Non-caseating granulomas in patients with hematologic malignancies. A report of three cases

Sarcoidosis or sarcoid-like lesions occurred in three patients with hematologic malignancies. In one patient, an overlap syndrome sarcoidosis/polycythemia vera was the most probable diagnosis. In the other two cases, the granulomas were probably secondary to myelofibrosis and Waldenstr?m's disease, respectively. Recent epidemiological studies have failed to show a causal relationship between sarcoidosis and malignancy. The co-existence of sarcoidosis and malignancy is probably fortuitous, but non-caseating granulomas may occur secondary to malignant diseases.     

No benefit from adding GM-CSF to induction chemotherapy in transforming myelodysplastic syndromes: better outcome in patients with less proliferative disease.

In this prospective randomized multicenter trial 93 patients, median age 72 years, with RAEB-t (n=25) and myelodysplastic syndrome (MDS)-AML (n=68) were allocated to a standard induction chemotherapy regimen (TAD 2+7) with or without addition of granulocyte-macrophage-CSF (GM-CSF). The overall complete remission (CR) rate was 43% with no difference between the arms. Median survival times for all patients, CR patients, and non-CR patients were 280, 550, and 100 days, respectively, with no difference between the arms. Response rates were significantly better in patients with serum lactate dehydrogenase (S-LDH) levels 相似文献   

Rapid recovery protocol applied to 5,658 consecutive "on-pump" coronary bypass patients

Background. Increasing hospital costs, restricted resources, and new surgical strategies have stimulated effectiveness of all routines in cardiac surgery. Over a 10-year period, 5,658 consecutive patients undergoing coronary artery bypass grafting followed a protocol aiming at short postoperative intubation times and rapid physical rehabilitation.

Methods. The patients were prepared for rapid recovery, emphasizing (1) preoperative education and respiratory training, (2) low-dose fentanyl anesthesia, (3) limited ischemic times and pump times, (4) mild hypothermia and rewarming to a rectal temperature of 36°C, (5) restricted use of extended monitoring, (6) autologous blood salvage to avoid allogeneic blood transfusions, and (7) active physical training from postoperative day 1. All in-hospital data relevant to these steps were prospectively stored in a database.

Results. The median extubation time after arrival in the intensive care unit was 1.5 hours (0 to 320 hours). More than 99% of the patients were extubated within 5 hours. Sixty-two patients (1.1%) were reintubated and ventilated for a median of 24 hours (1 to 430 hours), mostly due to resternotomy for bleeding or cardiopulmonary decompensation. In total, 5,594 patients (98.9%) were able to sit in a chair the first postoperative day. Within the fourth postoperative day, 82.5% were able to move freely in the hospital area and were in fact physically fit for hospital discharge. Allogeneic blood products were given to 3.9% of the patients. Twenty-three patients (0.41%) died in-hospital.

Conclusions. With the application of a protocol for rapid physical recovery in patients undergoing “on-pump” coronary artery bypass grafting, extubation within 1 to 2 hours was safe and feasible in most patients. After 5 hours, 99.3% of the patients were extubated, with a reintubation rate of 1.1%. More than 80% of the patients were fully physically mobile within 4 days after the operation.     

Brain metastases in patients under 50?years of age: retrospective analysis

Several previous publications suggested that younger patients with brain metastases have longer survival than older patients. However, detailed studies of younger patient groups are scarce. Therefore, a multi-institutional analysis of younger patients with brain metastases was performed (defined as adults with age <50?years). Prognostic factors for survival were examined by uni- and multivariate analyses and compared to those obtained in patients with age ??50?years. Multivariate analysis of 106 patients (median age 44?years, range 23?C49?years) revealed three independent prognostic factors for survival: performance status, extracranial metastases and primary tumor control. Survival was significantly better in patients treated after the year 2000 (median 9.4?months) as compared to those treated before the year 2000 (median 5.1?months, p?=?0.04). This improvement appeared to be related to an increased use of surgery or radiosurgery (SRS) and decreasing numbers of patients with uncontrolled primary tumor. Irrespective of management approach, survival beyond 5?years was uncommon (actuarial rate 6?%; 17?% in patients treated with upfront surgery or SRS). In conclusion, more intense multidisciplinary approaches aiming at control both in the brain, extracranial metastatic sites, and primary tumor site might have contributed to gradual survival improvements in recent years. Nevertheless, further efforts are necessary to improve long-term survival.     

Discriminant analysis of factors distinguishing patients with functional dyspepsia from patients with duodenal ulcer

Patients with duodenal ulcer or functional dyspepsia do not differ on dyspeptic symptoms. The aim of the present study was to test the hypothesis that functional dyspepsia and duodenal ulcer are two different diagnostic entities by examining the discriminating power of several anamnestic, biological, and psychosocial variables. Ninety-four patients with duodenal ulcer and 86 patients with functional dyspepsia were included. Anamnestic data, global assessment,Helicobacter pylori status, blood group, Lewis^a+ phenotype, and several measures of psychological distress and somatic complaints were registered. Compared to patients with functional dyspepsia, the duodenal ulcer patients were more often infected byHelicobacter pylori and had their stomach discomfort more often relieved by eating. Compared to patients with duodenal ulcer, patients with functional dyspepsia had higher scores of depression, trait anxiety, general psychopathology and different somatic complaints (called somatization). They were also less satisfied with the health care system, their disorder had a greater negative impact on their quality of life, and their global assessment of own health was poorer. Discriminant analysis including age, smoking,Helicobacter pylori status, global assessment, and somatic complaint classified 86.1% of the patients correctly (77.9% of the patients with functional dyspepsia and 93.6% of the patients with duodenal ulcer). It is concluded that duodenal ulcer and functional dyspepsia are two separate diagnostic entities. Patients with duodenal ulcer are older, smoke more often, and almost all are infected withHelicobacter pylori, while patients with functional dyspepsia are characterized by somatization and a negative assessment of their own health.     

Severe disruptive vocalizers

OBJECTIVES: To describe the most severe disruptive vocalizers in nursing facilities, in regard to their clinical and behavioral characteristics, staff responses, and treatments used, and to report on their prognosis over 6 months. DESIGN: A longitudinal cohort study. SETTING: One hundred seven skilled nursing facilities. PARTICIPANTS: The 203 residents who were among the two most disruptive vocalizers in their respective facilities and who vocalized at least 2 hours a day. MEASUREMENTS: Telephone interviews of licensed nursing staff who cared for the subjects, conducted at baseline, 2, 4, and 6 months. Data gathered included subject demographics, physical function, diagnoses, medication and restraint use, behavioral problems, vocalization characteristics, treatments used, and status at follow-up. RESULTS: Subjects tended to have dementia, to be dependent in most activities of daily living, to have multiple medical problems, to be physically restrained (48%), and to be taking psychotropic medication (76%). Nearly all (95%) were audible at least 50 feet away, with loudness associated with more severe cognitive impairment (OR 4.90, P = .001). When subjects who primarily made nonverbal noises ("screamers") were compared with those whose predominant expressions were words ("talkers"), hearing impairment, severe cognitive impairment, and greater dependency in activities of daily living characterized the screamers. Staff reported trying a variety of treatments with all subjects, often with little success. Two months after enrollment, 66% of surviving subjects vocalized fewer hours than at baseline, and 45% were rated as improved. Independent predictors of improvement included greater ADL independence, hearing and vision problems, shorter length of stay, urinary incontinence, and use of a treatment other than one-on-one interventions. Nearly one-quarter of subjects (23.4%) died within 6 months. Baseline factors associated independently with a higher probability of death included age, use of activity intervention, physical abusiveness, and absence of wandering. CONCLUSION: Severe disruptive vocalization is associated with severe cognitive and physical impairment and with a high probability of mortality within 6 months. Subcategorization of severe vocalizers by vocalization type or other associated factors may be useful for prognostic and treatment purposes.