Primary amyloidosis presenting with massive generalized lymphadenopathy

Systemic amyloidosis is an unusual cause of generalized massive lymphadenopathy. In such cases the clinical picture may mimic lymphoma. We report a case of generalized massive lymphadenopathy caused by amyloidosis. The 55-year old female patient was admitted to our hospital with dyspnea and edema in the lower extremities. These were diminished breath sounds with bilateral basal congestion hepatosplenomegaly and generalized massive lymphadenopathy in axillary, cervical, and inguinal areas. The diagnosis was made by excisional biopsy of one of the involved lymph nodes. Amyloidosis (AL type) was shown and treatment with melphalan and prednisone was initiated. Unfortunately the patient died after 51 days in hospital.     

Does systematic lymphadenectomy have a benefit on survival of suboptimally debulked patients with stage III ovarian carcinoma? A DEGOG* Study

BACKGROUND AND OBJECTIVES: The aim of this study was to investigate whether systematic lymphadenectomy is necessary in suboptimally cytoreduced patients with stage III ovarian carcinoma. METHODS: Prognostic significance and the effect on survival of systematic pelvic and para-aortic lymphadenectomy were investigated retrospectively in 61 suboptimally debulked patients with stage III ovarian carcinoma. All patients received platinum-based chemotherapy after surgery; 51 patients had been followed for > or =1 year, or until death. Survival curves were calculated according to the Kaplan-Meier method and were evaluated by log-rank test. RESULTS: Most patients had stage IIIC disease (60.7%), poorly differentiated tumor (45.9%), and serous histological type (59%). Systematic pelvic and para-aortic lymphadenectomy was performed in 29 patients (47.5%). Lymph node metastases were found in 17 (58.6%) patients; the median number of metastatic nodes was 7 (5-10). Lymph node metastasis was significantly higher in patients with residual disease of >2 cm (P < 0.05). Both univariate and multivariate analyses showed that systematic pelvic and para-aortic lymphadenectomy was not a significant prognostic factor (P > 0.05). In lymph node-dissected patients, survival was significantly longer in patients with minimal residual tumor than in those with residual tumor size >2 cm (P = 0.005). CONCLUSIONS: Lymphadenectomy seems not to have an evident prognostic value and a benefit on survival in suboptimally debulked patients with stage III ovarian carcinoma.     

The effect of postmenopausal hormone therapy with or without folic acid supplementation on serum homocysteine level.

OBJECTIVE: To evaluate the effects of postmenopausal hormone therapy (HT) with or without the addition of folic acid (FA) on serum homocysteine levels in a randomized, placebo-controlled design. Additionally, a non-randomized control group with no treatment was included. METHODS: Forty non-hysterectomized healthy postmenopausal women were randomly allocated to receive either oral continuous combined HT (0.625 mg conjugated equine estrogen with 2.5 mg medroxyprogesterone acetate daily) and oral folic acid (5 mg/day, n = 20) or HT and placebo (n = 20) for 3 months. A control group (n = 15) did not receive any study medication and was followed in the same manner. The fasting total serum homocysteine level was measured by fluorescence polarization immunoassay with a sensitivity of < 0.5 micromol/l. Serum levels of folate, estrogen and lipid profile were also followed. RESULTS: The mean age of the postmenopausal women was 52 +/- 6 years. Baseline homocysteine level was the highest in the HT + FA group (9.96 +/- 2.82 micromol/l), compared to HT + placebo (9.64 +/- 1.89 micromol/l) and control groups (9.01 +/- 1.83 micromol/l) (ANCOVA, p = 0.022). Low baseline folate and vitamin B12 levels contributed significantly to the high level of baseline homocysteine in the HT + FA group. The addition of FA to HT led to a significant decrease in the serum homocysteine level from the baseline level of 9.96 +/- 2.82 micromol/l to the final level of 8.92 +/- 2.53 micromol/l (p = 0.023). On the other hand, HT alone (HT + placebo group) significantly increased the serum homocysteine level from 9.64 +/- 1.89 micromol/l to 10.22 +/- 1.77 micromol/l without a decline in serum folate level (p = 0.045). The serum homocysteine level in the control group did not change significantly (from 9.01 +/- 1.83 micromol/l to 9.58 +/- 2.05 micromol/l, p = 0.29). CONCLUSIONS: Three months of oral continuous combined HT increased the fasting total serum homocysteine level without affecting the serum folate level. Lowering the homocysteine level in postmenopausal woman on HT is achievable by folic acid supplementation.     

