Usefulness of endomyocardial biopsy in tertiary care.

Over a 51-month period, 143 patients underwent right ventricular endomyocardial biopsy as part of their evaluation for cardiac disease. Of these, 82 patients presented with a clinical dilated cardiomyopathy, 28 patients with unexplained arrhythmia, 22 with other cardiomyopathies, 7 with anthracycline exposure, and 4 with miscellaneous indications. Overall, 47 of the 143 patients (33%) had findings on endomyocardial biopsy that changed the clinical diagnosis. Of these, 18 (38%) had a change in diagnosis based on nonspecific criteria. Although 32 of the 143 patients (22%) had specific therapeutic alterations based on the endomyocardial biopsy findings, the vast majority of these received immunosuppression for myocarditis, a therapy that is currently of unproven benefit. Therefore, endomyocardial biopsy is of limited therapeutic use for most patients with primary myocardial disease. Its current primary indications are for clinical diagnosis and investigation.     

131I Radioiodine therapy in Graves’ disease: Us et coutumes,controversies and guidelines

For almost 80 years ¹³¹I radioiodine (RAI) therapy has proven to be an efficient and well-tolerated therapeutic option in patients with Graves’ disease (GD). Along with anti-thyroid drugs (ATD) and thyroidectomy, RAI is one the three major therapeutic tools for this autoimmune disease. The objective of this article is to review how RAI treatment is usually conducted in clinical routine and to discuss the main controversies surrounding this treatment in the light of recent national or international guidelines. This will be an opportunity to discuss the indications and contraindications for this treatment, its advantages and limits, and more generally its practical organization by a specialized team.     

Trephine lung biopsy

Forty-five percutaneous trephine lung biopsies using the Steel apparatus were performed on 38 patients. Tissue was obtained on 42 occasions (94%) leading to histological or culture diagnosis in 33 patients (87%). Pneumothoraces (12 patients), bleeding into the airways or pleural space (4 patients), and tumour seeding along the needle track (1 patient) occurred in 38% of biopsy attempts (45% of patients). In contrast to the Vim-Silverman technique, the Steel trephine appears to produce a higher tissue yield and superior specimens for histological study. Trephine lung biopsy is comparable to open lung biopsy in providing positive diagnoses. With anticipation and expeditious management of complications, trephine lung biopsy is both safe and useful in the diagnosis of pulmonary disease.     

Digital subtraction angiography of patent ductus arteriosus

Digital subtraction angiography (DSA) was performed in 31 patients with the open arterial duct (OAD), of them 15 were outpatients. Diagnosis was made in all primary patients using DSA, indications and contraindications for endovascular occlusion of the OAD were defined. Of 17 patients examined at varying time after endovascular occlusion of the duct, valid signs of reliable occlusion of the duct were obtained in 16. In one patient a contrast medium got from the aorta to the pulmonary artery via the arterial duct indicating OAD incomplete closure. DSA can be used under outpatient conditions to define indications and contraindications for endovascular occlusion of the OAD and to assess its long-term effectiveness.     

Laparoscopy and laparotomy combined with bone marrow biopsy in staging Hodgkin's disease.

The relative merits of laparoscopy with liver and spleen biopsy and staging laparotomy were studied in 91 unselected patients with Hodgkin''s disease. Laparoscopy with liver and spleen biopsy were combined with needle biopsy of the bone marrow and laparotomy was combined with open bone marrow biopsy. In 65 untreated patients six out of seven with liver or marrow disease, or both, were shown to have extranodal lymphomas in these sites by laparoscopy plus needle marrow biopsy. Among 26 patients who had been treated this finding occurred in six out of 10 patients. Spleen biopsies during laparoscopy detected infiltration by lymphoma in 14 out of 37 (38%) patients with diseases spleens. Morbidity was higher after laparotomy than after laparoscopy. Laparoscopy produced abdominal bleeding secondary to splenic biopsy in two patients. All patients with Hodgkin''s disease should be subjected to laparoscopy plus needle marrow biopsy before undergoing laparotomy.     

