delay is considered to be a serious impediment to markedly improving the prognosis in the case of ACS.     

Prospective randomized controlled trial to evaluate “fast-track” elective open infrarenal aneurysm repair

Background and aims Fast-track programs have been introduced in many surgical fields to minimize postoperative morbidity and mortality. Morbidity after elective open infrarenal aneurysm repair is as high as 30%; mortality ranges up to 10%. In terms of open infrarenal aneurysm repair, no randomized controlled trials exist to introduce and evaluate such patient care programs. Materials and methods This study involved prospective randomization of 82 patients in a “traditional” and a “fast-track” treatment arm. Main differences consisted in preoperative bowel washout (none vs. 3 l cleaning solution) and analgesia (patient controlled analgesia vs. patient controlled epidural analgesia). Study endpoints were morbidity and mortality, need for postoperative mechanical ventilation, and length of stay (LOS) on intensive care unit (ICU). Results The need for assisted postoperative ventilation was significantly higher in the traditional group (33.3% vs. 5.4%; p = 0.011). Median LOS on ICU was shorter in the fast-track group, 41 vs. 20 h. The rate of postoperative medical complications was significantly lower in the fast-track group, 16.2% vs. 35.7% (p = 0.045). Conclusion We introduced and evaluated an optimized patient care program for patients undergoing open infrarenal aortic aneurysm repair which showed a significant advantage for “fast-track” patients in terms of postoperative morbidity. German Society of Surgery, Surgical Forum 2008, Best of Abstracts.     

Surgical Education to Improve the Quality of Patient Care: the Role of Practice-Based Learning and Improvement

Health care is going through immense change, and concerns regarding the quality of patient care and patient safety continue to be expressed in many national forums. A variety of stakeholders are demanding greater accountability from the health care profession. Education is key to supporting surgeons’ efforts to provide high-quality patient care during these challenging times. Educational programs for surgeons should be founded on principles of continuous professional development (CPD) and practice-based learning and improvement (PBLI). CPD focuses on the specific needs of individual surgeons and involves lifelong learning throughout a surgeon’s career. It needs to form the basis of PBLI efforts. PBLI involves a cycle of four steps—identifying areas for improvement, engaging in learning, applying new knowledge and skills to practice, and checking for improvement. Ongoing involvement in PBLI activities to address specific learning needs should positively impact a surgeon’s practice and improve outcomes of surgical care.     

How to improve satisfaction with hospital stay of severely injured patients

Background In the context of medical quality assurance, patient satisfaction with medical and organisational aspects of health care service is considered to be a relevant outcome of patient surveys after a stay in hospital. Within quality research, it is assumed that assessments of patient satisfaction represent a direct measure of the quality of health care received. Furthermore, there is evidence that satisfied patients demonstrate higher levels of compliance for the course of their treatment and that the probability of successful treatment completion thus considerably increases. The present analysis aims to identify determinants of satisfaction of seriously injured patients with regard to their acute hospitalisation. Materials and methods One hundred twenty-one seriously injured survivors of work-related or traffic-related accidents treated in two hospitals in Cologne during the years 1996 to 2001 were sent a survey questionnaire. In addition to socio-demographic details, the survey covered the subjective evaluation of organisational and structural aspects of the acute hospitalisation and the psychosocial care provided by the medical staff. Results Employing the “tailored design method”, a response rate of 74.4% (n = 90) was obtained. Three highly significant factors influencing the satisfaction of seriously injured patients were identified by means of logistic regression: (1) patients’ perception of being involved in treatment, (2) patients’ feeling of being neglected by physicians and (3) patients’ perception of trust in physicians. Conclusions In the present study, the perceived quality of psychosocial care proved to have a significant effect on patients’ satisfaction with their hospital stay. Results of the current analysis thus indicate that psychosocial aspects of physician–patient interaction are of considerable importance in the medical care of seriously injured patients. Although this study is mainly based on subjective patient reported outcome, there is evidence that the subjective view of a patient is relevant in many aspects of medical treatment and outcome. These results already gave the motivation to develop a prospective interventional study with a training programme of communication skills to improve subjective and objective outcome parameters of severely injured patients.     

Conceptional and structural conditions for successful clinical research

The efficiency of surgical research has again become the subject of debate. Clinical research is required to improve our understanding of surgical disorders and our ability to treat patients. This involves both experimental research (research in the test tube) and clinical research in actual patients. The surgeon must remain the expert because it is he who deals with the patient and is confronted with his problems. On the other hand, care for the patient, must always be the central issue. Here a new orientation is needed, evaluating the effectiveness of surgical research from the patient's point of view. Surgical treatment, particularly surgical research, must be adapted first to the individual patient and only secondly to the surgical disease – the problem must determine the method, not vice versa. While it is clear that a creative atmosphere, supportive structure and efficient organisation are enormously helpful, today's exaggerated attention to matters of structure and organisation are often poor substitutes for creativity and intuition. Surgical research does not refer solely to therapy research but includes methods for carrying out controlled clinical trials, establishing guidelines and scores and designing instruments for measuring outcome. Socio-economic and analyses and ethical considerations are crucial for facing such conflicts as “quality versus quantity”, “profession versus business”, “patient care versus economics costs”. Proposals for designing more effective concepts, structure and organisation for clinical research are presented here, and three models are introduced: the cooperation model, the integration model and a mixture of the two. Received: 29 January 1998 / Accepted: 25 May 1998     

Chronic locked posterior shoulder dislocation with severe head involvement

Arthroplasty is the treatment of choice for severely damaged humeral heads in chronic locked posterior dislocation of the shoulder. We retrospectively reviewed the results of 12 shoulder arthroplasties (11 patients) between 1999 and 2005. Mean follow-up was 37.4 ± 16.8 months. Mean postoperative Constant score (CS) was 59.4 ± 21.6 (normative age and gender-related CS 67.1 ± 24). There was a significant improvement in range of motion for flexion, abduction and external rotation. There was negative correlation (Pearson’s coefficient) between the related CS and number of previous operations, pain and duration of symptoms. One patient underwent revision surgery 36 months postoperatively with polyethylene insert exchange. There were two patients with mild and one with severe migration of the humeral head. Shoulder arthroplasty resulted in good midterm results for this patient group with benefits for range of motion, pain and patient satisfaction.     

Multimodal protocol for awake craniotomy in language cortex tumour surgery

Summary Background. Intra-operative neurophysiological language mapping has become an established procedure in patients operated on for tumours in the area of the language cortex. Awake cranial surgery has specific risks and patients are exposed to an increased physical and mental stress. The aim of the study was to establish an algorithm that enables tailoring the neurosurgical and anaesthetic techniques to the individual patient. Method. A total of 25 patients underwent awake craniotomy for intra-operative language mapping between 1999 and 2004. Following craniotomy under analgesia and sedation without rigid pin fixation of the head, cortical language mapping was performed in the fully co-operative patient. The results of functional magnetic resonance imaging and of cortical language mapping were incorporated into the 3D dataset for neuronavigation. Depending on the functional data and the individual operative risk tumour resection then proceeded either under conscious sedation with the option of subcortical language monitoring or under general anaesthesia. Findings. After cortical language mapping patients are assigned to one of four groups: BACC (Berlin awake craniotomy criteria) I–IV. BACC I (9 patients): adequate functional data + operative risk not increased ⇒ tumour resection in the awake patient; BACC II (4 patients): limited functional data + operative risk not increased ⇒ tumour resection in the awake patient with the option of language monitoring as needed; BACC III (9 patients): adequate functional data + increased operative risk ⇒ tumour resection under general anaesthesia using functional navigation; BACC IV (3 patients): limited functional data + increased operative risk ⇒ tumour resection in the awake patient with the option of language monitoring as needed. We observed less adverse events in group BACC III. No permanent deterioration of language function occurred in this series. Conclusions. The multimodal protocol for awake craniotomy provides for tumour resection under general anaesthesia in selected patients using functional neuronavigation. Our experience with the algorithm suggests that it is a useful tool for preserving function in patients undergoing surgery of the language cortex while reducing the operative risk on an individual basis.     

Laryngeal exposure during laryngoscopy is better in the 25 degrees back-up position than in the supine position

Background: Good visualization of the glottis is important for trachealintubation. This study evaluated whether the 25° back-upposition improves the quality of the laryngeal view during laryngoscopy. Methods: Laryngoscopy with a curved blade was performed on 40 anaesthetizedpatients. The patients were randomly assigned to two groups.Laryngeal views were captured with a rigid 0° endoscope.Views were recorded for each patient in Group A (n = 20) duringlaryngoscopies performed with the patient lying first in thesupine position and then in the 25° back-up position. Laryngealviews for patients in Group B (n = 20) were first captured whilethe patient was in the 25° back-up position and then whilethe patient was in the flat supine position. An anaesthetistblinded to the position graded the quality of the images usingthe percentage of glottic opening (POGO) score. Results: Comparing the two positions, mean (SD) POGO scores increasedsignificantly from 42.2 (27.4)% in supine position to 66.8 (27.6)%in 25° back-up position (P < 0.0001). Conclusions: During laryngoscopy, the laryngeal view, as assessed by POGOscores, improves significantly in the 25° back-up positionwhen compared with the flat supine position.     