Evaluating social work discharge planning services for elderly people: access, complexity, and outcome.

The discharge planning role of hospital social workers has become increasingly important in services to elderly people. This article examines three issues: (1) the extent to which elderly people most in need receive social work services, (2) the extent to which the discharge planning performed is a professional task, and (3) the effectiveness of discharge planning for those who return to their homes after hospitalization. The study focused on 1,100 elderly patients from five Baltimore hospitals. Data were gathered from their social workers, from the patients themselves (by phone after discharge), and from medical records. Results show that only a minority of elderly patients who return to the community after hospitalization receive social work services while in the hospital but that those who do are likely to have posthospital needs. In most cases, the discharge planning uses professional skills, but 28 percent of cases are fairly routine. Finally, social work services were effective in reducing the level of unmet needs in the areas of nursing, medication, and physical therapy.     

A case of coumarin necrosis with penile and pedal involvement

A 57-year-old male patient with advanced adenocarcinoma of the lung, who was administered oral anticoagulant therapy because of pulmonary embolism, developed coumarin necrosis confined to the penis and feet. To our knowledge, this patient showing acral involvement is the seventh case of coumarin-induced penile necrosis reported to date.     

Effectiveness of vardenafil versus papaverine in penile Doppler ultrasonography

PURPOSE: To evaluate erectile dysfunction, penile color Doppler ultrasound is currently considered the best method. But intracavernous injection is invasive and has adverse effects, such as prolonged erection and risk of priapism. In our study we want to evaluate whether vardenafil can be used instead of papaverine in penile Doppler ultrasonography. MATERIALS AND METHODS: A total of 24 patients with erectile dysfunction underwent color Doppler ultrasound before and after intracavernous injection of 60 mg papaverine with genital and audiovisual sexual stimulation. Peak flow and end diastolic velocity were measured in the recorded waveforms obtained 0, 1, 5, 10 and 20 min after injection. The patients also underwent color Doppler ultrasound after a 10-mg oral dose of vardenafil with genital and audiovisual sexual stimulation and at least 5 days after the prior examination. The same parameters were measured at 30, 45, 60, 75 and 90 min after the drug administration. We compared the results with the values obtained after papaverine injection. RESULTS: After oral vardenafil mean peak flow velocity significantly increased starting at 30 min and achieving a maximum value at 60 min. There were no significant differences in the 2 methods in mean peak velocity 1, 5, 10 and 20 min after papaverine injection, and 30, 45, 60, 75 and 90 min after oral vardenafil administration. Although papaverine injection is the gold standard for penile color Doppler ultrasound, it has severe adverse effects such as prolonged erection which we observed in 3 patients (12.5%) and required pharmacological detumescence. After vardenafil no severe adverse effects were observed. CONCLUSIONS: Vardenafil administration achieved increased peak flow velocity comparable to that after intracavernous papaverine injection. With no prolonged erection vardenafil is a safer alternative compared to more invasive intracavernous injection and is also an alternative for patients who fear injections.     

Elevated plasma concentrations of transforming growth factor-beta 1 in patients with unilateral ureteral obstruction

We measured plasma concentrations of TGF-beta 1 in patients with obstructive ureteral calculi and compared them with the plasma concentrations of healthy volunteers. The present study was a prospective study containing a homogenous group of patients with unilateral ureteral obstruction (UUO). The study consisted of patients with ureteral stones less than 7 mm in diameter that caused mild to moderate obstruction. All patients were referred by the emergency department of our hospital and examined between April 2003 and April 2004. The presence and characteristics of both stone and obstruction were determined by plain abdominal x-ray and gray-scale ultrasonography (US). Blood samples were collected from both patients and control individuals on admission and 1 week after conservative follow-up. The plasma TGF-beta 1 concentration was determined using a quantitative sandwich enzyme immunoassay specific for TGF-beta 1. There were 35 patients with 20 women and 15 men (average age 26.8±5.9 years), and 15 volunteers in the control group, with nine women and six men (average age 24.2±4.5 years). Average stone size was 5.6 mm±1.2 mm (range 3.5–7) for the patient group. US showed the presence of mild hydronephrosis in 24 and moderate hydronephrosis in 11 patients. Plasma concentrations of TGF-beta 1 in patients with ureteral obstruction (1,117±5.8 ng/ml, range 36–2,442 ng/ml) were significantly higher than those in the healthy control group (32±4 ng/ml) on admission (P<0.001). There was a significant increase in TGF-beta 1 plasma concentrations in the patient group (33,525±6.8 ng/ml, range 1,107–73,288 ng/ml) after 1 week follow-up (P<0.001). Ureteral obstruction increases plasma TGF-beta 1 concentrations in patients with ureteral stones as in UUO models in animal studies. A concomitant treatment with an anti-fibrotic agent may reduce the incidence of renal injury during obstruction.     

Management of acute calculous cholecystitis in high-risk patients: percutaneous cholecystotomy followed by early laparoscopic cholecystectomy

Emergency cholecystectomy for acute cholecystitis is associated with high morbidity and mortality rates in patients with significant comorbidities and high-risk surgery. The aim of this study was to evaluate the effectiveness, possible advantages, and complications of percutaneous cholecystostomy (PC) followed by an early laparoscopic cholecystectomy (LC) in relation to conservative treatment followed by a delayed LC in high-surgical risk patients. Between 2002 and 2004, patients were randomly classified into 2 groups: the first group consisted of patients who had PC followed by an early LC (PCLC group, n = 31) and the second group consisted of patients who had conservative treatment followed by a delayed LC (DLC group, n = 30). The groups were statistically compared regarding their demographic, comorbidity, hospital stay, conversion, and complication rates. PC was technically successful in 31 patients with no attributable mortality or major complications. No difference had been found in regarding demographic, comorbidity, and complication rates. In PCLC group, all the patients experienced symptom relief within 24 hours, and early LC was attempted in 31 patients once their clinical condition was sufficiently stable, this was successfully accomplished in 29 (93.5%). In the DLC group, delayed LC was attempted in 30 patients, and this was successfully accomplished in 26 (86.6%). The hospital stay was shorter and cost was in the PCLC group was lower than in the DLC group. PC allows resolution of sepsis in patients at high surgical risk. Early LC could be safely performed once sepsis and acute infection resolved in these patients.     

Outcome of Surgery for Lung Cancer in Young and Elderly Patients

Purpose It has been suggested that lung cancer follows a more aggressive course and has a poorer prognosis in young patients than in elderly patients. We conducted this study to determine whether the basal characteristics and survival of young patients undergoing surgical resection of lung cancer differ from those of elderly patients.Methods Eighty patients who underwent surgery for lung cancer at our hospital between 1989 and 2004 were divided into two groups according to age. Group 1 comprised 50 patients aged 45 years or younger and group 2 comprised 30 patients aged 70 years or older. The patients’ medical records were reviewed with respect to age, gender, histological diagnosis, coexisting diseases, smoking history, postoperative staging, type of operation, and postoperative morbidity, mortality, and survival results.Results The average ages were 40.2 ± 3.77 years (range, 29–45 years) in group 1 and 72.2 ± 2.53 years (range, 70–80 years) in group 2. The incidence of postoperative complications was significantly higher in group 2 (P = 0.02). However, the 5-year survival rates for patients who underwent surgery for non-small cell lung cancer did not differ between groups 1 and 2, at 33.3% versus 21.3%, respectively (P = 0.09).Conclusions The incidence of adenocarcinoma was higher in the young patients, whose prognosis was slightly better than that of the elderly patients. Coexisting diseases and postoperative complications were the major factors that adversely affected the prognosis of the elderly patients.