RESUMEN
OBJECTIVE: To evaluate the active implementation of the Dutch Institute for Healthcare Improvement's guideline for the diagnostic work-up for pulmonary embolism in a general training hospital, and to analyse reasons for not following the guideline strategy. DESIGN: Partly retrospective and partly prospective. METHOD: The diagnostic strategy was analysed for all consecutive patients with clinically suspected pulmonary embolism who underwent a perfusion lung scintigraphy. The extent to which the guideline was followed was investigated in the year before (July 1999-June 2000; n = 384) and the year after (July 2000-June 2001; n = 380) its active implementation. The possible reasons for not completing the strategy in the prospective cohort of the study were also analysed. RESULTS: Following a non-high-probability perfusion-ventilation scan, the guideline was completed in 23/117 (20%) patients prior to the implementation and in 50/109 (46%) patients after the implementation of the guideline. In 27% and 60%, respectively, an additional duplex ultrasound of the legs was made to check for deep vein thrombosis, and in 65% and 70% respectively, pulmonary angiography was performed after a normal ultrasound result. The main reasons for not following the diagnostic work-up included low clinical probability (41%, without a proper alternative diagnosis), an alternative diagnosis (36%; pneumonia, heart failure, malignancy) and a reluctance to perform angiography. The mean age of the patients for whom the guideline was completed was lower (51 years) compared to patients for whom the guideline was not followed (65 years; p < 0.001). The risk of not completing the diagnostic workup in accordance with the guideline was six-fold higher for patients > or = 80 years compared with patients < 40 years of age, whereas an alternative diagnosis was not more prevalent in patients > or = 65 years. CONCLUSION: Although active implementation of the guideline-based diagnostic work-up for pulmonary embolism increased the number of adequate diagnoses, the diagnostic work-up was not completed in half of the patients with inconclusive lung scans. The main reasons for this were the advanced age of the patient, alternative diagnoses, and a reluctance to perform pulmonary angiography.
Asunto(s)
Adhesión a Directriz/estadística & datos numéricos , Guías de Práctica Clínica como Asunto , Embolia Pulmonar/diagnóstico , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Angiografía/estadística & datos numéricos , Diagnóstico Diferencial , Femenino , Hospitales Generales/normas , Hospitales de Enseñanza/normas , Humanos , Pierna/irrigación sanguínea , Pierna/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Países Bajos , Estudios Prospectivos , Embolia Pulmonar/diagnóstico por imagen , Cintigrafía , Estudios Retrospectivos , Ultrasonografía , Relación Ventilacion-PerfusiónRESUMEN
A 48-year-old male patient from Surinam presented with anorexia, nausea and weight loss. An extreme hypercalcaemia of 5.08 mmol/l was found. Further diagnostic investigations showed that this patient had a HTLV-1 positive adult T-cell leukaemia/lymphoma (ATL/L). This is often associated with multilobularly nucleated lymphocytes, bone destruction and hypercalcaemia. Skin localisations are frequently observed. The combination of cytomorphology, immunophenotyping, HTLV-1 seropositivity and clinical findings points to the diagnosis. The patient was treated with 6 courses of chemotherapy consisting of cyclophosphamide, doxorubicin, teniposide, prednisone, vincristine and bleomycin. Upon inquiry it appeared that he had died elsewhere. Chemotherapy induces a short-lived remission in a minority of ATL/L patients. Antiviral therapy (alpha interferon, zidovudine) might offer new possibilities.
Asunto(s)
Anticuerpos Anti-HTLV-I/aislamiento & purificación , Hipercalcemia/etiología , Leucemia-Linfoma de Células T del Adulto/diagnóstico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Diagnóstico Diferencial , Resultado Fatal , Humanos , Leucemia-Linfoma de Células T del Adulto/complicaciones , Leucemia-Linfoma de Células T del Adulto/tratamiento farmacológico , Leucemia-Linfoma de Células T del Adulto/patología , Masculino , Persona de Mediana Edad , Suriname/etnologíaRESUMEN
From 1975 through 1985 88 patients with a primary manifestation of non-Hodgkin's lymphoma in the upper digestive and respiratory tract were referred to our hospital. Fifty-seven of them were in Stage I or II. The results of therapy in 48 evaluable patients are the subject of this retrospective study. Low, intermediate, and high grade malignant histologic features were encountered in 6, 27, and 15, respectively. The authors compared retrospectively the patients treated with radiotherapy (RT) with those who received additionally chemotherapy (RT + CT). Patients have been followed for a minimum of 1 year. Four of 29 patients with intermediate-grade or high-grade malignant lymphoma treated with CT and RT relapsed whereas eight of 13 patients treated with RT alone relapsed. Actuarial survival curves differed significantly in favour of the CT and RT group. These figures were also significant when the high-grade lymphomas plus centroblastic lymphomas were considered. It is recommended to add CT to RT in both Stage I and II NHL of high-grade and intermediate-grade malignancy.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica , Neoplasias de Cabeza y Cuello/terapia , Linfoma no Hodgkin/terapia , Neoplasias del Sistema Respiratorio/terapia , Adulto , Anciano , Anciano de 80 o más Años , Terapia Combinada , Ciclofosfamida/uso terapéutico , Doxorrubicina/uso terapéutico , Femenino , Neoplasias de Cabeza y Cuello/tratamiento farmacológico , Neoplasias de Cabeza y Cuello/radioterapia , Humanos , Linfoma no Hodgkin/tratamiento farmacológico , Linfoma no Hodgkin/radioterapia , Masculino , Persona de Mediana Edad , Neoplasias de la Boca/tratamiento farmacológico , Neoplasias de la Boca/radioterapia , Neoplasias de la Boca/terapia , Estadificación de Neoplasias , Neoplasias Nasales/tratamiento farmacológico , Neoplasias Nasales/radioterapia , Neoplasias Nasales/terapia , Neoplasias de los Senos Paranasales/tratamiento farmacológico , Neoplasias de los Senos Paranasales/radioterapia , Neoplasias de los Senos Paranasales/terapia , Neoplasias de la Parótida/tratamiento farmacológico , Neoplasias de la Parótida/radioterapia , Neoplasias de la Parótida/terapia , Prednisona/uso terapéutico , Neoplasias del Sistema Respiratorio/tratamiento farmacológico , Neoplasias del Sistema Respiratorio/radioterapia , Estudios Retrospectivos , Vincristina/uso terapéuticoRESUMEN
In acute myeloid leukaemia the peripheral leukocyte count is known to be a prognostic factor. The preserved capacity of leukaemic cells to mature has also been suggested to be one. In a series of 179 cases of adult acute myeloid leukaemia peripheral leukaemic cell count and degree of maturation were found to be inversely correlated. As the degree of maturation of leukaemic cells in peripheral blood was lower than that in bone marrow in the majority of cases, blast cells appear to be released more easily from the marrow than cells that have matured to some extent in the direction of the larger promyelocytic or promonocytic cell type. In a series of 35 cases we found peripheral blast cells to be smaller than those in bone marrow. Moreover, central blast cell diameter and peripheral leukaemic cell count were inversely correlated. Therefore, leukaemic cell size or some factor related to it may contribute to the preferential egress of small immature cells from the marrow. Differences in proliferative activity could not account for the inverse correlation between degree of maturation and leukaemic cell count.
