Invasive Diagnostic Studies Research Articles

The use of quantitative ultrasound in a tertiary-level children hospital: role in the follow-up of chronically ill patients.

To evaluate the use of QUS for the bone status assessment in children cared because of a chronic disease such as: inherited metabolic disorder, kidney disease and endocrine defect and considered by the attending physician as at specific risk. QUS outputs were calculated for each disorder and compared to: sex, age, Tanner stage, Z-score for height, weight and BMI (body mass index). One-hundred-sixty-eight subjects aged between 3.5 and 18years met the inclusion criteria. The overall bone quality indexes were under the normal range in all the groups considered. Impairment of bone quality parameters was more evident in the group of patients with inherited metabolic disorders, in which 65% of patients in charge were studied by QUS. Older age and sexual development were associated with less pronounced bone quality impairment, as measured by QUS, in the vast majority of conditions. Overall, the diseases for which the prediction of outcome was the strongest were: hyperphenylalaninemia, nephrotic syndrome and insulin dependent diabetes mellitus. QUS is capable to provide information on skeletal status in children. Initial evaluation by QUS may allow defining patients with chronic disorders who deserve further, more invasive diagnostic studies. Inherited metabolic disorders warrant specific attention and strict monitoring for their potential effect on bone.

Fecal S100A12 in Takayasu arteritis predicts disease activity and intestinal involvement.

Gastrointestinal involvement in Takayasu Arteritis (TA) requires invasive or expensive diagnostic studies. Instead a fecal biomarker can be used as an initial screening test. In this context, S100A12 is promising as an established biomarker in intestinal inflammation and its role in TA pathogenesis. As such we aimed to test the feasibility of fecal S100A12 as a means of the fecal biomarker in gastrointestinal involvement in TA in this pilot study. Our study population consisted of 30 TA patients and 14 control patients with non-inflammatory arthralgia. Patients with inflammatory or infectious gastrointestinal tract diseases, or used oral antibiotics or NSAIDs for the 3weeks were excluded. Vasculitis involvements were determined with cross-sectional radiologic studies. TA disease activity was evaluated per Indian Takayasu's Activity Score (2010) criteria and vascular involvements were classified according to Numano classification. ELISA test was used to determine fecal S100A12 levels. Fecal S100A12 levels were higher in TA patients when compared to the controls (37.9ng/ml vs. 12.5ng/ml p = 0.038). ESR and CRP levels were also higher in the TA group, however not correlated with fecal S100A12. Among TA patients, fecal S100A12 levels were higher inactive ones with ITAS2010 > 1 (72.9ng/ml vs. 16.7ng/ml p = 0.016) correlated with total ITAS2010 scores. (R = 0.52 p = 0.003). TA patients with abdominal symptoms had higher fecal S100A12 levels when compared to the remaining TA population (327.8ng/ml vs. 28.0ng/ml p = 0.003). However, fecal S100A12 levels in patients with or without mesenteric vessel involvement did not differ. Fecal S100A12 shows promise as a fecal biomarker to screen intestinal ischemia and inflammatory bowel disease in TA patients.

Analysis of Malpractice Claims Involving Diagnostic and Interventional Neuroradiology