Cyst fluid tumor-associated trypsin inhibitor may be helpful in the differentiation of cystic pancreatic lesions

In clinical practice it is important to differentiate pseudocysts from cystic pancreatic tumors, especially potentially malignant mucinous cystic tumors. We investigated three new markers—tumor-associated trypsin inhibitor (TATI) and the free α and β subunits of human choriogonadotropin (hCGα and hCGβ, respectively)—in the cyst.uid of patients with cystic pancreatic lesions and compared the concentrations of these markers to those of carcinoembryonic antigen (CEA), CA 19-9, CA 242, CA 125, CA 15-3, alpha-fetoprotein, and tissue polypeptide antigen in order to distinguish benign cysts from malignant cysts. Between 1995 and 2001, a total of 34 patients operated on for cystic pancreatic lesions at Tampere University Hospital were included. Cyst fluid was aspirated at operation and stored at_70 C. Thehistologic diagnosis was pseudocyst in 23 patients, serous cystadenoma (SCA) in four patients, benign mucinous cystadenoma (MCA) in four patients, cystic papillary neoplasm (CPN) in one patient, glucagonoma in one patient, and malignant endocrine islet cell carcinoma (EC) in one patient. Significantly higher concentrations of TATI were found in patients with MCA and EC (2239 ± 149 μg/L [mean ± SEM]) than in patients with pseudocyst (55 ± 29 μg/L; P = 0.001) and in patients with SCA (36 ± 23 μg/L; P = 0.01). The patient with CPN and the patient with glucagonoma had relatively low levels of TATI (30.7 and 46.5 μg/L). Mean CEA was higher in patients with MCA compared to those with pseudocysts (19,993 ± 9418 vs. 53 ± 20 μg/L, P = 0.002) and SCA (0.4 ± 0.1 μg/L; P = 0.02), but in the patient with malignant EC, the patient with CPN, and the patient with glucagonoma, CEA was normal. HCGα, hCGβ, CA 19-9, CA 242, CA 125, CA 15-3, alpha fetoprotein, and tissue polypeptide antigen could not distinguish between MCA vs. pseudocyst or SCA, because both normal and elevated values were seen in all groups. To our knowledge, this is the first time that TATI has been quantitated in the cyst fluid of patients with cystic pancreatic lesions. It appears to be a potential marker in the differential diagnosis of benign from malignant cystic pancreatic lesions. Supported by the Medical Research Fund of Tampere University Hospital.     

Screening for Osteoporosis Using Easily Obtainable Biometrical Data: Diagnostic Accuracy of Measured, Self-Reported and Recalled BMI, and Related Costs of Bone Mineral Density Measurements

The aims of the present study were: to determine the diagnostic accuracy of objectively measured, self-reported and recalled body mass index (BMI) for osteoporosis and osteopenia; to determine the diagnostic costs, in terms of bone mineral density (BMD) measurements, per osteoporotic or osteopenic patient detected, using different BMI tests; and to determine the extent to which the results can be used within the framework of the current screening program for breast cancer in The Netherlands. Within the framework of a cross-sectional study on the prevalence of osteoporosis in the south of The Netherlands, 1155 postmenopausal women aged 50–80 years were asked for their present height and their weight at age 20–30 years. Subsequently their actual weight, height and BMD of the lumbar spine (DXA) were measured. The BMD cutoff was 0.800 g/cm² for osteoporosis and 0.970 g/cm² for low BMD (osteoporosis + osteopenia). After receiver operating characteristic analysis, age was cut off at 60 years and BMI at 27 kg/m². Diagnostic accuracies of objectively measured, self-reported and recalled BMI were evaluated using predictive values (PV) and odds ratios. The resulting ‘true positive’ and ‘false positive’ rates were used to calculate diagnostic costs (i.e., DXA) for each osteoporotic patient or low-BMD patient detected. The prevalence of osteoporosis in the study population was 25%, that of low BMD 65%. Only the age–BMI tests ‘age ≥60, BMI ≤27’ showed PVs for osteoporosis (31–41%) and for low BMD (71–81%) that were higher than the prior probabilities for these conditions. Related odds ratios were 2.14–3.18 (osteoporosis) and 1.87–3.04 (low BMD). The objective BMI test detected 50% of the osteoporotic patients. Using the self-reported BMI test and the recalled BMI test, detection rates increased to 55% and 69%, respectively. Concomitant costs per osteoporotic patient detected rose by 24%. Detection of patients with a low BMD increased from 38% for objective BMI and 42% for self-reported BMI to 60% for recalled BMI. Related costs increased by 11%. If all women over 50 years of age (irrespective of their BMI) were to be referred for BMD measurement, costs per osteoporotic patient or low-BMD patient detected would be 304 and 116 Euros, respectively. Only in women over 60 years does a BMI below 27 kg/m2 provide a better prediction of the presence of osteoporosis or low BMD than could be expected solely on the basis of the relevant prevalences in postmenopausal women aged 50–80 years. If the use of BMI for the detection of osteoporotic or low-BMD patients is still considered, measuring weight and just asking for a person’s height will do. Although age and BMI are the strongest risk factors for osteoporosis, they are of less significance when used for screening the population for osteoporosis. More research is needed before age and BMI can be included in any screening program. As regards practical considerations alone, measurements of BMD could be implemented within the screening program for breast cancer. Received: 29 October 1998 / Accepted: 17 August 1999     

The art of surgery in the 21st century: based on natural sciences and new ethical dimensions

Background and aims In the future, new surgical techniques will only be introduced in clinical practice if evidence-based results—frequently the results of controlled clinical trials—are presented. Unlike any other medical discipline, surgeons provide their diagnostic and operative skills through the surgeons’ hand and the use of technical equipment, which ranges from instruments and devices employed during operation to the use of surgical robots. Results Analysing the fundaments of surgery on the turn of the century, there is only a little doubt about the increasing impact of data deriving from natural sciences on knowledge in medicine and management of diseases. The natural scientific method of detecting, measuring, and verifying facts is the methodological basis of surgery as well. The autonomy of the surgeon’s clinical decision making is significantly restricted by the definition of guidelines. They shift the decision from a single patient to a collective panel. Patient safety and the efficiency of new treatment modalities compared with previous standards are the criteria for the judgement of innovative surgery today. The communication and interaction between surgeon-scientist and patients is guaranteed legally by written consensus. But beside of the high probability of benefit from therapy and written consensus, the surgeon–patient relation is determined by these factors: limitation of time for care of an individual patient, increase of time for administration and documentation, increase of bureaucratic barriers for medical research, and health cost constraints. Conclusion The medical mandate to cure a sick patient is an individual mandate to take action. Measures, numbers, and images are only preconditions for a surgeon’s action in daily clinical work; they can never replace it. The call for an ethical imperative in scientific surgery that is dependent on technology is justified when the state of science and uncritical use of surgical skills and financial constraints have major impact on providing medical care.     

Comparison of chronic peritoneal dialysis outcomes in children with and without spina bifida

This study was designed to compare chronic peritoneal dialysis (CPD) long-term outcomes (patient and technique survival, incidence of peritonitis, and overall average death outcomes) between seven patients with lumbar spina bifida (SB) and 20 controls without SB. Both groups were matched for potentially outcome-confounding factors: gender, and socioeconomic status (SES). SES was established using modified Graffar’s method. No significant differences were found in CPD outcomes. The incidence of peritonitis was one episode per 17.6 and 10.3 months in SB patients and controls, respectively (p = 0.5). Overall patient survival at 5 years was 86% and 73% in SB patients and controls, respectively (p = 0.55). Overall average death rate between SB and control patients was 47.6/1,000 and 79.4/1,000 patient years, respectively (p = 0.63). Overall technique survival at 5 years was 83% and 73% in SB patients and controls, respectively (p = 0.84). There were no cases of retrograde brain ventricular infection secondary to PD-related peritonitis. We conclude that SB is not a risk factor for CPD, and therefore, it is an effective renal replacement alternative in children with SB.     

Surgical management of acute complications and critical restenosis following carotid artery stenting

Carotid artery angioplasty with stenting (CAS) is being increasingly used in the treatment of extracranial carotid artery stenosis. As in other catheter-based approaches to the treatment of arterial disease, surgical intervention may be required because of either acute complications or correct critical restenosis. We have reviewed our experience managing early complications and critical in-stent restenoses after CAS in a tertiary care university hospital and a Veterans Affairs Medical Center. During the last 5 years, 22 carotid arteries (21 patients) underwent CAS. One patient developed thrombosis and rupture of the carotid artery during stenting. Two other patients (3 arteries) developed critical restenosis within 12 months. Subsequent surgical reconstructions included an internal carotid artery (ICA)–to–external carotid artery (ECA) transposition and a common carotid artery (CCA)–to–ICA bypass with reversed saphenous vein (RSV). The patient who underwent CCA–to–ICA bypass later required subclavian–to–ICA bypass because of rapidly progressive intimal hyperplasia and subsequent occlusion of the CCA. The other patient has not had surgical repair because of his deteriorating condition and significant co-morbidities. During the same time period, two additional patients were referred from outside institutions specifically for surgical intervention after carotid stenting. One had delayed rupture of the carotid artery 1 day after stenting and underwent urgent surgical repair. Another patient had early, critical restenosis within the stent and underwent placement of a CCA–to–ICA interposition graft using RSV. Acute treatment failures after CAS can be successfully managed using standard surgical techniques. Patients who develop critical in-stent restenosis requiring surgical repair may need more challenging surgical reconstructions to maintain cerebral perfusion.     

“The Stork Lift”: A Circumoccipital Extended Neck-Lift

Background  The goal of the lower face- and neck-lift is restoration of a sharp cervicomental angle. However, standard cervical rhytidectomy for the patient with extensive excess skin of the neck often leaves the patient with objectionable vertical or diagonal skin folds of the lateral neck, a large hair-step deformity, or both. To remove extensive excess skin of the neck and to avoid vertical/diagonal folds and a stepped hairline, the authors “walk” the excess skin posteriorly along the hairline, often from ear to ear along the inferior posterior hairline. Methods  Patients with extensive excess skin of the neck underwent neck-lift procedures using the circumocciput incision technique during a 1-year period. With the patient in a sitting position, a postauricular face-lift incision is extended along the inferior hairline from ear to ear. The flap is “walked” posteriorly to and along the occiput on either side of the midline. It is closed using a divide and close technique. Flaps are created, and the wound is closed in a multilayered fashion with a posterior midline A-to-T flap. Results  During a 1-year period, 25 patients (22 women and 3 men) underwent a cheek/neck-lift, and 2 patients (1 man and 1 woman) underwent isolated neck-lift procedures using the circumocciput incision technique. The average patient age was 64.8 years (range, 49–79 years). There were no instances of obvious lateral neck folds. Complications included hematoma (1 patient), Candida wound infection (1 patient), and a widened scar revised secondarily (1 patient). All the patients were satisfied with their cosmetic result 6 months after the operation. None of the patients stated that their final scar was noticeable or objectionable. Conclusions  The patients in this study who presented with excessive redundant skin of the neck were treated with the “stork lift,” which provided excellent lifting of the anterior, lateral, and posterior neck as well as excellent cervicomental angles without postoperative sequelae of lateral neck folds or stepped hairlines.     

Cystic β2-microglobulin amyloidoma in a patient on long-term hemodialysis

We report a patient with β2 microglobulin amyloidosis (β2M) in whom cystic tumors were seen in the bilateral axillary region. The patient was a 68-year-old woman who had been on hemodialysis for more than 20 years because of IgA nephropathy. Computed tomography-guided biopsy was performed to confirm the diagnosis. Congo red staining, β2M immunohistochemistry, and electron microscopy examination of the biopsied sample showed extended β2M deposits in the cystic tumor. β2M-related amyloidosis in patients with long-term dialysis commonly presents as osteoarticular disease, although a soft-tissue pseudotumor, known as amyloidoma, has been reported. This is the first report in the English-language literature of amyloidosis presenting as bilateral axillary cystic tumors.     

Allograft Membranous Glomerulonephritis and Renal-vein Thrombosis in a Patient with a Lupus Anticoagulant Factor

A circulating lupus anticoagulant factor was detected in a 38-year-oldman with end-stage renal disease and a ‘lupus-like’syndrome with a diffuse proliferative glomerulonephritis. Whentreated with steroids, the ‘lupus’ complicationswere controlled and the anticoagulant factor disappeared; however,renal function did not recover and the patient commenced regularhaemodialysis. Four months later the patient received a cadaverkidney transplant. At transplantation and during follow-up therewas neither clinical nor laboratory evidence of lupus activity,but 19 months after transplantation, when steroids were taperedto a low dose, the lupus anticoagulant factor was detected,and renal-vein thrombosis complicated by sepsis led to the patient'sdeath. A membranous glomerulonephritis was found on autopsy.This is the first time in which a (probably ‘de novo’)membranous glomerulonephritis has been detected in the allograftof a patient with circulating lupus anticoagulant factor.