单鼻孔-蝶窦入路垂体瘤切除术的体会

目的：探讨经单鼻孔-蝶窦入路垂体瘤切除手术的效果。方法：应用单鼻孔-蝶窦入路切除22例垂体瘤患者。结果：22例患者手术均顺利进行并于术后3月均获随访,全切除14例,次全切除5例,部分切除3例。结论：经单鼻孔-蝶窦入路显微切除垂体瘤属于微侵袭及功能保护性手术,符合现代神经外科的发展方向,严格把握适应症及禁忌症,完善手术技巧是提高手术效果的关键。     

单鼻孔- 蝶窦入路垂体瘤切除术的体会

目的:探讨经单鼻孔-蝶窦入路垂体瘤切除手术的效果。方法:应用单鼻孔-蝶窦入路切除22例垂体瘤患者。结果:22例患者手术均顺利进行并于术后3月均获随访,全切除14例,次全切除5例,部分切除3例。结论:经单鼻孔-蝶窦入路显微切除垂体瘤属于微侵袭及功能保护性手术,符合现代神经外科的发展方向,严格把握适应症及禁忌症,完善手术技巧是提高手术效果的关键。     

Potentially Serious Side Effects of High-dose Twice-weekly Rifampicin

Daily rifampicin in a single dose of 600 mg, combined with other drugs, usually streptomycin and isoniazid, was given to 49 patients for three months. It was planned to continue for another 15 months with twice-weekly rifampicin 1,200 mg plus isoniazid 900 mg, but the high incidence of side effects led to cessation of the intermittent regimen when only two patients had completed 18 months.Though there was no serious problem with daily treatment 11 patients (22%) were unable to continue rifampicin on the intermittent regimen. In 8 (16%) a pyrexial syndrome occurred. In one of these patients there was also temporary renal failure, and in another precipitous thrombocytopenia led to epistaxis and bleeding into the tongue and lips. Symptomless thrombocytopenia developed in two other patients, making three cases (6%) of thrombocytopenia in all.In 16 (33%) of the 49 patients antibodies to rifampicin were detected in the blood. Side effects occurred in 9 (56%) of these, including the three developing thrombocytopenia, but in only 2 (6%) of the 33 patients with no antibodies detected. This association of toxic reactions with antibodies is highly significant (P<0·001).     

Control of Heparin Therapy

Heparin therapy in 114 patients was controlled by daily blood tests—the whole blood coagulation time, kaolin-activated partial thromboplastin time of plasma, and plasma heparin assay. Bleeding episodes occurred in 7 out of 92 patients (7·6%) who had normal haemostatic mechanisms before therapy and in 11 out of 22 patients (50%) with defective haemostasis, mostly due to intravascular coagulation or renal failure. The dose of heparin ranged from 20,000 to 60,000 units in each 24-hour period. In some patients bleeding was related to overdosage, but in others the laboratory tests indicated satisfactory or suboptimal dosage at the time of bleeding. Though there were positive correlations between the results of the three tests, these were not close, and no one test was preferable. Hence laboratory control of heparin therapy is unsatisfactory and patients may bleed despite careful control of the dose by all three methods.     

The Indications for Dilatation and Curettage

Historical aspects of dilatation and curettage are discussed and the indications reviewed for this procedure in three major age-groups: (1) childhood and adolescence, (2) maturity and reproductive period, (3) menopause and post-menopause. As the most frequently performed obstetrical and gynecological procedure, it is not an innocuous operation, and clear-cut indications for its use are presented with reference to abnormal vaginal bleeding in all age groups, infertility, functional ovarian tumours, neoplasia of the uterus, cervical biopsy, and major pelvic surgery. It is concluded that dilatation and curettage has a major place in the diagnostic and the therapeutic armamentarium of the thorough obstetrician and gynecologist.     

Is needle-directed breast biopsy overused?

We undertook this study of needle-localized breast biopsy--a frequently done surgical procedure--to examine current practice patterns and to determine if the technique is overused in any group of patients. From a retrospective review of medical records of all patients who had needle-localized breast biopsy at a teaching hospital between June 1, 1988, and October 31, 1990, we found that a total of 125 were done: 24 biopsy specimens showed malignancy (19%). Mammographic indications for biopsy were microcalcification (n = 62, or 50%), mass or density (n = 60, or 48%) and mass and calcifications (n = 3, or 2%). Indications for biopsy in patients with cancer were microcalcification (14 patients) and mass or density (10 patients). The incidence of malignancy increased with age. In patients younger than 40 years, no biopsy showed malignancy. Only 2 of 30 biopsies done in patients younger than 50 showed cancer (7%). Breast cancer was most frequently discovered in patients in the seventh and eighth decades of life, and this group accounted for 75% of "positive" biopsies. Needle-localized breast biopsy is a useful technique in the early diagnosis of breast cancer. Although indications for the procedure should remain liberal, in women younger than 50, the percentage of biopsies that reveal malignancy is low.     