BackgroundRadiologists are increasingly the subject of costly medical malpractice claims. As the field continues to expand to include numerous minimally invasive procedures and diagnostic studies, radiologists are more exposed than ever to medical malpractice. Despite this, little is known on the outcomes of these litigations. MethodsA retrospective investigation of the VerdictSearch legal claims database was performed, examining litigations involving radiologists’ interpretation of neuro-imaging and neurological procedures performed by radiologists (including interventional radiologists and diagnostic neuroradiologists). Allegations, outcomes, and payouts were examined. ResultsIn total, 126 cases were analyzed. Mean age of plaintiffs was 45 ± 18.8 years; 64 (50.8%) plaintiffs were men. Fifty-two (41%) cases listed irreversible brain damage as a complication. Paralysis and death were listed in 40 (32%) and 34 (27%) cases, respectively. In total, 44% (55) resulted in a defendant ruling, 25% (25) in a plaintiff ruling, 26% (33) in a settlement, and 5% (7) in a mixed decision. Total liabilities of the 126 cases were $390,329,929, with individual awards ranging from $50,000 to $45,000,000. Median plaintiff award was $2,877,847 (interquartile range: $1,250,000-$6,412,159; mean: $8,446,547 ± $13,036,244). Median settlement amount was $1,950,000 (interquartile range: $934,250-$3,625,000; mean: $2,455,250 ± $1,951,549). ConclusionsThis study is the first examination of legal claims involving neuroradiology. Over 50% of claims against radiologists end in provider loss, which is both financially costly and detrimental to physicians, practices, and institutions. This information may inform physicians regarding common diagnostic and interventional errors, and potentially minimize medicolegal risk.

How to Distinguish Patients with pSS among Individuals with Dryness without Invasive Diagnostic Studies.

In the course of pSS, inflammatory cell infiltration consists mainly of lymphocytes infiltrating exocrine glands, which leads to their impaired function. The characteristic feature is generalized dryness. The aim of this study was to attempt to answer the question whether it is possible to distinguish between patients with pSS and individuals with dryness caused by other pathologies without applying invasive studies. The study included 68 patients with pSS and 43 healthy controls with dryness. FS ≥ 1 was observed in 90% of patients with pSS (with or without dryness), and only in 23% of the control group (only with xerostomia). In the pSS group, anaemia (p = 0.0085), lymphocytopenia (p = 0.0006), elevated ERS (p = 0.001), higher RF titer, and ANA antibodies were noted. Configuration of anti-SSA + SSB + Ro52 antibodies was characteristic for the pSS group. Considering the clinical symptoms, statistically significant differences were noted between pSS patients and the control group in frequency (p = 0.02) and severity (p = 0.042) of fatigue, lymphadenopathy, major salivary gland involvement, and photosensitivity to UV light. In conclusion, invasive methods are pivotal in pSS diagnosis in this salivary gland biopsy. Chronic fatigue syndrome is more common in pSS patients and can be subjective distinguishing factor in the group of people with dryness.

Family Caregivers to Adults with Cancer: The Consequences of Caring.

A person living with cancer will potentially have some degree of physical, cognitive, and/or psychological impairment, periods of unemployment, financial concerns, social isolation, and existential questions, any or all of which can impact the family and friends who surround them. In our current era of health care, patients with cancer receive invasive diagnostic studies and aggressive treatment as outpatients, and then convalesce at home. As such, cancer family caregivers are de facto partners with the healthcare team. The cancer family caregiver role is demanding and may lead to increased morbidity and mortality-in effect, the cancer family caregiver can become a second patient in need of care. This chapter discusses the consequences cancer family caregivers may accrue. The topics covered include caregiver mood disturbance and psychological impairment and some of the mutable factors that contribute to these states (i.e., sleep disturbance, decline in physical health, restriction of activities, and financial concerns), uncertainty, spiritual concerns, and caregiver witnessing. There is a discussion of the factors that influence the caregiving experience (caregiver characteristics, patient characteristics, and social supports). The chapter concludes with comments on intervention studies that have been conducted to ameliorate the burden of caregiving, and the state of caregiver research.