Asunto(s)
Leucemia Mieloide Aguda/patología , Leucocitos/patología , Adulto , Médula Ósea/patología , Granulocitos , Humanos , Leucemia Mieloide Aguda/sangre , Recuento de Leucocitos , Mitosis , PronósticoRESUMEN
A number of fixation and decalcification procedures were evaluated to determine their suitability for immunohistochemistry on trephine samples of bone marrow after paraffin embedding. In particular, the immunoreactivity of antigens characteristic for various hematopoietic cell lines (immunoglobulin heavy and light chains for plasmacytoid cells; elastase for neutrophil myeloid cells; lysozyme, alpha-1-antitrypsin and alpha-1-antichymotrypsin for hystiocytic cells; leukocyte common antigen for lymphocytes; hemoglobin and glycophorin A for erythroid cells; Factor VIII-related antigen for thrombocytoid cells) as well as some antigens specific for epithelial tumors (CEA, 115D8, and keratin) were investigated. Fixation in a mercuric chloride-formaldehyde mixture followed by decalcification in acetic acid-formaldehyde-saline proved to be the best procedure for antigen preservation and retention of morphologic detail. Moreover, there is no need of trypsinization when using this procedure. The only exception was Factor VIII-related antigen in megakaryocytes, which was best demonstrated in trypsin-digested sections of formalin-fixed and acetic acid-decalcified biopsies.
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Antígenos/análisis , Huesos/patología , Citoplasma/análisis , Técnica de Descalcificación , Fijadores/farmacología , Histocitoquímica/métodos , Inmunoquímica/métodos , Coloración y Etiquetado , Biopsia , Médula Ósea/inmunología , Médula Ósea/patología , Huesos/inmunología , Formaldehído , Técnicas Histológicas , Humanos , Parafina , Succión , TripsinaRESUMEN
A patient is described with immunoblastic non-Hodgkin's lymphoma and autoimmune haemolytic anaemia of the cold autoantibody type. The autoantibodies were monoclonal IgM-kappa cold haemagglutinins/haemolysins with blood-group specificity, anti-P. Red-cell autoantibodies directed against blood-group-P antigen have until now only been detected, as polyclonal IgG antibodies, in paroxysmal nocturnal haemoglobinuria.
Asunto(s)
Aglutininas/análisis , Anemia Hemolítica Autoinmune/inmunología , Antígenos de Grupos Sanguíneos/inmunología , Proteínas Hemolisinas/análisis , Inmunoglobulina M/análisis , Sistema del Grupo Sanguíneo P/inmunología , Anemia Hemolítica Autoinmune/complicaciones , Anticuerpos Monoclonales/análisis , Autoanticuerpos/análisis , Crioglobulinas , Humanos , Cadenas kappa de Inmunoglobulina/análisis , Linfoma/complicaciones , Masculino , Persona de Mediana EdadRESUMEN
The case history of a patient with Budd-Chiari syndrome (BCS) is described. The underlaying disease proved to be essential thrombocytosis. Congential elliptocytosis was also present. The value of the conventional liver scan, percutaneous splenoportoscintigraphy and isotopic phlebography of the inferior vena cava in the diagnosis of BCS is described. It is suggested that a combination of these three noninvasive techniques be used when BCS is suspected.
Asunto(s)
Síndrome de Budd-Chiari/diagnóstico , Adulto , Síndrome de Budd-Chiari/diagnóstico por imagen , Eliptocitosis Hereditaria/complicaciones , Humanos , Hígado/diagnóstico por imagen , Masculino , Radiografía , Cintigrafía , Bazo/diagnóstico por imagen , Tecnecio , Trombocitosis/complicaciones , Vena Cava Inferior/diagnóstico por imagenRESUMEN
Scanning electron microscopy of the hollow, harpoon-like radula tooth of the toxoglossan gastropod Conus has elucidated the structure and relationships of its component parts: apex, cutting edge, barbs, serration, adapical and basal openings of the lumen, external and internal folds of the shaft, and base. The functional roles of these components in prey capture are proposed.