We compared several clinical parameters between two different prostatectomy procedures, transurethral prostatectomy (TUR-P, 26 cases) among aged cases of benign prostatic hypertrophy. All patients were over 80 years old and were treated at Nippon Medical School Hospital from January 1983 to December 1988. TUR-P was superior to open prostatectomy in the following aspects, (1) operation time, (2) total amount of transfused blood and (3) hospital stay.

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Asthma was classified into four types, Ia-1 (bronchospasm with 0-49ml/day of expectoration), Ia-2 (with 5-99ml/day), Ib (over 100ml/day) and II (bronchiolar obstruction), according to clinical symptoms. Characteristics of airway responses in each clinical asthma type were compared between 25 elderly (mean age, 65.2 years) and 30 younger subjects (mean age, 44.9 years) with bronchial asthma, by observing ventilatory function and cellular composition in bronchoalveolar lavage (BAL) fluid. 1. In patients with types 1a-2 and Ib, the %V₂₅ value was significantly lower in the elderly subjects than in the younger subjects. 2. Comparing the values of ventilatory parameters of type Ia-1 cases with other asthma types, %V₂₅ value was lower in other asthma types than in type Ia-1 in the elderly. All ventilatory parameters examined were generally lower in type II cases than in other asthma types in the elderly, but this difference was not significant. In contract, in the younger subjects, the values of %MMF, %V₅₀ and %V₂₅ were significantly lower in type II cases than in other asthma types. 3. The proportion of neutrophils in bronchoalveolar lavage (BAL) fluid was higher in the younger patients with type II than in the elderly patients with the same type, although there was no significant difference between older and younger subjects. The proportion of BAL eosinophils in patients with type Ib was significantly higher in younger subjects than in elderly subjects. These results indicate that airway responses which are characteristic of each asthma type are stronger in younger patients than in elderly patients.

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A nutritional assessment is necessary to evaluate the pathophysiological state of patients, and serum lipids are one of the factors which must be evaluated. Body fat distribution is considered to be associated with cardiac diseases, metabolic diseases and hypertension. In this study, we performed quantitative measurements of fat distribution by X-ray computed tomography (CT) in 31 elderly outpatients. Thirteen males (mean age 74.8 years) and 18 females (mean age 75.4 years) were examined by abdominal CT. All subjects had body mass indices within the normal range and did not have malignant disease, hyperlipidemia, liver dysfunction or diabetes mellitus. CT scans were carried out at the level of the middle abdomen; these scan slices included intraabdominal fat which consisted of omental, retroperitoneal and perirenal adipose tissues. Subcutaneous fat areas and intraabdominal fat areas were measured from six 10-mm-thick slice films using a 2-dimensional computerized calculator. The relationship between serum lipids and fat distribution was also examined. The ratio of intraabdominal adipose tissue area to subcutaneous adipose tissue area (V/S) was higher in males than in females. V/S correlated positively with serum triacylglycerol and correlated negatively with serum HDL-Ch. These results suggest that the measurement of body fat distribution is important to evaluate lipid metabolism and nutritional states in the elderly.

