RESUMEN
OBJECTIVES: Levels of undiagnosed HIV infection and late presentation remain high globally despite attempts to increase testing. The objective of this study was to evaluate a risk-based prototype application to prompt HIV testing when patients undergo routine blood tests. METHODS: Two computer physician order entry (CPOE) systems were modified using the application to prompt health care workers (HCWs) to add an HIV test when other tests selected suggested that the patient was at higher risk of HIV infection. The application was applied for a 3-month period in two areas, in a large London hospital and in general practices in Teesside/North Yorkshire. At the end of the evaluation period, HCWs were interviewed to assess the usability and acceptability of the prompt. Numbers of HIV tests ordered in the general practice areas were also compared before and after the prompt's introduction. RESULTS: The system was found to be both useable and generally acceptable to hospital doctors, general practitioners and nurse practitioners, with little evidence of prompt/alert fatigue. The issue of the prompt appearing late in the patient consultation did lead to some difficulties, particularly around discussion of the test and consent. In the general practices, around 1 in 10 prompts were accepted and there was a 6% increase in testing rates over the 3-month study period (P = 0.169). CONCLUSIONS: Using a CPOE-based clinical decision support application to prompt HIV testing appears both feasible and acceptable to HCWs. Refining the application to provide more accurate risk stratification is likely to make it more effective.
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Infecciones por VIH/diagnóstico , Tamizaje Masivo/métodos , Sistemas de Apoyo a Decisiones Clínicas , Estudios de Factibilidad , Personal de Salud , HumanosRESUMEN
BACKGROUND: Moderate sedation is routinely performed in patients undergoing minor therapeutic and diagnostic procedures outside the operating room. The level of sedation is often monitored by sedation nurses using clinical criteria, such as sedation scores. The Bispectral Index (BIS) is derived from changes in the electroencephalograph profile that may provide an objective measure of the level of sedation. In this prospective observational study, we investigated whether using BIS values to guide sedative drug administration influences the level of sedation and the incidence of adverse events compared with using Ramsay sedation scale (RSS) only in nurse-administered moderate sedation. We hypothesized that both depth of sedation and the incidence of adverse events related to oversedation would decrease when sedation nurses used BIS values to help guide sedative drug administration. METHODS: Sedation care was provided by trained sedation nurses under the supervision of a physician performing the procedure. The sedation regimen was initiated with IV midazolam 1 to 2 mg and fentanyl 50 mcg or hydromorphone 0.2 mg. Additional small boluses of midazolam, fentanyl, or hydromorphone were administered to maintain an RSS of 2 to 3 (cooperative, oriented, and responding to verbal command). Propofol was not used. Information including patient demographics, type of procedure, medication administered, RSS, and rates of adverse events was recorded by the sedation nurses for each patient on a computer-readable form. The study was divided into 3 phases. In phase 1 (baseline, 6 months' duration), baseline data on sedation practice were prospectively collected. There was no change from standard of care for all patients except that each patient had a BIS sensor attached, but the monitor was covered and nurses were blinded to the BIS values. In phase 2 (training, 3 months), the sedation nurses received comprehensive education on the use of BIS to guide sedative drug administration, pharmacology of commonly used drugs, and methods for rescue from oversedation. The recommended BIS range for moderate sedation was 75 to 90. Adequate training of all sedation nurses on the use of BIS was documented. In phase 3 (implementation, 6 months), the BIS values were used to guide drug administration. RESULTS: Data were available on 1766 patients (999 and 767 patients in phases 1 and 3, respectively). Most of the procedures were colonoscopies, upper gastrointestinal endoscopies, examinations under anesthesia, endoscopic retrograde cholangiopancreatography, and central venous access catheter placements. No differences in the demographics between the 2 groups were observed. The RSS was inversely associated with the BIS value, r = -0.16 (95% confidence interval, -0.19 to -0.12; P < 0.00001). An RSS of 2 to 3 was maintained in 94% of patients in phase 1 and 96% of patients in phase 3 The mean (±SD) BIS values were 80.9 ± 6.8 in phase 1 and 80.4 ± 6.5 in phase 3. The number of sedation-related adverse events was lower in our sample when BIS was used, with an odds ratio of 0.41 (95% confidence interval, 0.28-0.62; P < 0.0001), and patients with restlessness had a lower BIS value than those without this symptom (P < 0.0001). No serious adverse events or deaths were reported. CONCLUSIONS: Nurse-administered moderate sedation using midazolam and fentanyl was usually associated with appropriate levels of sedation as assessed by both the RSS and BIS with an overall low incidence of adverse events. The use of BIS did not change the mean level of sedation significantly, although the number of sedation-related adverse events appears to be lower when BIS was used.
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Sedación Consciente/efectos adversos , Electroencefalografía , Hipnóticos y Sedantes/administración & dosificación , Enfermeras y Enfermeros , Adulto , Anciano , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico , Estudios ProspectivosRESUMEN
AIM: To compare efficacy and complications of partially covered self-expandable metal stent (pcSEMS) to plastic stent (PS) in patients treated for malignant, infrahilar biliary obstruction. METHODS: Multicenter prospective randomized clinical trial with treatment allocation to a pcWallstent(®) (SEMS) or a 10 French PS. Palliative patients aged ≥ 18, for infrahilar malignant biliary obstruction and a Karnofsky performance scale index > 60% from 6 participating North American university centers. Primary endpoint was time to stent failure, with secondary outcomes of death, adverse events, Karnofsky performance score and short-form-36 scale administered on a three-monthly basis for up to 2 years. Survival analyses were performed for stent failure and death, with Cox proportional hazards regression models to determine significant predictive characteristics. RESULTS: Eighty-five patients were accrued over 37 mo, 42 were randomized to the SEMS group and 83 patients were available for analyses. Time to stent failure was 385.3 ± 52.5 d in the SEMS and 153.3 ± 19.8 d in the PS group, P = 0.006. Time to death did not differ between groups (192.3 ± 23.4 d for SEMS vs 211.5 ± 28.0 d for PS, P = 0.70). The only significant predictor was treatment allocation, relating to the time to stent failure (P = 0.01). Amongst other measured outcomes, only cholangitis differed, being more common in the PS group (4.9% vs 24.5%, P = 0.029). The small number of patients in follow-up limits longitudinal assessments of performance and quality of life. From an initially planned 120 patients, only 85 patients were recruited. CONCLUSION: Partially covered SEMS result in a longer duration till stent failure without increased complication rates, yet without accompanying measurable benefits in survival, performance, or quality of life.
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Colestasis/terapia , Drenaje/instrumentación , Metales , Neoplasias/complicaciones , Stents , Centros Médicos Académicos , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Colestasis/diagnóstico , Colestasis/etiología , Colestasis/mortalidad , Drenaje/efectos adversos , Drenaje/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Estado de Ejecución de Karnofsky , Masculino , Persona de Mediana Edad , Neoplasias/mortalidad , América del Norte , Cuidados Paliativos , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Diseño de Prótesis , Calidad de Vida , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
CONTEXT: Animal studies have demonstrated a role for substance P binding to neurokinin-1 receptor in the pathogenesis of acute pancreatitis. OBJECTIVE: Our aim was to assess the efficacy of a neurokinin-1 receptor antagonist (aprepitant) at preventing post-ERCP pancreatitis in high risk patients. DESIGN: Randomized, double-blind, placebo controlled trial at a single academic medical center. INTERVENTION: Patients at high risk for post-ERCP pancreatitis received either placebo or oral aprepitant administered 4 hours prior to ERCP, 80 mg 24 hours after the first dose, and then 80 mg 24 hours after the second dose. PATIENTS: Thirty-four patients received aprepitant and 39 patients received placebo. STATISTICS: Fisher's exact test was used to compare incidence of post-ERCP pancreatitis in the two groups. RESULTS: Baseline characteristics were similar between the two groups. Incidence of acute pancreatitis was 7 in the aprepitant group and 7 in the placebo group. Hospitalization within 7 days post-procedure for abdominal pain that did not meet criteria for acute pancreatitis occurred in 6 and 9 patients in the aprepitant and placebo groups respectively (P=0.772). CONCLUSIONS: Aprepitant did not lower incidence of post-ERCP pancreatitis in this preliminary human study. Larger studies potentially using the recently available intravenous formulation are necessary to conclusively clarify the efficacy of aprepitant in this setting.
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Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Morfolinas/uso terapéutico , Pancreatitis/prevención & control , Administración Oral , Adulto , Antieméticos/administración & dosificación , Antieméticos/uso terapéutico , Aprepitant , Método Doble Ciego , Humanos , Masculino , Persona de Mediana Edad , Morfolinas/administración & dosificación , Pancreatitis/etiología , Proyectos Piloto , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: There is debate about whether intraoperative cholangiography (IOC) should be performed routinely or selectively during laparoscopic cholecystectomy (LC) in patients with suspected choledocholithiasis. The timing of endoscopic retrograde cholangiopancreatography (ERCP) in these patients also is an issue. We reviewed the experience in our center, where a management algorithm limiting ERCP in relation to LC was adopted. METHODS: We retrospectively reviewed every LC performed by one surgeon during 6 years and the related ERCPs. RESULTS: A total of 264 LCs were performed. In 30 patients, stones were cleared or excluded by preoperative ERCP. In the remaining 234 LCs, 31 of 34 IOCs were successfully performed. Two of 31 IOCs were positive for bile duct stones; stone removal was successful in each patient at subsequent ERCP. Only 10 of 201 patients who did not have IOC required postsurgical ERCP within 10 weeks of LC, 3 of whom had common bile duct stones at ERCP. CONCLUSIONS: For patients who underwent LC, we performed selective IOC with postoperative ERCP for positive studies. Review of our experience using this algorithm showed it to be a powerful tool in limiting unnecessary ERCPs. Our data suggest that routine preoperative ERCP cannot be justified. Selective IOC during LC misses relatively few cases of biliary stones; these can be managed quickly by experienced endoscopists.
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Colangiografía , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomía Laparoscópica , Coledocolitiasis/diagnóstico por imagen , Radiografía Intervencional , Procedimientos Innecesarios , Algoritmos , Manejo de Caso , Colangiografía/estadística & datos numéricos , Colangiopancreatografia Retrógrada Endoscópica/estadística & datos numéricos , Colecistitis/cirugía , Coledocolitiasis/epidemiología , Colelitiasis/cirugía , Pruebas Diagnósticas de Rutina , Femenino , Humanos , Cuidados Intraoperatorios , Masculino , Cuidados Posoperatorios , Radiografía Intervencional/estadística & datos numéricos , Estudios Retrospectivos , RiesgoRESUMEN
BACKGROUND: There is debate as to whether recurrent biliary complications are more common in patients who do not have elective cholecystectomy after endoscopic retrograde cholangiopancreatography (ERCP) management of common bile duct (CBD) stones. The aim of this study was to determine the fate of patients with intact gallbladders who have had CBD stones removed at ERCP, and to assess their risk of recurrent biliary symptoms. METHODS: We retrospectively identified all patients in our large tertiary center population with intact gallbladders who had an ERCP for CBD stones from December 1999 to March 2002. We determined which patients had subsequent elective cholecystectomy, and the outcomes of patients who did not have elective surgery. RESULTS: 309 patients had CBD stones at ERCP during the study period, of which 139 had intact gallbladders at the time of ERCP. Of these 139 patients 59 had subsequent elective cholecystectomy, 11 by open operation and 48 laparoscopically. Of these 139 patients, 27 had cholecystectomy planned; 47 patients were managed with a wait-and-see strategy, 30 of whom were poor surgical candidates. Of these 47 patients in whom a wait-and-see policy was adopted, 9 (19%) developed complications including recurrent pain and/or abnormal liver function tests (LFTs), recurrent biliary colic, and pancreatitis. Eight of these nine patients were from the poor surgical candidate group. Sphincterotomy had been performed at initial ERCP in all patients. CONCLUSIONS: Over half of our population of 139 patients with CBD stones at ERCP and intact gallbladders had actual or planned elective cholecystectomy. For those patients in whom a decision to wait-and-see was made, almost 20% developed complications. Elective cholecystectomy after a finding of choledocholithiasis is supported by many and is a common strategy in our experience. Recurrent biliary complications are relatively common in those who do not undergo elective cholecystectomy, especially those patients who represent a high operative risk.
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Colangiopancreatografia Retrógrada Endoscópica , Colecistectomía , Cálculos Biliares/diagnóstico por imagen , Cálculos Biliares/cirugía , Esfinterotomía Endoscópica , Anciano , Anciano de 80 o más Años , Colecistitis/etiología , Colecistitis/patología , Colecistitis/terapia , Estudios de Cohortes , Femenino , Cálculos Biliares/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
We have developed an automated surveillance system to detect bloodstream infection (BSI) occurring after endoscopic retrograde cholangiopancreatography (ERCP). We retrospectively applied this automated surveillance tool to all patients who underwent ERCP at out institution between July 2004 and April 2006 to determine the baseline rates of BSI after ERCP and identify the epidemiology of the pathogens. A total of 2052 ERCPs were performed during the study period; 46 BSIs occurred within 30 days after ERCP (overall rate of post-ERCP BSI, 2.24/100 procedures). The most commonly isolated organisms were Enterobacteriaceae (n = 18; 29%) and enterococci (n = 14; 22%). Because invasive procedures are performed in various outpatient and inpatient settings, novel methods are needed to conduct effective surveillance for infection.
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Bacteriemia/epidemiología , Bacteriemia/etiología , Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Infección Hospitalaria/epidemiología , Infección Hospitalaria/etiología , Vigilancia de Guardia , Bacteriemia/microbiología , Infección Hospitalaria/microbiología , Procesamiento Automatizado de Datos , Enterobacteriaceae/aislamiento & purificación , Enterococcus/aislamiento & purificación , HumanosRESUMEN
BACKGROUND: The management strategies for Barrett's esophagus (BE) that contains high-grade dysplasia (HGD) include intensive endoscopic surveillance, photodynamic therapy, thermal ablation, EMR, and esophagectomy. OBJECTIVE: To assess the safety and effectiveness of endoscopic circumferential balloon-based ablation by using radiofrequency energy for treating BE HGD. DESIGN: Multicenter U.S. registry. SETTING: Sixteen academic and community centers; treatment period from September 2004 to March 2007. PATIENTS: Patients with histologic evidence of intestinal metaplasia (IM) that contained HGD confirmed by at least 2 expert pathologists. A prior EMR was permitted, provided that residual HGD remained in the BE region for ablation. INTERVENTION: Endoscopic circumferential ablation with follow-up esophageal biopsies to assess the histologic response to treatment. OUTCOMES: Histologic complete response (CR) end points: (1) all biopsy specimen fragments obtained at the last biopsy session were negative for HGD (CR-HGD), (2) all biopsy specimens were negative for any dysplasia (CR-D), and (3) all biopsy specimens were negative for IM (CR-IM). RESULTS: A total of 142 patients (median age 66 years, interquartile range [IQR] 59-75 years) who had BE HGD (median length 6 cm, IQR 3-8 cm) underwent circumferential ablation (median 1 session, IQR 1-2). No serious adverse events were reported. There was 1 asymptomatic stricture and no buried glands. Ninety-two patients had at least 1 follow-up biopsy session (median follow-up 12 months, IQR 8-15 months). A CR-HGD was achieved in 90.2% of patients, CR-D in 80.4%, and CR-IM in 54.3%. LIMITATIONS: A nonrandomized study design, without a control arm, a lack of centralized pathology review, ablation and biopsy technique not standardized, and a relatively short-term follow-up. CONCLUSIONS: Endoscopic circumferential ablation is a promising modality for the treatment of BE that contains HGD. In this multicenter registry, the intervention safely achieved a CR for HGD in 90.2% of patients at a median of 12 months of follow-up.
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Esófago de Barrett/patología , Esófago de Barrett/cirugía , Ablación por Catéter/métodos , Neoplasias Esofágicas/prevención & control , Esofagoscopía/métodos , Lesiones Precancerosas/patología , Anciano , Biopsia con Aguja , Educación Médica Continua , Neoplasias Esofágicas/patología , Femenino , Estudios de Seguimiento , Humanos , Inmunohistoquímica , Masculino , Persona de Mediana Edad , Lesiones Precancerosas/cirugía , Sistema de Registros , Medición de Riesgo , Sensibilidad y Especificidad , Resultado del Tratamiento , Estados UnidosRESUMEN
Adaptation of osteochondral tissues is based on the strains experienced during exercise at each location within the joint. Different exercise intensities and types may induce particular site-specific strains, influencing osteochondral adaptation and potentially predisposing to injury. Our hypotheses were that patterns of equine distal tarsal subchondral bone (SCB) thickness relate to the type and intensity of exercise, and that high-intensity exercise leads to site-specific increases in thickness. SCB thickness was measured at defined dorsal and plantar locations on magnetic resonance images of cadaver tarsi collected from horses with a history of low [general purpose (n=20) and horse walker (n=6)] or high [elite competition (n=12), race training (n=15), and treadmill training (n=4)] exercise intensity. SCB thickness was compared between sites within each exercise group and between exercise groups. SCB thickness in elite competition and race training, but not treadmill training, was greater than low-intensity exercise. For general purpose horses, lateral SCB thickness was greater than medial throughout. Horse walker exercise led to relatively thicker lateral and medial SCB compared with the midline. Elite competition was associated with increased SCB thickness of the proximal small tarsal bones medially and the distal bones laterally. For race training and treadmill training, there were minimal differences between sites overall, although the lateral aspect was greater than medial, and medial greater than midline at a few sites for race training. In conclusion, different types of high-intensity exercise were associated with different patterns of SCB thickness across the joints from medial to lateral and proximal to distal, indicating that both exercise intensity and type of exercise affect the SCB response at any particular site within the equine distal tarsal joints.
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Tobillo/anatomía & histología , Tobillo/fisiología , Caballos/anatomía & histología , Caballos/fisiología , Condicionamiento Físico Animal/métodos , Resistencia Física/fisiología , Esfuerzo Físico/fisiología , Adaptación Fisiológica/fisiología , Animales , Técnicas In VitroRESUMEN
REASONS FOR PERFORMING STUDY: Understanding of the development of pathology and source of pain in distal tarsal osteoarthritis is poorly understood. Magnetic resonance imaging is often used in the analysis of human osteoarthritis (OA) because it is sensitive to early changes. HYPOTHESIS: In association with distal tarsal joint (DTJ) pain, there will be an alteration in the characteristic subchondral bone (SCB) thickness pattern of horses with no history of pain when subjected to low-level exercise. METHODS: Sixteen cadaver tarsal joints were collected from 9 mature horses with a history of tarsal pain and radiographic evidence of OA; 3 cadaver tarsi were collected from 2 mature horses with a history of tarsal pain and no radiographic abnormality. Magnetic resonance images were acquired using high-resolution sagittal 3D T1 weighted spoiled gradient echo sequence. Subchondral bone thickness was measured on sagittal images at dorsal and plantar locations on the proximal and distal aspects of the central (CT) and third (T3) tarsal bones and proximal aspect of the third metatarsal bone (MT3). RESULTS: In tarsi with radiographic evidence of OA medial and lateral SCB thicknesses were greater than midline on the proximal and distal aspects of CT and T3. Lateral SCB thickness was greater than medial on the proximal aspect of MT3. There was an increase in SCB thickness at the majority of sites compared with normal horses. There were too few joints in the group without radiographic changes to analyse statistically. In painful tarsi SCB thickness was greater medially than laterally at all sites. In horses without tarsal pain all lateral sites had greater SCB thickness, except the proximal aspect of CT. CONCLUSIONS: There is alteration of normal SCB thickness patterns in painful tarsi. Different thickness patterns could represent different types of pathological processes. POTENTIAL CLINICAL RELEVANCE: Further work is required to elucidate the pathological processes leading to OA of the DTJs.
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Artralgia/veterinaria , Enfermedades de los Caballos/etiología , Osteoartritis/veterinaria , Tarso Animal/anatomía & histología , Tarso Animal/patología , Animales , Artralgia/diagnóstico , Artralgia/etiología , Artralgia/patología , Huesos/anatomía & histología , Huesos/patología , Cadáver , Femenino , Enfermedades de los Caballos/diagnóstico , Enfermedades de los Caballos/patología , Caballos , Cojera Animal/diagnóstico , Cojera Animal/etiología , Cojera Animal/patología , Imagen por Resonancia Magnética/métodos , Imagen por Resonancia Magnética/veterinaria , Masculino , Osteoartritis/diagnóstico , Osteoartritis/etiología , Osteoartritis/patología , Articulaciones Tarsianas/anatomía & histología , Articulaciones Tarsianas/patologíaRESUMEN
BACKGROUND: Diagnosing pancreatic cancer by EUS-FNA is a potentially appealing alternative to percutaneous biopsy. AIM: To compare EUS-FNA with CT or US-guided FNA for diagnosing pancreatic cancer. DESIGN: Single center, prospective, randomized, cross-over. SETTING: Duke University Medical Center. POPULATION: Eighty-four patients referred with suspicious solid pancreatic mass lesions randomized to CT/US-FNA (n = 43) or EUS-FNA (n = 41). INTERVENTION: Patients underwent an imaging procedure/FNA. If cytology was nondiagnostic, cross over to the other modality was offered. Final outcome was determined by clinical follow-up every 6 months for 2 years and/or surgical pathology for patients with negative FNA. MAIN OUTCOME MEASUREMENTS: Sensitivity and accuracy of EUS-FNA versus CT/US-FNA for pancreatic cancer. RESULTS: There were 16 true positive (TP) by CT/US-FNA and 21 TP by EUS-FNA. Sixteen of the 20 CT/US-FNA negative patients crossed over to EUS-FNA; 12 underwent FNA, 4 had no mass at EUS. Seven of the 12 had positive EUS-FNA. Eight EUS-FNA negative crossed over to CT/US; 4 had no mass at CT/US, 3 remained true negative throughout follow-up, 1 had chronic pancreatitis at surgery. The sensitivity of CT/US-FNA and EUS-FNA for detecting malignancy was 62% and 84%, respectively. A comparison of the accuracy for CT/US-FNA and EUS-FNA was not statistically significant (P = .074, chi(2)). LIMITATIONS: Failure to meet target enrollment resulted in an inability to demonstrate a statistically significant difference between the 2 modalities. CONCLUSIONS: EUS-FNA is numerically (though not quite statistically) superior to CT/US-FNA for the diagnosis of pancreatic malignancy.
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Adenocarcinoma/patología , Biopsia con Aguja Fina/métodos , Endosonografía , Neoplasias Pancreáticas/patología , Tomografía Computarizada por Rayos X , Adenocarcinoma/diagnóstico por imagen , Anciano , Algoritmos , Estudios Cruzados , Endoscopía Gastrointestinal/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias Pancreáticas/diagnóstico por imagen , Estudios Prospectivos , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Despite advances in imaging modalities, preoperative diagnosis of pancreatic cystic lesions remains difficult. AIM: To assess the accuracy of endoscopic ultrasound and computer tomography to preoperatively distinguish benign from potentially malignant and malignant pancreatic cystic lesions. METHODS: Photograph series obtained from endoscopic ultrasound examinations of 66 patients with cystic pancreatic lesions were blindly reviewed by three endoscopic ultrasonographers. Forty-one of those 66 patients also underwent a computer tomography scan at our institution, which was blindly reviewed by a single radiologist. Computer tomography and endoscopic ultrasound classification into benign and malignant and potentially malignant pancreatic cystic lesions was correlated with the final diagnosis, which was established by surgical pathology (n = 43), diagnostic fine needle aspiration (n = 13) or follow-up imaging (n = 10). Interobserver agreement was measured using kappa statistics. RESULTS: Endoscopic ultrasound classification by the three examiners into benign versus malignant or potentially malignant cystic lesions was correct in 65-67%. Interobserver agreement was 50%. Kappa values for pairs of endoscopic ultrasound examiners were 0.16, 0.43 and 0.53. Computer tomography classification was correct in 71% and in agreement with the endoscopic ultrasound classification in 56-61% (kappa 0.12 to 0.27). CONCLUSIONS: Endoscopic ultrasound and computer tomography cannot accurately distinguish between benign pancreatic cystic lesions and malignant or potentially malignant ones. There is poor-to-modest interobserver agreement in classifying these lesions.
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Endosonografía , Quiste Pancreático/clasificación , Tomografía Computarizada por Rayos X , Adulto , Anciano , Anciano de 80 o más Años , Biopsia con Aguja , Femenino , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Quiste Pancreático/diagnóstico , Quiste Pancreático/patología , Neoplasias Pancreáticas/diagnósticoRESUMEN
REASONS FOR PERFORMING STUDY: Osteoarthritis (OA) is a common cause of distal tarsal pain, but disease development is poorly understood. Awareness of normal tarsal structure and function is important in order to understand the pathogenesis of OA. Thickening of the subchondral bone (SCB) plate has been related to the development of OA, but SCB plate patterns in the equine tarsus have not been documented. HYPOTHESES: There is a repeatable pattern of SCB thickness across the distal tarsal joints, and specifically that thickness would be greatest dorsally and laterally. METHODS: Twenty cadaver tarsi were collected from mature horses that had undertaken low-level exercise only with no history of hindlimb lameness. Magnetic resonance images were acquired using a high-resolution sagittal 3-dimensional T1-weighted spoiled gradient echo sequence. Subchondral bone thickness was measured on sagittal images at dorsal and plantar locations on the proximal and distal aspects of the central (CT) and third (T3) tarsal bones and proximal aspect of the third metatarsal bone (Mt3). RESULTS: On the proximal aspect of CT, medial and lateral SCB thickness were significantly greater than midline. On the distal aspect of CT and T3 and proximal Mt3, lateral SCB thickness was significantly greater than medial and midline sites. Dorsal SCB thickness was greatest on the proximal and distal aspects of CT and proximal Mt3. Subchondral bone accounted for a greater proportion of CT and T3 on the dorsal aspect than the plantar. CONCLUSIONS: There is a repeatable pattern of SCB thickness in the distal tarsal bones of horses with no history of hindlimb lameness. This reflects the pattern of loading across the joints. POTENTIAL RELEVANCE: This study provides evidence of a consistent osteochondral pattern in the equine tarsus for reference in identification of osteoarticular pathologies.
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Caballos/anatomía & histología , Articulaciones Tarsianas/anatomía & histología , Articulaciones Tarsianas/fisiología , Tarso Animal/anatomía & histología , Tarso Animal/fisiología , Animales , Huesos/anatomía & histología , Huesos/metabolismo , Huesos/fisiología , Cadáver , Femenino , Miembro Posterior , Enfermedades de los Caballos/diagnóstico por imagen , Enfermedades de los Caballos/patología , Caballos/fisiología , Cojera Animal/diagnóstico por imagen , Cojera Animal/patología , Imagen por Resonancia Magnética/veterinaria , Masculino , Osteoartritis/diagnóstico por imagen , Osteoartritis/patología , Osteoartritis/veterinaria , Radiografía , Articulaciones Tarsianas/diagnóstico por imagen , Tarso Animal/diagnóstico por imagenRESUMEN
BACKGROUND: Neoadjuvant (preoperative) chemoradiotherapy (CRT) for pancreatic cancer offers theoretical advantages over the standard approach of surgery followed by adjuvant CRT. We hypothesized that histological responses to CRT would be significant prognostic factors in patients undergoing neoadjuvant CRT followed by resection. METHODS: Since 1994, 193 patients with biopsy-proven pancreatic adenocarcinoma have completed neoadjuvant CRT, and 70 patients have undergone resection. Specimens were retrospectively examined by an individual pathologist for histological responses (tumor necrosis, tumor fibrosis, and residual tumor load) and immunohistochemical staining for p53 and epidermal growth factor receptor. Factors influencing overall survival were analyzed with the Kaplan-Meier (univariate) and Cox proportional hazards (multivariate) methods. RESULTS: The estimated overall survival (median +/- SE) in the entire group of patients undergoing resection was 23 +/- 4.2 months, with an estimated 3-year survival of 37% +/- 6.6% and a median follow-up of 28 months. Complete histological responses occurred in 6% of patients. Overexpression of p53 was more common in patients with large residual tumor loads. Tumor necrosis was an independent negative prognostic factor, as were positive lymph nodes, a large residual tumor load, and poor tumor differentiation. CONCLUSIONS: Histological response to neoadjuvant CRT--as measured by residual tumor load--may be useful as a surrogate marker for treatment efficacy. Characterization of the tumor cells that survive neoadjuvant CRT may help us to identify new or more appropriate targets for systemic therapy.
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Adenocarcinoma/tratamiento farmacológico , Adenocarcinoma/radioterapia , Terapia Neoadyuvante , Neoplasias Pancreáticas/tratamiento farmacológico , Neoplasias Pancreáticas/radioterapia , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Anciano , Análisis de Varianza , Antineoplásicos/uso terapéutico , Quimioterapia Adyuvante , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Pronóstico , Modelos de Riesgos Proporcionales , Radioterapia Adyuvante , Estudios Retrospectivos , Factores de Riesgo , Análisis de Supervivencia , Resultado del TratamientoAsunto(s)
Gastritis Hipertrófica/tratamiento farmacológico , Fármacos Gastrointestinales/administración & dosificación , Gastroscopía , Hipoproteinemia/tratamiento farmacológico , Hipotensión Ortostática/tratamiento farmacológico , Octreótido/administración & dosificación , Adulto , Biopsia , Preparaciones de Acción Retardada , Mucosa Gástrica/patología , Gastritis Hipertrófica/diagnóstico , Gastritis Hipertrófica/patología , Humanos , Hipoproteinemia/etiología , Hipotensión Ortostática/etiología , Inyecciones Intramusculares , Masculino , Albúmina Sérica/metabolismo , Estómago/patologíaRESUMEN
BACKGROUND AND STUDY AIMS: It is still difficult to differentiate reliably between benign and malignant biliary tract lesions. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has added to the diagnostic power of EUS for other gastrointestinal tumors. A retrospective analysis of experience with FNA sampling of bile duct lesions was therefore carried out. PATIENTS AND METHODS: All EUS-FNA procedures for bile duct masses or strictures were analyzed at our tertiary referral center from May 2000 through October 2002. Data for EUS findings, the results of EUS-FNA, and tissue sampling at surgery were included. EUS-FNA procedures were carried out using a 22-gauge needle. An experienced cytopathologist was present during FNA in all but three cases. Clinical follow-up details were recorded when available for patients in whom a suitable diagnostic gold standard was not available for comparison. RESULTS: A total of 35 patients underwent EUS-FNA of bile duct lesions during the study period. There were no complications. Data for EUS-FNA of bile duct masses or strictures and tissue obtained at surgery were available for 23 patients. If positive cytology at surgical pathology is taken as the gold standard, EUS-FNA has a diagnostic yield for cancer of 100 % (if atypia/inconclusive findings in the FNA sample are regarded as benign). Eleven patients had a definite malignancy on surgical pathology. Of these 11 patients, five had a finding of malignancy on EUS-FNA, giving a sensitivity of 45 % (if FNA cytology reported as atypia/inconclusive is regarded as benign). Twelve patients had findings of no malignancy from tissue obtained at surgery. Of these 12 patients, nine had benign pathology and three had atypia/inconclusive findings in the EUS-FNA sample (specificity of 100 % if atypia/inconclusive findings are considered benign). A further 12 patients did not have surgical specimens for comparison with EUS-FNA results. Four patients had definite findings of malignancy on EUS-FNA alone, and one patient had FNA findings suspicious for malignancy. Seven patients had negative or equivocal EUS-FNA results. These 12 patients are described but excluded from further analysis, as a gold standard was not available for comparison. However, clinical follow-up data were available for eight of these 12 patients, and in each case the follow-up findings were compatible with previous benign or malignant EUS-FNA findings. CONCLUSIONS: The practice of EUS-FNA has improved the diagnostic yield of EUS. These results suggest that it is a safe and useful procedure for investigating biliary masses or strictures that have hitherto caused considerable diagnostic confusion, especially in patients with negative brush cytology findings. The possibility of false-negative findings remains, but core biopsy needles may improve the situation. The results of further studies are awaited.
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Neoplasias de los Conductos Biliares/diagnóstico , Enfermedades de las Vías Biliares/diagnóstico por imagen , Enfermedades de las Vías Biliares/diagnóstico , Endosonografía , Anciano , Neoplasias de los Conductos Biliares/diagnóstico por imagen , Neoplasias de los Conductos Biliares/patología , Enfermedades de las Vías Biliares/patología , Biopsia con Aguja Fina/métodos , Femenino , Humanos , Masculino , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: It has been suggested that preoperative biliary drainage increases the risk of infectious complications of pancreaticoduodenectomy. AIMS: The aim of this study was to assess complications related to biliary stents/drains and postoperative morbidity in patients undergoing neoadjuvant chemoradiotherapy for periampullary cancer. PATIENTS: One hundred and eighty-four patients with periampullary neoplasms were prospectively selected for neoadjuvant external beam radiation therapy and 5-fluorouracil-based chemotherapy between 1995 and 2002. METHODS: The data were retrospectively completed and analysed with respect to biliary drainage, efficacy and complications of endoscopic biliary stents and postoperative morbidity. Patients who had undergone a surgical biliary bypass were excluded. RESULTS: Data were completed in 168 patients. One hundred and nineteen patients were treated with endoscopic biliary stents, 18 patients had a percutaneous biliary drain and 31 patients did not require biliary drainage. Hospitalisation for stent-related complications was necessary in 15% of the patients with endoscopic biliary stents. Seventy-two patients underwent pancreaticoduodenectomy. There was no significant difference in the rate of wound infections, intra-abdominal abscesses and overall complications between the groups with and without preoperative biliary drainage. CONCLUSIONS: Postoperative infectious complications are common in patients both with and without preoperative biliary drainage. A statistically significant difference in complication rates was not observed between these groups.
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Drenaje , Neoplasias Pancreáticas/terapia , Pancreaticoduodenectomía/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Ampolla Hepatopancreática , Antimetabolitos Antineoplásicos/uso terapéutico , Bilis , Quimioterapia Adyuvante , Endoscopía del Sistema Digestivo , Femenino , Fluorouracilo/uso terapéutico , Humanos , Ictericia Obstructiva/etiología , Ictericia Obstructiva/terapia , Masculino , Persona de Mediana Edad , Terapia Neoadyuvante , Pancreaticoduodenectomía/mortalidad , Cuidados Preoperatorios , Estudios Prospectivos , Radioterapia Adyuvante , Estudios Retrospectivos , StentsRESUMEN
BACKGROUND: This study aimed to define PDS characteristics that predict malignancy and would thus invoke further diagnostic evaluation or aggressive treatment. METHODS: 355 cases of PDS were diagnosed by ERCP during a 7-year period at a single institution. A retrospective review identified clinical/demographic patient data and ERCP results. RESULTS: 218 (61%) patients with a PDS were found to have an isolated PDS. Twelve percent of isolated PDS and 79% of CBD stricture-associated PDS were malignant. The sensitivity and specificity for the double duct sign for malignancy were 77% and 80% respectively, and the positive predictive value was 65%. Predictors of malignancy were statistically similar for both isolated PDS and those associated with a CBD stricture. Univariate predictors of malignancy included stricture location in the pancreatic head/neck, jaundice, and patient age. Predictors of benign disease included a history of pancreatitis, the presence of multiple strictures, pancreatic duct stones, pseudocyst, pancreas divisum anatomy, irregular side branches, and irregular pancreatic duct morphology. Less than 1% of patients with either pancreas divisum anatomy, pancreatic duct stones, or pancreatic pseudocyst had malignancy. Using malignancy as the dependent variable, multivariate factors included in the final prognostic equation were history of pancreatitis (odds ratio 0.009 with history of pancreatitis), stricture location in the head or neck (odds ratio 42) and irregular pancreatic duct side branches (odds ratio 0.05 with irregular branches). CONCLUSIONS: This study demonstrates that certain characteristics of PDS can predict the subset of patients who have an increased risk of cancer.
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Colangiopancreatografia Retrógrada Endoscópica , Enfermedades Pancreáticas/diagnóstico por imagen , Conductos Pancreáticos/diagnóstico por imagen , Neoplasias Pancreáticas/diagnóstico por imagen , Algoritmos , Análisis de Varianza , Constricción Patológica , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Enfermedades Pancreáticas/epidemiología , Enfermedades Pancreáticas/patología , Conductos Pancreáticos/patología , Neoplasias Pancreáticas/epidemiología , Neoplasias Pancreáticas/patología , Pronóstico , Estudios Retrospectivos , Sensibilidad y Especificidad , Estados Unidos/epidemiologíaRESUMEN
REASONS FOR PERFORMING STUDY: There have been no previously published case series of horses examined using either scintigraphy or MRI to diagnose collateral ligament injuries not detectable using ultrasonography or radiography, nor have other concurrent soft tissue lesions been described. OBJECTIVES: To describe the clinical features of horses with desmitis of the collateral ligaments of the distal interphalangeal (DIP) joint and to evaluate the results of radiographic, ultrasonographic, scintigraphic and magnetic resonance imaging (MRI) examinations. METHODS: Horses were examined between January 2001 and January 2003 and were selected for inclusion in the study if there was unequivocal evidence of collateral desmitis of the DIP joint based on ultrasonography or MRI. Subject details, case history, results of clinical examination and responses to local analgesic techniques were reviewed. The results of radiographic, ultrasonographic, scintigraphic and MRI examinations were assessed. RESULTS: Eighteen horses were identified with desmitis of a collateral ligament of the DIP joint, 3 horses (Group 1) based on ultrasonography alone, 7 (Group II) with positive ultrasonographic and magnetic resonance images and 8 (Group III) with no lesion detectable using ultrasonography, but lesions identified using MRI. Seventeen horses had forelimb injuries and one a hindlimb injury. The medial collateral ligament was injured most frequently (13 horses). In the majority of horses, no localising clinical signs were seen. Lameness was invariably worse in circles compared with straight lines. Lameness was improved by palmar digital analgesia in 16 horses (87%), but only 6 were nonlame. Intra-articular analgesia of the DIP joint produced improvement in lameness in 6/15 horses (40%). In 16 horses, no radiographic abnormality related to the DIP joint or collateral ligament attachments was identified. Eight of 14 horses (57%) had focal, moderately or intensely increased radiopharmaceutical uptake (IRU) at the site of insertion of the injured collateral ligament on the distal phalanx. Alteration in size and signal in the injured collateral ligament was identified using MRI. In addition, 5 horses had abnormal mineralisation and fluid in the distal phalanx at the insertion of the ligament. Eleven horses had concurrent soft tissue injuries involving the deep digital flexor tendon, distal sesamoidean impar ligament, navicular bursa or collateral ligament of the navicular bone. CONCLUSIONS AND POTENTIAL RELEVANCE: Collateral desmitis of the DIP joint should be considered as a cause of foot lameness. Although some injuries are detectable ultrasonographically, false negative results occur. Focal IRU at the ligament insertion on the distal phalanx may be indicative of injury in some horses. MRI is useful for both characterisation of the injury and identification of any concurrent injuries. Further follow-up information is required to determine factors influencing prognosis.