ADRENAL SPARING SURGERY DURING RADICAL NEPHRECTOMY IN PATIENTS WITH RENAL CELL CANCER: A NEW ALGORITHM

PURPOSE: Ipsilateral adrenalectomy is usually performed during radical nephrectomy because of renal cell cancer. Because renal tumors are detected more often in the earlier stages due to widespread use of ultrasound and computerized tomography, we define a subset of patients who would be eligible for adrenal sparing surgery. In a retrospective analysis we evaluated whether parameters obtained preoperatively are able to predict adrenal metastasis. MATERIALS AND METHODS: A total of 866 consecutive patients who underwent nephrectomy and ipsilateral adrenalectomy from 1983 to 1999 were evaluated. Preoperative parameters, including tumor size, location, clinical stage, number of tumors, and patient age and sex, were retrospectively compared with the histological results. Univariate and multivariate analyses were performed. RESULTS: A total of 27 (3.1%) adrenal metastases were noted in the 866 patients, and 63% were on the left side and 37% on the right side. Mean tumor size was 10 cm. with versus 6 cm. without adrenal involvement. Of the 27 patients 21 had multiple metastases at diagnosis and only 6 (0.7% of all 866) presented with solitary ipsilateral adrenal metastasis. Univariate and multivariate analyses revealed tumor size and M stage as best preoperative predictors of adrenal involvement. CONCLUSIONS: Adrenal sparing surgery is possible, and we suggest a new algorithm. If maximum tumor size measured by computerized tomography is less than 8 cm. and staging examination does not show organ or lymph node metastases, adrenalectomy is not necessary because of oncological reasons. This algorithm has to be validated by a prospective analysis.     

THYROREGULATORY CHANGES ASSOCIATED WITH SMOKING IN 70-YEAR-OLD MEN

In a previous study we have analysed serum free T4 concentrations in a representative population of 70-year-old men. In the present study the effect of previous or present tobacco smoking on free T4, T4, T3, rT3, TSH and thyroid hormone binding proteins was analysed in 181 of the 460 men, excluding those with past or present goitre, those who were obviously ill or had died between 70 and 75 years of age and those who had any disease or medication influencing free T4 concentrations. Smokers had higher T4 and rT3 levels, and lower TSH levels but T3 levels no different from non-smokers. The difference in T4 levels, but not rT3 or TSH levels, between smokers and non-smokers could be attributed to differences in body mass and also to differences in TBG levels. The results indicate that tobacco smoking is associated with long-term alterations in thyroregulatory function.     

GM-CSF-induced acute eosinophilic pneumonia

Summary. There is increasing evidence that haemopoietic growth factors are effective in reversal of neutropenia associated with large granular lymphocytes (LGLs) proliferation. A 19-year-old woman with CD3⁺/TCRγδ⁺, CD4⁻, CD8⁻ LGL proliferation and severe neutropenia repeatedly developed blood eosinophilia, fever and dyspnoea after administration of GM-CSF. Acute eosinophilic pneumonia with a lobar lung infiltrate pleural effusion, and marked bronchoalveolar lavage fluid eosinophilia was diagnosed. Treatment with corticosteroids and discontinuation of GM-CSF lead to rapid improvement. In addition, haematological analysis revealed that H*1 Technicon, a widely-used automated cell counter, may misinterpret eosinophils erroneously as neutrophils, therefore examination of blood smears to prevent eosinophil-medlated toxicity during GM-CSF treatment is recommended.     

Haematological Abnormalities and Reference Intervals in the Elderly

Abstract. We compared three representative population samples aged 70 (n=312), 75 (n=486) and 81 (n=404) years. Anaemia defined either as blood haemoglobin concentration below the corresponding health-related lower reference limits or according to WHO was, in the total study groups, more common at age 81. Anaemia of unknown cause was rare, but somewhat more common at age 81. Mean blood haemoglobin concentrations in subsamples without definable disorders were significantly lower at age 81 than at ages 70 and 75, whereas the lower health-related reference limits did not differ significantly. White blood cell counts tended to be lower and iron deficiency was somewhat more common at age 81. No significant differences were found in platelet counts or in the prevalence of low plasma cobalamin concentrations. These results indicate a fall in blood haemoglobin with advancing age. The arbitrary WHO criteria for anaemia are clinically applicable at age 70–81.     

Suppression of vagus-mediated pancreatic polypeptide release by the μ-opiate receptor agonist loperamide in man

1Morphine suppresses the release of pancreatic polypeptide, a hormone under vagal cholinergic control. The intention of the study was to detect whether the μ-opiate receptor agonist loperamide is also able to inhibit pancreatic polypeptide release, and to define its site of action. 2In groups of healthy subjects (n=6 each) stimulation of pancreatic polypeptide was assessed in five different tests: (i) insulin-hypoglycaemia; (ii) modified sham feeding; (iii) intravenous infusion of the cholecystokinin analogue ceruletide; (iv) injection of corticotropin releasing hormone; (v) infusion of the muscarinic acetylcholine agonist bethanechol. All tests were performed after oral application of either a placebo or loperamide (16 mg), tests (ii) and (iii) were repeated with loperamide in smaller doses (2 and 6 mg), with loperamide plus naloxone, with naloxone alone, and with infusion of atropine. Plasma concentrations of pancreatic polypeptide were measured radioimmunologically. 3Release of pancreatic polypeptide in test (i) to (iv) was completely blocked by 16 mg loperamide, whereas bethanechol-stimulated release (test 5) was not influenced. Tests (ii) and (iii) showed that the inhibition was dose-dependent and could be attenuated by naloxone. The inhibitory effect of loperamide was comparable with that of atropine. 4We conclude that loperamide causes a dose-dependent inhibition of pancreatic polypeptide release mediated by vagal-cholinergic pathways, but does not have an atropine-like peripheral action.     

The effectiveness of inpatient and outpatient treatment for alcohol abuse: the need to focus on mediators and moderators of setting effects

Previous reviews have concluded that there was no evidence for the superiority of inpatient over outpatient treatment of alcohol abuse, although particular types of patients might be more effectively treated in inpatient settings. In this review, we first consider the conceptual rationales that have been offered to support inpatient and outpatient treatment. Following that, the results of the relevant research on setting effects are presented. Five studies had significant setting effects favoring inpatient treatment, two studies found day hospital to be significantly more effective than inpatient treatment, and seven studies yielded no significant differences on drinking-related outcome variables. In all but one instance in which a significant effect emerged, patients in the ‘superior’ setting received more intensive treatment and patients were not ‘preselected’ for their willingness to accept random assignment to treatment in either setting. Studies finding significant setting effects also conducted more treatment contrasts (18.6 vs. 4.9), on average, and had a mean statistical power level of 0.71 (median 0.79) to detect a medium-sized effect, whereas studies with no significant findings had an average power level of 0.55 (median 0.57). When inpatient treatment teas found to be more effective, outpatients did not receive a respite in the form of inpatient detoxification and the studies were slightly less likely to have social stability inclusion criteria and to use random assignment to treatment settings. We consider the implications of our findings for future research, especially the need to examine the conceptual rationales put forward by proponents of inpatient and outpatient treatment, i.e. mediators and moderators of setting effects.