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A 78-year-old woman was admitted to our hospital because of disorientation and fever on January 21, 1992. Two days before admission she experienced vomiting, anorexia and general malaise. Laboratory examinations on admission disclosed a hemoglobin level of 11.1g/dl and a platelet count of 8, 000/μl. The peripheral blood smear revealed anisocytosis with numerous schistocytes and poikilocytes. Polychromatophilic and nucleated red blood cells were also seen, and the reticulocyte count was 38‰. Her serum lactate dehydrogenase (LDH) value was 2, 977WU and the total serum bilirubin level was 3.5mg/dl with 2.7mg/dl indirect reacting fraction. Serum creatinine was 4.7mg/dl. Her consciousness became semicomatose after a systemic seizure which lasted approximately 15 seconds and her hemoglobin level decreased to 8.5g/dl on hospital day 2. Therefore, we diagnosed her as having thrombotic thrombocytopenic purpura (TTP) because of the presence of all 5 features, that is, thrombocytopenia, microangiopathic hemolytic anemia, fluctuating neurologic abnormalities, renal dysfunction and fever. A plasmapheresis with fresh frozen plasma (FFP) replacement was begun on that day. She was also treated with anti-platelet agents, 80mg/day aspirin, and 300mg/day dipyridamole. Moreover, packed red blood cells (PRC) were infused. While also receiving diphenylhydantoin and phenobarbital to prevent convulsions, status epilepticus developed on day 3. Because of inhibited spontaneous respiration which was an adverse effect derived from diazepam and sodium thiamylal administered intravenously to treat the status epilepticus, an artificial respiration was initiated. Twelve plasmaphereses were performed over 23 days with 25 to 50 units at each procedure and with a total of 375 units of FFP replacement. A total of 9 units of PRC was also transfused. Later, convulsions disappeared on the fifth hospital day and her consciousness gradually became normal, so she was weaned from artificial respiration on day 17. Platelet count rose to over 10×10⁴/μl on day 5, and serum creatinine decreased to the normal range on day 10. Moreover, her indirect bilirubin level also normalized on day 10, but it required about a month for the serum LDH value returned to normal. As sequelae of TTP, mild weakness of the right upper limb and neurogenic bladder were found, and computed tomogram of the brain demonstrated multiple small low density areas. Moreover, thrombophlebitis and edema in the lower limbs due to a bedridden condition for nearly a month were also noted. She was discharged with complete remission on April 11, 1992, 82 days after admission, continuing to be treated with daily anti-platelet agents, 80mg aspirin, and 300mg dipyridamole, as prophylaxis against relapse of TTP. At present, no evidence of relapse was found.

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A 77-year-old male had been noticing progressive weakness of the legs for three years. By the age of 75 he had difficulty in climbing stairs. On admission, serum level of CPK was moderately high. There were weakness and atrophy of the proxymal muscles. Deep tendon reflexes were depressed. Sensation was normal. The electromyogram and the biopsy of the femoral quadriceps muscles showed nonspecific changes. In 1989, he developed difficulty in walking and had congestive heart failure. On the second admission, moist rales were heard over the chest, and pitting edema was present in the lower extremities. The chest roentgenogram showed a cardiothoracic ratio of 63% and bilateral pleural effusion. The electrocardiogram showed atrial flutter with 2:1 conduction, QS in V_1∼3, rS in V₄, and ST depression and T inversion in V_{5, 6}. The echocardiogram revealed a thick left ventricular wall and impaired left ventricular contraction (EF 22%). Macroglossia, hepatosplenomegaly and renal dysfunction were not noted. Congestive heart failure progressed and he suddenly died of ventricular tachycardia in December 1989. At autopsy, skeletal muscle fibers varied in size and showed fiber splitting. A cellular infiltration was observed in the stroma. Amyloid deposit was positively stained with Congo red. The heart weight was 570g with marked left ventricular hypertrophy and moderate bilateral atrial dilatation. In both atria and ventricles, extensive amyloid deposition was found around myocardial fibers as well as in perivascular spaces. Amyloid was present also in the liver, the kidneys, the gastrointestinal tracts, and the other organs. This case was characterized as primary systemic amyloidosis with skeletal muscle atrophy and congestive heart failure. In primary amyloidosis, skeletal muscle atrophy is rare, however, myopathy can be the major manifestation of amyloidosis.

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In this paper we report on a 74-year-old female patient who was suffering from acute promyelocytic leukemia (APL) and who, upon admission to our hospital on February 20, 1992, was also found to be stricken with disseminated intravascular coagulation (DIC). The DIC, however, was quickly arrested by administration of heparin and there was no exacerbation. Also, on admission her peripheral blood leukocyte count was 700/ul, but after oral administration of all-trans retinoic acid (ATRA) (45mg/m/day) was begun on February 22, this count gradually increased and peaked at 35, 200/ul on March 7. Some of these matured leukocytes revealed dysplastic features; some had Auer bodies. At this time cytogenetic analysis of bone marrow cells showed 46 XX, t (15;17). The leukocyte count gradually decreased to 1, 500/ul, and the dysplastic features disappeared. On March 21 her thrombocytes and reticulocytes began to increase, and she achieved complete remission when her abnomral karyotype disappeared on March 24. She suffered no severe complications such as infection or hemorrhage during treatment. We therefore suggest that ATRA is very effective for APL in elderly patients. It neither exacerbates DIC nor increases the risk of infection. In fact, when ATRA treatment is compared to the standard cytotoxic chemothrapy there is a reduced risk of infection.

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