1/7. Monoclonal gammopathy and spurious hypophosphatemia.BACKGROUND: Spuriously low levels of plasma phosphate have been reported previously in patients with multiple myeloma and polyclonal gammopathy. We report 2 cases of spurious hypophosphatemia in patients with elevated concentrations of serum monoclonal immunoglobulins, 1 of whom had monoclonal gammopathy of undetermined significance and the other multiple myeloma. methods: Plasma phosphate concentrations were measured using nondeproteinized and deproteinized plasma samples from patients with monoclonal gammopathies. RESULTS: In 2 patients with monoclonal gammopathy, the levels of plasma inorganic phosphate were reported as <1.0 mg/dL when the phosphate concentration was determined using an analyzer that employs nondeproteinized plasma. When the samples were reanalyzed using a laboratory method that removes serum proteins, normal or elevated concentrations of phosphate were found. Plasma levels of phosphate in 4 other patients with monoclonal gammopathy were normal by both methods. CONCLUSIONS: These data confirm previous reports that spurious hypophosphatemia occurs in some patients with increased levels of serum monoclonal immunoglobulins when laboratory methods using nondeproteinized samples are employed. The occurrence of unusually low plasma phosphate concentrations in patients without symptoms or clinically apparent causes of hypophosphatemia should alert physicians to search for monoclonal gammopathy.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/7. Fatal hepatic decompensation in a bone marrow transplant recipient with HBV-related cirrhosis following lamivudine withdrawal.lamivudine is a nucleoside analogue with a potent antiviral activity used as prophylaxis against hepatitis b virus reactivation in patients with chronic HBV infection receiving chemotherapy. No standard guidelines exist, however, for the duration of lamivudine treatment. We report a clinical case of a 56-year-old patient with HBeAg-negative cirrhosis who developed a multiple myeloma. He was treated with lamivudine for 1 year while receiving chemotherapy and a subsequent bone marrow transplant. Complete remission from multiple myeloma was achieved. Four months after lamivudine was withdrawn, he experienced HBV reactivation with jaundice, though no YMDD mutations were detected. The patient rapidly developed fatal decompensation with septicemia and renal failure. In conclusion, this case shows that physicians should avoid discontinuing nucleoside therapy in patients with HBV infection who undergo immunosuppression for concomitant neoplastic conditions.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/7. Surgical stabilization of pathological neoplastic fractures.The most important factor to consider in deciding between treatment options in the management of metastatic bone disease is the level of the patient's dysfunction and pain. Severe dysfunction or pain demands a treatment that predictably leads to a quick resumption of the painless activities of daily living. A treatment that predictably will restore function in months may seem reasonable in patients with a normal remaining life span, but is untenable if those months represent a high percentage of remaining life span, as they do in metastatic disease afflicted patients. The treating physician needs also to understand the basis for the patient's dysfunction. A destroyed joint will not return to painless function even if the metastasis responsible is totally eliminated. A bone that has lost its structural integrity, even though not grossly fractured, will not support weight bearing for months even if the metastasis is eliminated. Control of the metastatic tumor does not always equate with return to function. Treatment options in the management of metastatic bone disease are not mutually exclusive. In many patients treatment options are combined. Surgical stabilization may best return the patient's function while he is being treated postoperatively with radiotherapy or chemotherapy for good neoplasm control. Neoplasm control should not be such an overriding concern that function is not addressed. Function can almost always be returned to the patient, but neoplasm "cure" is rarely achieved in this group of patients. It is a reasonable goal to avoid allowing bone metastasis to progress to pathological fracture. Routine periodic examinations and bone scans should commonly alert the treating physician to the presence of metastatic bone disease well before fracture occurs. Pathological fracture narrows the range of treatment options, mitigates against full functional restoration, demands a rehabilitation hiatus, and acutely frightens the patient who does not have time to participate fully in treatment decisions. An impending pathological fracture can be treated with surgery, radiotherapy, chemotherapy, or hormonal manipulation. The options are basically operative or nonoperative. Lesions that predictably will fracture short term, involve joints, or will cause catastrophic consequences if fracture occurs should be strongly considered for surgical stabilization. Other factors to consider are the location of the metastasis, the primary tumor, and the expected response to nonoperative therapy. The patient becomes a surgical candidate for the above reasons and not because of any estimated life span.(ABSTRACT TRUNCATED AT 400 WORDS)- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
4/7. Identical twin marrow transplantation in multiple myeloma.We performed the first successful syngeneic bone marrow transplantation (BM Txp) in a patient with multiple myeloma. The patient and his normal identical twin are 50-year-old physicians. Prior to BM Txp, a partial remission was achieved with 1 year of continuous low dosage melphalan and prednisone therapy. Immediately before BM Txp, high dose cyclophosphamide and total body irradiation were administered in an attempt to eradicate the residual tumor. For 17 months after BM Txp, the patient was asymptomatic and hematologically normal although a low concentration of serum monoclonal IgGK persisted. In the 18th month, recurrence of bone pain and increase in the monoclonal IgG signalled exacerbation of the disease. Chemotherapy was resumed and again produced objective and subjective evidence of response. This study demonstrates the feasibility and potential usefulness of syngeneic BM Txp in myeloma.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/7. Electroencephalographic abnormalities in interferon encephalopathy: a preliminary report.Although several studies have shown that interferon does not readily cross the blood-brain barrier, recent reports have described central nervous system effects in patients receiving interferon. At our institution, we encountered three patients who had symptoms of toxicity of the central nervous system (somnolence, confusion, and gait difficulties) in association with electroencephalographic abnormalities while receiving alpha 2-interferon therapy for multiple myeloma. The electroencephalogram showed diffuse slow-wave abnormalities in two of the patients and generalized sharp-wave discharges in the third patient. Because the use of interferon is increasing, physicians should be aware of the central nervous system complications and the electroencephalographic changes that can be associated with such therapy.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/7. Proliferative disorders of the plasma cell.The incidence of plasma cell malignancies increases with age. Since the average age of the American population is increasing, family physicians can expect to diagnose and manage an increasing number of these patients. Symptomatology is varied and, in early stages, subtle. The principal entities are multiple myeloma. Waldenstrom's macroglobulinemia and heavy chain diseases. Comparatively benign disorders include benign monoclonal gammopathy and plasmacytoma. The cornerstone for diagnosis of plasma cell malignancies is serum immunoglobulin electrophoresis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/7. 'A home-body' or 'antrums to Alkeran'.This case sharpened my ideas on the comprehensive management of hypertension, and the variety of approaches possible for certain benign, minor complaints that still required sensitive handling. It tested my ability to remain objective and investigative when the need arises, especially when there is a risk of complacency when seeing a patient regularly over several years. It illustrates the role of the general practitioner in the team that enables old folk to stay on at home; it illustrates the role of our specialist colleagues in enhancing our comprehensive primary care functions. And I am constantly reminded of the major challenges for the primary care physician in the decade ahead in the provision of health care for the elderly.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |