Transactions of the House of Delegates

Aspiration of vomitus is one of the leading causes of anesthetic deaths. These deaths can be prevented only by proper evaluation of the patient preoperatively and assuming that any patient dealt with in emergency has a full stomach until proven otherwise.Preliminary observations on the incidence of “silent regurgitation and aspiration” in a series of patients anesthetized for elective operation indicated that by obtaining a smooth induction and preventing any respiratory obstruction during anesthesia, regurgitation and aspiration can be minimized.     

Circulating thyroglobulin and antithyroglobulin antibodies after fine needle aspiration of thyroid nodules

Circulating thyroglobulin and antithyroglobulin antibodies were assayed in fifteen patients affected by solitary "cold" nodules of the thyroid who had undergone fine needle aspiration for cytologic diagnosis. The aim of the study was to investigate whether a minor insult to thyroid tissue such as fine needle aspiration is able to release thyroglobulin into the circulation and to induce the formation of antithyroglobulin antibodies. The results obtained are as follows: 1. Circulating thyroglobulin increased substantially after fine needle aspiration in 11 out of 15 patients. 2. Antithyroglobulin antibodies did not appear in any patient during a follow-up period of two months. 3. The magnitude of basal thyroglobulin and thyroglobulin increase after needle aspiration were unrelated to cytologic diagnosis.     

Aspiration-Related Deaths in 57 Consecutive Patients: Autopsy Study

Background

Aspiration can cause a diverse spectrum of pulmonary disorders some of which can lead to death but can be difficult to diagnose.

Patients and Methods

The medical records and autopsy findings of 57 consecutive patients in whom aspiration was the immediate cause of death at Mayo Clinic (Rochester, MN, USA) over a 9-yr period, from January 1 2004 to December 31 2012 were analyzed.

Results

The median age at death was 72 years (range, 13–95 years) and included 39 (68%) males. The most common symptom before death was dyspnea (63%) and chest radiography revealed bilateral infiltrates in the majority (81%). Most common precipitating factors for aspiration were depressed consciousness (46%) and dysphagia (44%). Aspiration-related syndromes leading to death were aspiration pneumonia in 26 (46%), aspiration pneumonitis in 25 (44%), and large airway obstruction in 6 patients (11%). Aspiration was clinically unsuspected in 19 (33%) patients. Antimicrobial therapy had been empirically administered to most patients (90%) with aspiration pneumonia and aspiration pneumonitis.

Conclusion

We conclude aspiration-related deaths occur most commonly in the elderly with identifiable risks and presenting bilateral pulmonary infiltrates. One-third of these aspiration-related pulmonary syndromes were clinically unsuspected at the time of death.     

Diagnostic pitfalls in fine needle aspiration of solitary pulmonary nodules: two cases with radio-cyto-histological correlation

Background

Fine needle aspiration is an important tool for diagnosis and preoperative evaluation of solitary nodules of the lung. It provides a definitive diagnosis in most patients at low cost with minimal trauma. However, because of the nature of the study and the presentation of the cells in a more distorted and incomplete tissue structure than a histological slide, false positive results can occur. Prior detailed clinical knowledge about the patient, procedures and methods of radiology in obtaining the aspirate specimen is extremely useful in the accurate interpretation of fine needle cytological specimens.

Case presentation

We report two cases of solitary pulmonary nodules in two elderly females, which were initially diagnosed as malignant by fine needle aspiration biopsy. Both cases subsequently underwent pulmonary lobectomy in which, one turned out to be a pulmonary hamartoma and the other appeared to be a middle lobe syndrome of the right lung with liver tissue contamination at the time of fine needle aspiration of the lung.

Conclusions

We are now strong believers that much care must be taken in the interpretation of fine needle aspiration of solitary nodules of the lung. Complete study of the entire specimen, including the cell block, is warranted, since what one interprets as malignant, could have different features in another part of the sample. Last but not the least, prior knowledge of the complete clinical history of the patient together with the salient radiological findings would greatly facilitate the cytopathologist to reach an accurate diagnosis.     

Management of uraemic pericarditis.

Of 250 patients undergoing haemodialysis from 1967 to 1974 17 presented with uraemic pericarditis. Seven of these patients who had been transferred early enough to peritoneal dialysis treatment were cured without pericardiectomy (mean survival 18 months (range 6-36); no deaths). Only one patient was cured from his pericarditis by "aggressive haemodialysis." In seven out of 10 patients treated with haemodialysis, pericardiectomy finally had to be performed because of pericardial tamponade (postoperative survival 20 months (range 8-36); one death). Two patients died from pericardial tamponade before surgery. In patients with evidence of uraemic pericarditis frequent peritoneal dialysis with high fluid withdrawal is the treatment of choice, but in cardiac tamponade pericardiectomy should follow a preoperative pericardiocentesis with limited fluid aspiration. Of possible significance in the aetiology of pericarditis were the findings that 10 of the 17 patients had hypertension with cardiac enlargement and that 14 presented with evidence of underdialysis, possibly due to the reuse of dialysis components.     

The cubital tunnel syndrome caused by intraneural ganglion cyst of the ulnar nerve at the elbow: a case report

Background

Cubital tunnel syndrome is common nerve compression syndrome among peripheral nerve compression diseases. However, the syndrome caused by intraneural ganglion cysts has been rarely reported. Medical approaches, like ultrasound-guided aspiration and open surgical treatment remain to be discussed.

Case presentation

A 57-year-old woman presented with occasional pain, numbness and paralysis in her left hand and a palpable, painless mass in the ulnar side of her left elbow. Ultrasound-guided aspiration of the mass was performed to decompress the ulnar nerve. The patient experienced an evident release of pain in her hand, but symptoms of numbness and paralysis recurred 3 months later which greatly bothered the patient’s daily life. After evaluation, we had to perform an open surgery to excise the cyst. External neurolysis and anterior subcutaneous transposition were done. The patient was followed up for 2 years, and she made a complete recovery with no functional limitation.

Conclusions

The symptoms caused by intraneural ganglion cyst can be alleviated by accurate puncture. But puncture may be not complete and symptoms could recur. Complete external neurolysis can be counted as a complete and reliable treatment. Therefore, early diagnosis, careful preoperative imaging assessment and full decompression can be expected to receive a good rehabilitation.

     

Usefulness of core needle biopsy for the diagnosis of thyroid Burkitt’s lymphoma: a case report and review of the literature

Background

Thyroid lymphomas are an exceptional finding in patients with thyroid nodules. Burkitt’s lymphoma is one of the rarest and most aggressive forms of thyroid lymphomas, and its prognosis depends on the earliness of medical treatment. Given the rarity of this disease, making a prompt diagnosis can be challenging. For instance, fine-needle aspiration (FNA) cytology, which is the first-line diagnostic test that is performed in patients with thyroid nodules, is often not diagnostic in cases of thyroid lymphomas, with subsequent delay of the start of therapy.

Case presentation

Here we report the case of a 52-year-old woman presenting with a rapidly enlarging thyroid mass. Thyroid ultrasonography demonstrated a solid hypoechoic nodule. FNA cytology was only suggestive of a lymphoproliferative disorder and did not provide a definitive diagnosis. It is core needle biopsy (CNB) that helped us to overcome the limitations of routine FNA cytology, showing the presence of thyroid Burkitt’s lymphoma. Subsequent staging demonstrated bone marrow involvement. The early start of an intensive multi-agent chemotherapy resulted in complete disease remission. At 60 months after the diagnosis, the patient is alive and has not had any recurrence.

Conclusions

Clinicians should be aware that thyroid Burkitt’s lymphoma is an aggressive disease that needs to be treated with multi-agent chemotherapy as soon as possible. To diagnose it promptly, they should consider to order/perform a CNB in any patient with a rapidly enlarging thyroid mass that is suspicious for lymphoma.

     

Endoscopic fine needle aspiration biopsy

A catheter assembly that can be passed through the biopsy channel of a standard fiberoptic gastroduodenoscope was devised to permit fine needle aspiration biopsy of gastrointestinal neoplasms under direct vision of the endoscope. This technique for endoscopic aspiration biopsy was performed in ten consecutive patients with esophageal and gastric carcinomas, along with the conventional endoscopic brushing and biopsy. Endoscopic aspiration biopsy gave a positive diagnosis in all ten cases while the other two techniques gave inconclusive results in one patient with an ulcerative growth. We feel that endoscopic aspiration biopsy can be used to obtain representative samples from gastrointestinal neoplasms, and it may add to the diagnostic accuracy of endoscopic biopsy and brushing cytology.     

Prevention of cardiac arrest: the role of the anesthesiologist

Many operating room deaths from "cardiac arrests" are potentially avoidable as well as potentially reversible. The incidence of these catastrophes may be substantially reduced by careful and adequate preoperative evaluation and preparation of the patient, by constant care and vigilance in the administration of anesthetic agents and adjuvants, and by close cooperation between members of the surgical team, with the safety of the patient being the first consideration at all times.     

The design and development of a biosensor to measure the concentration of meconium in amniotic fluid

Meconium aspiration syndrome occurs in 0.2% to 1% of all deliveries and has a mortality rate as high as 18%. The disease is responsible for 2% of all perinatal deaths. Meconium may be classified as being thick or thin, but this assessment is normally performed visually by clinicians. A "meconiumcrit" analysis has been developed to objectively define the concentration of meconium. However, this analysis does not provide real-time continuous readings. This study focused on the design and development of a sensor to provide an objective, continuous, real-time assessment of meconium thickness. Meconium has an absorption spectrum centered at 410 nm and observes Beer's law. Blue light centered at 430 nm was delivered through meconium solutions, and a photodiode translated the strength of the incoming light into a voltage. This voltage was analyzed by a microcontroller to determine the concentration of meconium.     

Fine needle aspiration of subcutaneous masses caused by Aspergillus: a report of 2 cases

BACKGROUND: Fine needle aspiration biopsy is a well-established method for dijfrrentiation of infective from neoplastic lesions. Varions infective agents, such as mycobacteria, leishmaniasis and microfaria can be diagnosed from aspirates, but there are few case reports on fungal infections in aspirates. Cytologic diagnosis of Aspergillus has occasionally occurred on sputum, pulmonary samples, vaginal secretions, endometrial washings and maxillary sinus specimens. One case of hepatic and subcutaneous masses was diagnosed as Aspergillus by fine needle aspiration and confirmed by culture and histology. CASES: Two cases of subcutaneous aspergillosis were diagnosed by fine needle aspiration and confirmed by culture and histology. CONCLUSION: Fine needle aspiration cytology is a rapid, sensitive and important method of diagnosing Aspergillus and provides a rapid diagnosis, which may be life saving in an immunocompromised patient.     

Granulocytic sarcoma of the small intestine in a child without leukemia: report of a case with cytologic findings and immunophenotyping pitfalls

BACKGROUND: Granulocytic sarcoma is a rare tumor that is often misdiagnosed as it can be confused with lymphoma. It has unique cytologic features independent of the site of the tumor and can be identified on fine needle aspiration. CASE: A 13-year old girl without a relevant medical history presented with an abdominal mass. Investigation revealed a tumor infiltrate in the small intestine and mesentery. The fine needle aspirate contained myeloid blasts with cytoplasmic granules. Immunohistochemistry on subsequent biopsy confirmed myeloid differentiation. There was no evidence of blood or bone marrow involvement suggestive of acute leukemia. The patient was well after 27 months of follow-up. CONCLUSION: Granulocytic sarcoma should be included in the differential diagnosis of any small intestine infiltrate. Cytomorphology is accurate and efficient for the diagnosis in conjunction with complete immunocytochemistry study.     

Neonatal Respiratory Distress: Experience at The Hospital for Sick Children,Toronto, 1960-1961

Four hundred and thirty infants selectively referred to the Newborn Unit of The Hospital for Sick Children, Toronto, with the symptom of respiratory distress, were reviewed. There were 142 cases of the “idiopathic respiratory distress syndrome” (IRDS), of which 67 were fatal. The remainder included 100 cardiac (76 deaths), 63 extra-pulmonary (28 deaths) and 109 other specific pulmonary conditions (54 deaths). Of the 109, half were due to massive aspiration. Serial observations and radiographs led to correct clinical diagnosis in 85% of necropsy-proved cases of IRDS and in a comparable proportion of all other conditions. The incidence and mortality rate of IRDS were twice as high in males as in females. A significant number of premature infants have transient respiratory distress after birth, and diagnostic criteria for inclusion in any study should be defined in detail. This study emphasized the large contribution of disorders of the respiratory and cardiac systems to neonatal mortality and led to the formation of a special department for intensive care and research in these conditions.     

Metastatic spindle-cell carcinoma. Cytologic features and differential diagnosis

Fine needle aspiration biopsies of tumors can yield a variety of spindle cells derived from several types of neoplasms. Among these is a rare lesion known as a "spindle-cell carcinoma" or "pseudosarcoma," which may represent a transformation of a preexisting squamous-cell carcinoma that has been subjected to radiotherapy or solar damage. The cytologic, histologic and ultrastructural features of a case of metastatic spindle-cell carcinoma of the rib subjected to fine needle aspiration are presented, and other spindle-cell tumors that should be considered in the differential diagnosis are discussed.     

"Aachen 3-D-finger". Development of a 3-D-digitizer for use in dental, oral and maxillary treatment

The "AACHEN 3D Finger" is a three-dimensional measuring system for use in all fields of dentistry. The system can equally as well be installed on a plane table, as fixed to the head of a patient. The measuring device is computer-assisted, and is able to localize, register and calculate any combination of points in the oral and maxillofacial area. The reference system can be changed at any time. The "AACHEN 3D Finger" can be used as a computer-a ded system in dentistry as well as in implantology or dental and maxillofacial surgery.     

Test reduction: I--Introduction and review of published work.

The word "test" is used in a more general sense to describe the process of eliciting evidence of any kind from a patient, and this paper explores the thesis that much evidence is unnecessary and that therefore much test reduction is possible. The value of test reduction can be measured by its efficiency--that is, its effect on the misclassification of disease--or, preferably, by some measure of its cost-effectiveness.     

Investigation into use of drugs preceding death from asthma.

Copies of death certificates were provided by the Registrar General for all deaths attributed to asthma in persons aged 5 to 34 years which were registered in England and Wales in the last quarter of 1966 and the first quarter of 1967. Information was obtained from the relevant general practitioners about 177 of the 184 subjects, and necropsy data were obtained for 113 of the 124 cases in which a post-mortem examination was known to have been made. Ninety-eight per cent. of the subjects for whom evidence was obtained were known to have been suffering from asthma, and signs of severe asthma (overdistended lungs and small bronchi plugged with mucus) were found in 91% of necropsies (57% of all deaths). Evidence that death might have been due to any other pathological condition was rare. Death was sudden and unexpected in 81% of the subjects (137 out of 171), and 59% of all deaths were referred to coroners. In 39% of cases (67 out of 171) the practitioner had not regarded the patient as suffering from severe asthma in his terminal episode. Corticosteroids and sympathomimetic preparations were the only drugs to have been used by a large proportion of patients. Two-thirds of the patients had received corticosteroids before the terminal episode, but detailed information about their use provided no suggestion that excess use could have been responsible for any large proportion of the deaths. Eighty-four per cent. of the patients were known to have used pressurized aerosol bronchodilators, and several instances of their use in excess were described. Routine inquiries about their use in the hours immediately preceding death were not made, and further evidence is required before their effect can be assessed adequately.     

Pulmonary histopathology in an experimental model of chronic aspiration is independent of acidity

Gastroesophageal reflux has become a major health concern in industrialized countries, with drugs aimed at blocking acid production being more frequently prescribed than any other drug. Damage to lung tissue as a result of chronic aspiration of gastric fluid is a primary health risk associated with gastro-esophageal reflux, with such aspiration being suspected in the induction or exacerbation of asthma and other lung diseases. In this study, a rodent model of chronic aspiration was used to characterize the pulmonary histopathology produced by repetitive aspiration events and to investigate the pathologic roles of individual gastric fluid components such as acid and particulate food matter. Rats exposed to chronic aspiration of whole gastric fluid developed a pathology distinct from that of acute lung injury, characterized by granulomatous interstitial pneumonitis with prominent formation of multinucleated giant cells. This pattern of injury could be reproduced with chronic aspiration of particulate food matter and with chronic aspiration of pH-neutralized gastric fluid, but not with chronic aspiration of hydrochloric acid. Thus, since acid-neutralizing therapy is currently the mainstay of treatment for patients with reflux-associated respiratory symptoms, these results strongly suggest that alternative therapeutic approaches aimed at preventing chronic-aspiration induced lung injury may be warranted.     

Telediagnosis of transbronchial fine needle aspirations--a feasibility study.

AIM: To analyze the diagnostic accuracy of telediagnostic procedures for transbronchial fine needle aspirations. MATERIAL AND METHODS: A double blind study was performed on cytological slides of 54 randomly selected cases with transbronchial fine needle aspirations. The slides were digitized using a Leica digital camera DC100 mounted on a microscope Leica Laborlux S, and analyzed by an experienced pathologist without knowing the definite diagnosis or any additional clinical data. The diagnoses stated by analyzing the digital images were compared to the final conventional diagnoses. In addition, the duration of the digital diagnosis, used magnifications, and difficulties for correct sampling were documented. RESULTS: The "digital" diagnoses of the 54 cases were all in general agreement with the definite diagnoses. No wrong positive or wrong negative case in respect to malignant/non-malignant (31/23) or to small cell/non-small cell (9/22) occurred. The performance of a digital diagnosis lasted for 115 s at average (15-260 s), and is significantly longer compared to that of conventional fine needle aspiration judgement (20 s). The screening magnification was commonly set to x2.5, that for definite diagnostic analysis x40. Benign diseases (2 tuberculosis and 3 sarcoidosis cases) were correctly classified. CONCLUSIONS: Telepathology systems can probably be used for fine needle aspiration analysis without major diagnostic errors. Their use can improve the endoscopic sampling and avoid second anesthesia when missing the lesion of request during the first examination.     

Does Large Needle Aspiration Biopsy Add Pain to the Thyroid Nodule Evaluation?

Thyroid large needle aspiration biopsy is disregarded because it is thought to be associated with pain. This is in contrast with our 32 years long experience. We surveyed reports of pain in patients examined with fine needle aspiration biopsy (78, 87.2% women, mean age 59 years) or FNAB+large needle aspiration biopsy (48, 87.5% women, mean age 60 years). Each patient was questioned regarding a) no unpleasant sensation (score “0”); b) unpleasant sensation (“1”); c) mild pain (no analgesic used; “2”); or d) pain (analgesic used; “3”). The mean size of the needle used was for FNAB 22.3±0.7 or 20.8±1 gauge in the fine needle aspiration or fine needle aspiration plus large needle aspiration biopsy group, respectively (p<.0001). The number of percutaneous punctures was higher in the fine needle aspiration plus large needle aspiration biopsy group. However, the pain score in the fine needle aspiration biopsy or fine needle aspiration biopsy plus large needle aspiration biopsy group was not significantly different. Large needle aspiration biopsy after fine needle aspiration biopsy does not add any discomfort or pain and therefore in light of the demonstrable benefits, should be included in clinical algorithms for the evaluation of thyroid nodules.