Abstract 5541: Molecular diagnostic tests to augment cytomorphologic diagnosis of lung cancer

Abstract Morphologic analysis of cytology samples obtained by transthoracic needle aspiration (TTNA) is one of the primary methods for diagnosing bronchogenic carcinoma. However, across multiple studies the false negative rate for cytomorphological analysis ranges from 0.2-0.3, and among those diagnosed with lung cancer, the false positive rate for diagnosing the sub-class of small cell carcinoma averages 0.09. These false results lead to additional invasive diagnostic studies and delay treatment. In an effort to augment accuracy and utility of cytopathologic evaluation of TTNA lung samples, we measured the previously reported c-myc x E2F-1/p21WAF1/CIP1 (p21 hereafter) gene expression index in cDNA samples from 78 non-malignant lung tissues and 57 lung cancer tissues. Using the optimal cut-off value, this test correctly classified 72/78 non-malignant and 50/57 malignant samples for a correct classification rate of 90% (95% CI 83.6% - 94.3%), sensitivity of 88%, and specificity of 92%. A CDKN2C/FOSL1 test for distinguishing non-small cell lung cancer (NSCLC) from small cell lung cancer (SCLC) had a PPV of 100% with 63% sensitivity. In order to optimize the robustness and utility of these tests, we developed qPCR methods that enable simultaneous measurement of each target gene and reference gene transcript relative to a known number of internal standard competitive template (CT) molecules using two-color flurometric analysis on real-time platform. For each gene, the native template was quantified with a sequence-specific FAM-labeled probe and the CT was quantified with a sequence-specific Quasar670 labeled probe. Results for each gene thus far demonstrate excellent linearity (R2 > 0.99, slope 1.0 +/- 0.05), relative accuracy (variance < 0.2), signal-to-analyte response (1.0 +/- 0.05) and precision (CV < 30%) over six orders of magnitude, and reliable detection of as few as 10 molecules. Assessing both the c-myc x E2F-1/p21 index and the CDKN2C/FOSL1 test promises to augment cytomorphologic diagnosis of bronchogenic carcinoma in TTNA samples biopsy samples. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 5541. doi:1538-7445.AM2012-5541

THE DIAGNOSTIC YIELD OF CORONARY ANGIOGRAPHY REMAINS LOW, DESPITE PRIOR MYOCARDIAL PERFUSION IMAGING TESTING, IN PATIENTS WITH SUSPECTED OBSTRUCTIVE CORONARY ARTERY DISEASE: RESULTS OF THE PREDICT (PERSONALIZED RISK EVALUATION AND DIAGNOSIS IN THE CORONARY TREE) TRIAL

Background: Non-invasive and invasive diagnostic studies for evaluating coronary artery disease (CAD) are on the rise. We examined the diagnostic yield of coronary angiography in patients with suspected obstructive coronary artery disease (CAD+) who had already undergone myocardial perfusion imaging (MPI) testing in a subset of the PREDICT trial, which validated a gene expression score for the detection of CAD+. Methods: The PREDICT trial was a prospective, multicenter study that enrolled patients referred for coronary angiography for the discovery, development, and validation of a gene expression score (GES) for the detection of obstructive CAD. Patients were referred for coronary angiography according to local practice, based on symptoms suggestive of CAD, high-risk clinical characteristics, and/or positive noninvasive stress test. In this subset, post-hoc analysis, evaluable nondiabetic patients were required to have both a MPI and coronary angiography. Local cardiologists interpreted CAD+ as left main disease ≥ 50% and/or epicardial coronary artery with ≥ 70% lumen obstruction. Results: We evaluated 1418 patients who underwent MPI followed by clinical angiography. The patients had an average age of 60 and 48% were female. Approximately, 78.1% (1107/1418) of the patients had possible (12.7%) or definite (65.3%) ischemia on MPI (MPI+). The overall yield for CAD+ in the MPI+ subgroup based on site-read angiograms, was 27.6% (37.2% for men and 16.2% for women, p value <0.0001). Conclusion: In this observational study of patients referred for diagnostic angiography after MPI testing for suspected CAD, 72% of patients did not have obstructive CAD on invasive testing. This rate is higher than previously reported in the ACC Cardiovascular Data Registry. The yield was significantly lower in women versus men. In over 75% of cases, a positive MPI test drove referral to cardiac catheterization. Adoption of more discriminating non-invasive diagnostic tests with high negative predictive value is needed to rule–out patients and ultimately improve the overall diagnostic yield on coronary angiography. Reference: Lansky AJ, McPherson J, Ellis S, et al. The diagnostic yield of coronary angiography remains low, despite prior myocardial perfusion imaging testing, in patients with suspected obstructed coronary artery disease: Results of the PREDICT (Personalized Risk Evaluation and Diagnosis In the Coronary Tree) trial. J Am Coll Cardiol. 2012;59:E171. ______________________________________________________________ Abstract Highlights:Highlights: • The PREDICT Trial is a prospective multi-center study designed to develop and validate a blood-based gene expression test (Corus CAD) for the detection of obstructive CAD in non-diabetic stable symptomatic or high risk asymptomatic patients clinically referred for invasive coronary angiography. (Rosenberg S et al. Ann Intern Med 2010;153:425-434) • The objective of this PREDICT subset analysis was to evaluate the diagnostic yield of invasive coronary angiography in the subgroup of patients in PREDICT (n=1418) who had undergone myocardial perfusion imaging (MPI) prior to referral for coronary angiography. • This study found a low diagnostic yield at coronary angiography in patients who had undergone MPI testing for suspected CAD prior to invasive testing – 72% of patients did not have obstructive CAD. The diagnostic yield was significantly lower in women versus men. Should you have any questions related to this study or abstract, please contact CardioDx Medical Affairs at medicalaffairs@cardiodx.com or 866-941-4996.