经皮椎间孔镜与Mast Quadrant通道技术治疗腰椎间盘突出症临床疗效比较

目的:研究和比较经皮椎间孔镜(Percutaneous Transforaminal Endoscopic Discectomy,PTED)与Mast Quadrant通道技术治疗腰椎间盘突出症(Lumbar disc herniation,LDH)的临床疗效及安全性。方法:回顾性分析2008年至2015年在本院接受手术治疗的单节段LDH患者90例,其中接受经皮椎间孔镜椎间盘突出髓核摘除术(PTED)患者58例,接受Mast Quadrant通道系统下腰椎间盘切除术患者32例,按手术方式的不同分为PTED组与Quadrant组。结合随访资料,评价并比较两组病例手术时间、术中出血量、术后住院天数、并发症发生情况。手术效果按照视觉疼痛模拟评分(VAS)、0swestry功能障碍指数(ODI)和改良Mac Nab标准进行评定。结果:椎间孔镜组术中出血量、术后住院天数、并发症发生率、术后1天、7天腰痛VAS评分及ODI均优于Quadrant组(P0.05);椎间孔镜组手术时间长于Quadrant组(P0.05);两组术后腿痛VAS评分、手术优良率比较差异无统计学意义(P0.05)。结论:经皮椎间孔镜与Mast Quadrant通道技术均能有效治疗腰椎间盘突出症,在严格掌握手术适应证和禁忌症的前提下,经皮椎间孔镜手术能够明显减少出血及并发症,是一种治疗腰椎间盘突出症理想的微创手术方式,但长期疗效有待进一步临床研究。     

Clinicopathologic Predictors of Survival in Patients with Desmoplastic Melanoma

Background and Objectives

Desmoplastic melanoma is a unique subtype of melanoma which typically affects older patients who often have comorbidities that can adversely affect survival. We sought to identify melanoma-specific factors influencing survival in patients with desmoplastic melanoma.

Methods

Retrospective review from 1993 to 2011 identified 316 patients with primary desmoplastic melanoma. Clinicopathologic characteristics were correlated with nodal status and outcome.

Results

Fifty-five patients (17.4%) had nodal disease: 33 had a positive sentinel lymph node biopsy and 22 developed nodal recurrences (no sentinel lymph node biopsy or false-negative sentinel lymph node biopsy). Nodal disease occurred more often in younger patients and in cases with mixed compared with pure histology (26.7% vs. 14.6%); both of these variables significantly predicted nodal status on multivariable analysis (p<0.05). After a median follow-up of 5.3 years, recurrence developed in 87 patients (27.5%), and 111 deaths occurred. The cause of death was known in 79 cases, with 47 deaths (59.5%) being melanoma-related. On multivariable analysis, Breslow thickness, mitotic rate ≥1/mm² and nodal status significantly predicted melanoma-specific survival (p<0.05).

Conclusions

Nodal status predicts melanoma-specific survival in patients with desmoplastic melanoma. However, since patients with desmoplastic melanoma represent an older population, and a considerable proportion of deaths are not melanoma-related (40.5%), comorbidities should be carefully considered in making staging and treatment decisions in this population.     

Arterial embolization in the treatment of bleeding uterine and bladder neoplasms

We evaluated effectiveness of transcatheter embolization for control of bleeding complicating bladder and uterine neoplasms in 60 patients. Post embolization, bleeding was completely controlled in 95% patients. Complications occurred in 5% of cases. Within 6 months interval haemorrhage recurred in 22% after embolization and its rate depended on selectivity of the procedure (14% vs 60% for proximal embolization). Arterial embolization is safe and effective for control of bleeding from bladder and uterine cancer.     

Significance of histiocytes on otherwise-normal cervical smears from postmenopausal women. A retrospective study of 108 cases

OBJECTIVE: To evaluate the significance of histiocytes on normal cervical smears from postmenopausal women and correlate them with endometrial pathology. STUDY DESIGN: Histiocytes were classified into three types. The clinical history was obtained from cytologic and surgical reports. RESULTS: Among 108 cervical smears, 13 had large, foamy histiocytes (type A), 88 had histiocytes resembling superficial endometrial stromal cells (type B), and 7 had variably sized histiocytes alone or in association with inflammatory or multinucleated cells (type C). Endometrial pathology was identified in 13 patients (12.0%): 4/13 with type A histiocytes (2 endometrial adenocarcinomas, 2 endometrial polyps), 8/88 with type B histiocytes (8 endometrial polyps) and 1/7 with type C histiocytes (endometrial polyp). Among 70 patients with no clinical indications for endometrial sampling except for the presence of histiocytes, 4 demonstrated endometrial pathology (all endometrial polyps). In contrast, endometrial pathology was identified in 9/38 with clinical indications for endometrial sampling. Among the 13 patients with endometrial pathology, 9 had a significant clinical history (sensitivity of 69.2%), and 4 had histiocytes as the only indication for endometrial biopsy (sensitivity of 30.8%). CONCLUSION: A significant clinical history is more predictive of endometrial pathology and outweighs the significance of histiocytes as an indication for endometrial biopsy.     

Prospective evaluation of eligibility for thrombolytic therapy in acute myocardial infarction.

OBJECTIVES--To determine the proportion of patients presenting with acute myocardial infarction who are eligible for thrombolytic therapy. DESIGN--Cohort follow up study. SETTING--The four coronary care units in Auckland, New Zealand. SUBJECTS--All 3014 patients presenting to the units with suspected myocardial infarction in 1993. MAIN OUTCOME MEASURES--Eligibility for reperfusion with thrombolytic therapy (presentation within 12 hours of the onset of ischaemic chest pain with ST elevation > or = 2 mm in leads V1-V3, ST elevation > or = 1 mm in any other two contiguous leads, or new left bundle branch block); proportions of (a) patients eligible for reperfusion and (b) patients with contraindications to thrombolysis; death (including causes); definite myocardial infarction. RESULTS--948 patients had definite myocardial infarction, 124 probable myocardial infarction, and nine ST elevation but no infarction; 1274 patients had unstable angina and 659 chest pain of other causes. Of patients with definite or probable myocardial infarction, 576 (53.3%) were eligible for reperfusion, 39 had definite contraindications to thrombolysis (risk of bleeding). Hence 49.7% of patients (537/1081) were eligible for thrombolysis and 43.5% (470) received this treatment. Hospital mortality among patients eligible for reperfusion was 11.7% (55/470 cases) among those who received thrombolysis and 17.0% (18/106) among those who did not. CONCLUSIONS--On current criteria about half of patients admitted to coronary care units with definite or probable myocardial infarction are eligible for thrombolytic therapy. Few eligible patients have definite contraindications to thrombolytic therapy. Mortality for all community admissions for myocardial infarction remains high.     

Ultrasound-Guided Percutaneous Renal Biopsy in 295 Children and Adolescents: Role of Ultrasound and Analysis of Complications

Introduction

Percutaneous renal biopsy (PRB) is a decisive diagnostic procedure for children and adolescents with renal diseases. Aim of this study was to evaluate retrospectively the complication rates of percutaneous kidney biopsies and their therapeutic consequences to assess the role of ultrasound-guidance including Doppler ultrasound examinations in preparation, execution and follow-up care and to present a recommended protocol.

Patients and Methods

Institutional review board approved this retrospective study; informed consent was waived. Between 1997 and 2011 a total of 438 ultrasound-guided biopsies were performed in 295 patients, 169 of the biopsies were performed on kidney transplants. Average age of patients was 10.2+/−5.2 years (range of 15 days until age of 23). Before and post biopsy ultrasound examination including Doppler examination was carried out. Biopsy itself was ultrasound monitored. Complications were analysed with regard to age of patient, kidney transplants, year of occurrence, number of punctures, performing physician and time interval of occurrence to develop an optimized protocol for ultrasound-guidance.

Results

In 99% of cases successful PRB were performed, i.e. enough kidney parenchyma for histological analysis was obtained. No lethal or major complication that required surgical intervention occurred. Eighteen relevant complications were observed (complication rate: 4.1%). Except in one case in which additional MRI diagnostic was necessary, ultrasound examination after 4 hours post biopsy or even earlier when symptoms occurred, was able to detect complications and determine indications for intervention.

Conclusion

Ultrasound-guided PRB is an established and effective method in children and adolescents, but shows a certain rate of complications and therefore should not be indicated without diligence. Ultrasound including Doppler ultrasound is a valuable tool in preparation, guidance of biopsy, detection of complications and in follow-up care. Ultrasound examinations (including Doppler) pre-, during and 4 hours post kidney biopsy and, depending from case, a few days until weeks after biopsy is recommended.     

