Giant splenic metastasis due to lung adenocarcinoma

Lung cancer is the most prevalent malignancy in western countries and most of the patients present at advanced stages, but single splenic metastasis is exceptional instead. We report on a case of a seventy-three-year old male presenting with non-hemoptoic productive cough, constitutional syndrome and pain in the left lower quadrant. Physical examination and complementary radiological and hystologycal procedures revealed the presence of an adenocarcinoma of the left lung with probable splenic metastasis. The patient underwent splenectomy, which confirmed the diagnose of splenic metastasis of lung adenocarcinoma and, secondly, lung resection was performed. Topics about lung cancer metastasis are discussed.     

Dystonia gravidarum: a new case with a long follow-up.

We report a case of cervical dystonia occurring in a 33-year-old without personal history of movement disorder but with family history of essential tremor, primigravid, primiparous woman at 1 weeks' amenorrhea, resolved completely after delivery in the course of 3 months. Dystonia never recurred in the following 5 years. Several neurological disorders are known to occur or worsen during pregnancy. As far as we know, this is the second reported case of dystonia occurring during pregnancy, thus confirming that dystonia gravidarum represents a new entity and should be considered in women of reproductive age affected by dystonia, especially when presenting with rapid-onset cervical dystonia.     

Management of status dystonicus: our experience and review of the literature.

Status dystonicus (SD) is a life threatening disorder that develops in patients with both primary and secondary dystonia, characterized by acute worsening of symptoms with generalized and severe muscle contractions. To date, no information is available on the best way to treat this disorder. We review the previously described cases of SD and two new cases are reported, one of which occurring in a child with static encephalopathy, and the other one in a patient with pantothenate kinase-associated neurodegeneration. Both patients were admitted to an intensive care unit and treated with midazolam and propofol. This approach proved to be useful in the former while the progressive nature of the dystonia of the second patient required the combination of intrathecal baclofen infusion and bilateral pallidal deep brain stimulation. We believe that a rapid and aggressive approach is justified to avoid the great morbidity and mortality which characterize SD. Our experience, combined with the data available in the literature, might permit to establish the best strategies in managing this rare and severe condition.     

The unusual association of three autoimmune diseases in a patient with Noonan syndrome.

We report on a 26-year-old female affected by Noonan syndrome (NS), a congenital disorder characterized by various phenotypic features and congenital anomalies) associated with a variety of autoimmune diseases, including systemic lupus erythematosus, celiac disease, and Hashimoto thyroiditis. Autoimmunity is seldom described in NS and the association between this congenital disease and three autoimmune disorders has not been previously reported. Should the occurrence of autoimmune disorders in NS be confirmed, a relevant clinical and laboratory evaluation of NS patients should be performed in order to clarify whether the immune system involvement represents only an occasional event or is a feature of the disease.     

Same-Day Upper and Lower Inpatient Endoscopy: A Trend for the Future

Performance of same-day upper and lower endoscopy has many potential advantages, as it may reduce costs, shorten hospital stay, and expedite patient care, but its feasibility, efficacy, and potential have not been carefully defined. We report here our experience with a group of 87 patients who underwent same-day upper and lower endoscopy (174 procedures) over a 2-yr period at a tertiary care VA Hospital, compared with an alternate-day upper and lower endoscopy group of 50 patients (100 procedures) over the same time period. Most patients were elderly males. Common indications for endoscopy were occult or overt gastrointestinal bleeding, previous or concomitant history of pertinent pathology (i.e., polyps, ulcers), abdominal pain, diarrhea, or other symptoms, abnormal radiological studies, and iron deficiency anemia. Both groups required similar amounts of intravenous sedation. There were no complications in either group. In both groups, common positive findings were inflammation (i.e., colitis, esophagitis), benign neoplasms, diverticulae, peptic ulcer, and cancer. In both groups, only 2-6% had negative upper and lower endoscopy, whereas either one procedure was negative in 25% and 18% of cases, respectively. We conclude that the practice of same-day inpatient upper and lower endoscopy is feasible, has excellent diagnostic yield, even in the elderly, and carries no increased risks. When indicated, the practice of same-day upper and lower endoscopy should be encouraged.     

Persistence of Mammary Artery Branches and Blood Supply to the Left Anterior Descending Artery

Background. Partial harvesting of the left internal mammary artery (LIMA) is a widespread technique used during minimally invasive coronary operations performed through a left anterior small thoracotomy. The influence of persisting LIMA branches was investigated to evaluate their effect on the blood flow of the left anterior descending artery.

Methods. Thirty patients, 15 with totally (group A) and 15 with partially (group B) harvested LIMAs, were evaluated. All the patients underwent postoperative angiography, during which a flow map of the LIMA was performed. The average peak velocity and the diastolic-to-systolic peak velocity ratio were recorded. The LIMA graft flow pattern was recorded in the proximal and distal thirds of the artery. Intramammary adenosine (12 to 14 μg) was injected and the average peak velocities before and after injection were calculated.

Results. The average peak velocity was similar in both groups in the proximal and distal thirds of the LIMA (25 ± 7 and 26 ± 5 cm/sec, respectively, in group A versus 27 ± 5 and 25 ± 5 cm/sec, respectively in group B; p = NS). The diastolic-to-systolic peak velocity ratio was similar proximally (0.78 ± 0.3 in group A versus 0.69 ± 0.3 cm/s in group B; p = NS), but not distally (1.72 ± 0.1 in group A versus 0.97 ± 0.3 in group B; p < 0.0005). The LIMA graft flow reserve was similar both proximally and distally (2.6 ± 0.6 and 2.5 ± 0.3 cm/s, respectively, in group A versus 2.6 ± 0.5 and 2.6 ± 0.3 cm/s, respectively, in group B; p = NS).

Conclusions. The persistence of LIMA branches does not influence the blood flow of the left anterior descending artery after acute adenosine-induced myocardial hyperemia. If a left anterior small thoracotomy is used in left anterior descending artery direct revascularization, complete LIMA harvesting is not mandatory and depends on the personal preference of the surgeon.