Hypothenar hammer syndrome: A case and brief review

Hypothenar hammer syndrome is an uncommon cause of upper-extremity ischemia that is often overlooked in the absence of a thorough occupational and recreational history. Importantly, it is a reversible cause of hand ischemia that, if missed, can lead to significant morbidity and even amputation. The occupational ramifications and quality of life of those affected can be significant. Its relative rarity, set against the ubiquitous use of the hand as a 'hammer' is noteworthy. Several other causes of hand ischemia can present similarly; therefore, consideration of other etiologies must be thoroughly investigated. Key distinguishing clinical features, in addition to a detailed occupational and recreational history, may include characteristic sparing of the thumb, the absence of a hyperemic phase in 'Raynaud's phenomenon', and a positive Allen's sign. Both non-invasive and invasive diagnostic studies, including bilateral upper-limb segmental pulse volume recordings (PVR), arterial duplex examination, and upper-extremity angiography, are complementary to a thorough history and physical examination. Optimal management strategies are not well defined because of its rarity and resultant lack of quality, evidence-based data. Though most cases can be successfully managed non-operatively, micrographic arterial reconstruction may be limb saving in severe or recalcitrant cases. Newer, experimental strategies including selective sympathetic blockage using botulinum toxin A have been reported in a few recalcitrant cases. The brief case description illustrates the typical presentation and potential treatment strategies employed in a difficult case. A review of relevant literature is also presented.

Multiplanar CT Reconstruction to Diagnose Lemierre Syndrome

Merry Sebelik, MD, FACS UTHSC Department of OTOHNS Email: msebelik@uthsc.edu Objective: 1. Review presentation, diagnosis and management of Lemierre syndrome (infectious jugular venous thrombosis). 2. Discuss use of multiplanar reconstruction of contrast CT images to diagnose internal jugular vein (IJV) thrombosis. 3. Learn the indications for obtaining alternative (non-axial) image views and discuss the need for more invasive diagnostic imaging studies such as angiography in detecting IJV thrombosis. Method: This study is a case report with a review of the literature. Conclusion: Lemierre syndrome is a rare but potential life threatening condition with high mortality rate (5%-18%). Diagnosis is made by the radiologic finding of thrombosis of internal jugular vein (IJV) associated with oro-pharyngeal infection. This case suggests that advanced imaging using contrast CT with reconstruction in alternate planes may avoid angiography for the diagnosis of Lemierre syndrome. Communication between the clinician and radiologist is essential. