Demographic and laboratory data may predict positive temporal artery biopsy.

BACKGROUND: Temporal artery biopsy is performed in patients suspected of having giant cell arteritis. This study was conducted to evaluate clinical and laboratory criteria correlating with positive biopsy results in an effort to limit the number of negative biopsies performed. METHODS: A retrospective review was performed of patients who underwent temporal artery biopsy at two urban medical centers from 2002 to 2009. A multivariate analysis of patient demographics, clinically relevant signs and symptoms, laboratory data, and pathologic outcomes was performed. RESULTS: Temporal artery biopsy histologically confirmed giant cell arteritis in 24% of cases. The mean age of those with disease was 77.8 y and those without were 73.1 y; age was found to be statically significant (P = 0.0227); 76% were female and 24% were male; gender was not significant (P = 0.9594); 42% were Caucasian (39% had a positive temporal artery biopsy), 27% were Hispanic (17% positive), and 31% of the patients were African-American (3% positive); ethnicity was significant (P = 0.0005). The PPV of elevated ESR was 27%; sensitivity was 100%; specificity was 16%. A history of headache or visual disturbance was not predictive of a positive biopsy CONCLUSION: Fewer negative biopsy results may be achieved by screening patients with normal ESR or lower risk patients with other modalities.

Mixed adenoneuroendocrine carcinoma (MANEC) of the gallbladder: a possible stem cell tumor?

A 48 year-old African American woman presented to her physician complaining of a rapidly evolving epigastric and right upper quadrant abdominal pain. A PET-CT of the abdomen and pelvis demonstrated hypermetabolic, polypoid masses within the gallbladder and several tumors in the left lobe of the liver for which she underwent diagnostic laparoscopy. The gallbladder revealed a 3.5 × 3.3 × 2.4 tan-brown exophytic mass located at the fundus and growing into the lumen with multiple contiguous papillary projections arising from the mucosal surface. A concurrent large cell neuroendocrine carcinoma and papillary adenocarcinoma of the gallbladder was revealed histologically. There was shared reactivity to antibodies directed against the distinct antigens for each morphological component with transitional tumor cells (of both histological components) located at the areas where the two tumor types merged, revealing common immunoreactivity for carcinoembryonic antigen, cancer antigen 19-9, keratin 19, c-kit (cluster of differentiation protein 117 (CD117)) and epithelial cell adhesion molecule. Ultrastructurally, individual cells were demonstrated to have overlapping features of neuroendocrine and glandular differentiation. The aforementioned histological, ultrastructural and immunohistochemical profile is strongly suggestive of a biphenotypic stem/progenitor cell tumor of the gallbladder.

The short-term and long-term effects of radical prostatectomy on lower urinary tract symptoms.

PURPOSE: We determined the long-term effect of radical prostatectomy on lower urinary tract symptoms. MATERIALS AND METHODS: Between October 1, 2000 and January 30, 2003, 587 men underwent open radical retropubic prostatectomy. Of these men 453 completed the American Urological Association symptom index at baseline, and 12 and 48 months. Mean changes in American Urological Association total, voiding and storage symptom scores were ascertained between baseline and 12 months (short term), baseline and 48 months (long term), and between 12 and 48 months (natural history of lower urinary tract symptoms without a prostate). Symptom scores were ascertained independently for men with baseline mild vs moderate/severe lower urinary tract symptoms. RESULTS: Clinically and statistically significant short-term and long-term improvements were observed in mean American Urological Association total, storage and voiding symptom scores for men presenting with moderate/severe lower urinary tract symptoms. The previously reported progression of lower urinary tract symptoms in the general population of men older than 40 years was not observed in our patients with an absent prostate. CONCLUSIONS: The current study provides compelling evidence that radical prostatectomy prevents the progression of lower urinary tract symptoms in men with and without baseline clinically significant lower urinary tract symptoms. This beneficial effect of radical prostatectomy on the natural history of lower urinary tract symptoms should be considered when weighing the risks and benefit of the treatment option for localized prostate cancer.

Informed consent for blood transfusion: what do medicine residents tell? What do patients understand?

Blood transfusion is a common intervention in the hospital setting, and its benefits may not be clear but it has associated risks. Despite this, transfusion consent may not be obtained satisfactorily. We assessed transfusion consent effectiveness by comparing information given by residents with information understood by patients who receive transfusions. Medicine department residents who obtained consent were surveyed via telephone in conjunction with bedside surveys of adult inpatients who received transfusions. A total of 43 patient and 34 resident surveys were completed. Deficiencies in the transfusion consent process were noted. Discussed transfusion benefits (such as wound healing) were not always true benefits whereas some important risks (such as transfusion-related acute lung injury) were infrequently conferred. Risks were more often reported as "not discussed" than benefits. Only a few participants were aware of the hospital's Transfusion Health Guide, which provides information on transfusion benefits, risks, and alternatives.

Russell body duodenitis: a histopathological and molecular approach to a rare clinical entity.

Russell bodies are pink eosinophilic accumulations within plasma cells. To date, two hypotheses have attempted to elucidate the biological events behind the formation of these bodies. One theory sustains that such bodies constitute cytoplasmic accumulation of immunoglobulin derivatives contained in the perinuclear cistern of the smooth endoplasmic reticulum because of an increased synthesis or altered secretion. On the other hand, since its initial description in the medical literature, several authors have attributed the formation of such bodies to the presence of microorganisms such as in the case of Russell body gastritis and its association to Helicobacter pylori infection. In an attempt to possibly characterize the presence of an infectious organism, we performed a thorough biomolecular analysis on a case of a 69-year-old female presenting with Russell body duodenitis which, to the best of our knowledge, constitutes the second report of this clinical entity in the English literature. In light that the events behind formation of such bodies in H. pylori-negative individuals remain unclear, we hypothesize on the possible pathways that could have led to their reactive mechanical and immune derivation.

Colonic-type adenocarcinoma of the base of the tongue: a case report of a rare neoplasm.

Lingual adenocarcinomas (ADC), either primary or metastatic to the tongue are extraordinarily rare neoplasms. Primary lingual adenocarcinomas are primarily of minor salivary gland origin. Two cases of primary colonic-type adenocarcinomas of the base of the tongue were recently reported for the first time in the English literature. We present an additional case of lingual intestinal-type adenocarcinoma with mucinous features that occurred in association with cervical node metastasis and discuss the clinicopathologic features and histogenetic aspects of this rare entity.

Carcinosarcoma of the bladder: case report and review of the literature.

Primary osteosarcomas of the bladder account for about 0.04% of bladder neoplasms. Most of the patients in the literature expired within 6 months and, in almost all of the cases in the literature, radical cystectomy with postoperative chemotherapy was the treatment choice. A 79-year-old gentleman presented with gross hematuria. Cystoscopy demonstrated a 2- to 3-cm tumour along the lateral wall of the bladder. The tumour was resected incompletely via initial transurethral resection of bladder tumour (TURBT), and a second TURBT was subsequently performed to fully resect the residual mass. Surgical pathology from these 2 resections revealed osteosarcoma with invasion into the muscularis propria. A cystoprostatectomy was performed and final pathologic specimen revealed high-grade CIS without evidence of residual osteosarcoma. Postoperatively, the patient did not receive chemotherapy or radiation and currently remains disease-free 2 years post-radical cystectomy. Only 33 well-documented cases of primary osteosarcoma of the bladder have been reported to date. However, there are only 3 cases in which TURBT resulted in complete resection.

The preoperative use of erythropoietin stimulating proteins prior to radical prostatectomy is not associated with increased cardiovascular or thromboembolic morbidity or mortality.

OBJECTIVES: To critically examine the cardiovascular and thromboembolic risks associated with erythropoietin stimulating proteins (ESPs) in men with normal hemoglobin levels undergoing open radical retropubic prostatectomy. METHODS: Between October 1, 2000, through December 31, 2006, a total of 1308 men underwent open radial retropubic prostatectomy by a single surgeon. Of these men, 1095 received preoperative ESPs. Hematocrit levels measured at baseline, immediately before anesthesia induction and at hospital discharge, were prospectively entered into a database. Thromboembolic and cardiovascular complications were prospectively captured during the hospitalization and after surgery. RESULTS: The mean Delta preoperative hematocrit level was 5.9 g/dL. The pre-anesthesia induction hematocrit level was 49.2%. Hospital discharge hematocrit level was 33.6 g/dL. The overall risk of cardiovascular and thromboembolic complications in men receiving ESP were 0.55% and 0.45%, respectively. The risk of cardiovascular and thromboembolic complications were independent of the Delta in preoperative hematocrit or the absolute level of the pre-anesthesia induction hematocrit. CONCLUSIONS: ESPs represent a safe and effective preoperative blood management strategy for men undergoing open radical retropubic prostatectomy.

Concurrent Chagas' disease and borderline disseminated cutaneous leishmaniasis: The role of amiodarone as an antitrypanosomatidae drug.

The occurrence of mixed infections of Trypanosoma cruzi and Leishmania spp. is becoming a common feature in Central and South America due to overlapping endemic areas. Unfortunately, the possibilities for treating flagellated kinetoplastid infections are still very limited and most of the available drugs exhibit severe side effects. Although the development of new drugs for Leishmania has markedly improved in the last years, the tendency is still to employ antimonial compounds. On the other hand, treatment for Chagas' disease is only available for the acute phase with no effective therapeutical options for chronic stage disease. The following case report substantiates the recently discovered effect of amiodarone as a nonconventional antiparasitic drug, particularly against Leishmania, breaching a new perspective in the therapeutic management of these important infectious parasitic diseases.

Postoperative blood loss predicts the development of urinary extravasation on cystogram following radical retropubic prostatectomy.