The results after transrectal prostate biopsy with 12 biopsy cores taken

This report describes the clinical value of transrectal prostate biopsy during which 12 biopsy cores are taken in comparison to the classical sextant method. There were 106 patients included in the study, who had transrectal prostate biopsy (TRB) due to abnormal finding after digitorectal examination (DRE) and/or values of PSA > 4 ng/ml in the period from 4 October 2001 till 14 August 2002. There were 117 biopsies with 12 biopsy cores taken, 6 cores from each lobe. Prostate cancer was confirmed in 49 patients (46%). Out of total number of confirmed cancer cases, initial biopsy detected 94%. There were three patients who had suspicious DRE finding, with PSA value of < 4 ng/ml, but cancer was not detected in any of them. In the patient group with PSA value between 4-10 ng/ml, cancer was detected in 26% of them and in the group with PSA value > 10 ng/ml cancer was detected in 58%. The most common Gleason score in the case of cancer was 7 (43%). During the biopsy procedure, 3 patients experienced strong vasovagal reactions, meaning that out of 117 biopsies incidence of complications was 2.6%. Few days after the biopsy, two patients developed urogenital tract infections (1.7%) and right after the procedure, there was one case of strong hematuria (0.8%) and strong rectal bleeding (0,8%) that needed hospitalization. Our results regarding the incidence of complications do not differ much from the results in the literature. According to data in the literature regarding sextant biopsy, 15-34% of cancer cases remain undiagnosed at initial biopsy. The method of 12 biopsy cores fails to diagnose only 6% of all cancers, but it is important to note that in the mentioned period, re-biopsy was indicated only in 11 from 60 patients with negative biopsies.     

Thoracic fine needle aspiration biopsy versus fine needle cutting biopsy. A comparative study of 40 patients

The fine needle aspiration (FNA) biopsy findings were compared with the results of fine needle cutting (FNC) biopsy in 40 patients. The lesions (38 pulmonary nodules, 1 mediastinal mass and one lytic rib lesion) were biopsied with 22-gauge Greene and 21-gauge E-Z-EM needles through a 19-gauge needle guide. The FNA biopsy findings were based on smears and cell blocks of material obtained with the Greene needles while the FNC biopsy findings were based on tissue cores obtained by the E-Z-EM needles. In 83% of the cases, both techniques yielded specimens with similar cellularity; in seven cases, the FNA samples were more cellular. Malignancy was diagnosed in 80% of the patients: by both techniques in 26 patients, by FNA biopsy only in 5 patients and by FNC biopsy only in 1 patient. The sensitivity of FNA biopsy was higher than that of FNC biopsy (96.8% vs. 84.3%). The specificity and predictive value of positive results were 100% for both techniques. The predictive value of negative results was higher for FNA biopsy (88.8% vs. 54.5%). The majority of FNC biopsy tissue cores consisted mostly of clotted blood, lung tissue and/or fibrous tissue and did not facilitate or improve the diagnosis. Those data suggest that the contribution of FNC biopsy to the diagnosis of thoracic neoplasms is very limited and that the performance of FNC biopsy with an E-Z-EM needle in addition to or instead of FNA biopsy is not justified.     

Outpatient cardiac catheterization and arteriography: Twenty-month experience at the Arizona Heart Institute

Arteriographic examination of the coronary, cerebral, and peripheral circulatory systems is the ultimate diagnostic technique for the identification and quantification of atherosclerotic occlusive disease. In the past, hospitalization has been required for this invasive procedure. Recently, however, the concept of outpatient catheterization and arteriography has become a reality. To investigate the integrity, safety, and cost-effectiveness of our outpatient invasive procedures laboratory, we analyzed our experience with 254 cardiac catheterizations and 174 peripheral arteriograms performed during a 20-month period. There were no deaths or major complications. Minor complications (11%) included bleeding from the cutdown site, nausea, numbness, and allergic reactions. Two patients with arrhythmias required cardioversion. Nine patients (2%) were transferred to the hospital for observation or immediate surgery due to the nature of their atherosclerotic lesions. This study reveals (1) the technical quality, safety, indications, and contraindications for outpatient catheterization and arteriography; (2) the enthusiastic patient acceptance of outpatient invasive diagnostic studies; (3) the economic impact of these procedures on escalating health-care costs; and (4) the potential for outpatient catheterization and arteriography on a broad scale.