PURPOSE: We determined if the degree of postoperative bleeding predicts the extent of urinary extravasation on initial postoperative cystogram. MATERIALS AND METHODS: Between October 2000 to June 2004, 879 men underwent radical retropubic prostatectomy performed by a single surgeon. Of these men 97% underwent the initial postoperative cystogram 3 to 8 days following radical prostatectomy. Postoperative bleeding was expressed as the absolute change in hematocrit between hematocrit values measured immediately upon arrival into the recovery room and hospital discharge. Three hematocrit points were added to the change in postoperative hematocrit for every unit of blood transfused postoperatively. The relationship between the change in postoperative hematocrit and the extent of extravasation was examined. RESULTS: None, mild, moderate and marked extravasation was observed on the initial cystogram in 82.7%, 7.9%, 8.8% and 0.6% of cases, respectively. A significant relationship was observed between changes in postoperative hematocrit and the extent of extravasation on initial cystography (p <0.001). Postoperative changes in absolute hematocrit points of less than 2, 2 to 6 and greater than 6 identified clinically meaningful risk groups for urinary extravasation. The degree of extravasation was not significantly related to risk of anastomotic stricture or urinary incontinence. CONCLUSIONS: The extent of postoperative bleeding predicts the extent of urinary extravasation on initial cystography. It may be a useful measurement for identifying men who can safely undergo early catheter removal without cystography.

Time to return to work and physical activity following open radical retropubic prostatectomy.

PURPOSE: We identified factors that predict return to part-time and full-time work and resumption of unlimited physical activity following open radical retropubic prostatectomy. MATERIALS AND METHODS: Between July 1, 2002 and February 28, 2005, 537 men with clinically localized prostate cancer underwent open radical retropubic prostatectomy, as performed by a single surgeon. Intraoperative, perioperative and postoperative parameters were recorded in real time and entered into a database. An assessment was made 1 and 3 months postoperatively regarding time to return to work and unrestricted physical activity. RESULTS: Of the men 50% returned to part-time and full-time work, and unrestricted activity within 14, 21 and 30 days after discharge home, respectively. Patient age and hematocrit at hospital discharge significantly predicted return to part-time and full-time work, and unlimited physical activity. The number of days that the urinary catheter was indwelling was also associated with return to part-time work. Occupation (blue vs white collar) and marital status were also associated with return to full-time work. In the multivariate model a unit increase in hematocrit decreased the time to return to part-time and full-time work, and unrestricted physical activity by 0.50, 0.60 and 0.59 days, respectively. Men with discharge hematocrit greater than 32% were 1.57 (p = 0.059), 1.65 (p = 0.041) and 2.03 (p = 0.002) times more likely to return to part-time and full-time work, and unlimited activity before 14, 21 and 30 days, respectively. Overall models were developed that accounted for 9.4%, 14.0% and 4.0% of the time to return to part-time work, full-time work and unrestricted physical activity, respectively. CONCLUSIONS: Efforts to increase discharge hematocrit by minimizing intraoperative blood loss or using preoperative blood management strategies and earlier removal of the urinary catheter have a favorable impact on the return to work and physical activity.

Outcomes for men younger than 50 years undergoing radical prostatectomy.

OBJECTIVES: To compare the surgical outcomes after radical prostatectomy between men younger than 50 years and men 50 years old or older. METHODS: Between October 1, 2000 and December 31, 2003, 790 men underwent open radical retropubic prostatectomy by a single surgeon. The intraoperative, perioperative, and postoperative parameters were recorded in real time and entered into a database. The outcomes were compared for 66 men younger than 50 years of age (group 1) versus 724 men who were 50 years old or older (group 2). RESULTS: The pathologic stage, percentage of cancer in the surgical specimen, positive surgical margin rate, and Gleason score were not significantly different among the two age groups. No significant difference was found in the risk factors for prostate cancer between groups 1 and 2 (33.3% versus 28.9%, respectively; P = 0.63). The operative complications were exceedingly low in both groups. Of the men in groups 1 and 2, 93.3% and 97.1% achieved continence, respectively (P = 0.26). Of the potent men at baseline who underwent bilateral nerve-sparing prostatectomy, 100% of men in group 1 versus 81.4% in group 2 (P = 0.02) were having erections adequate for intercourse with or without phosphodiesterase-5 inhibitors or intracavernous injection therapy, as determined by direct patient interview. Of the men who underwent bilateral nerve-sparing radical retropubic prostatectomy, 78.3% of group 1 versus 62.6% of group 2 (P = 0.14) were potent with or without phosphodiesterase-5 inhibitors. CONCLUSIONS: The preoperative and pathologic predictors of organ-confined disease and biochemical recurrence were similar in both age groups. The results of this study have demonstrated that radical retropubic prostatectomy can be performed with good results and low complication rates in men with localized prostate cancer who are younger than 50 years of age.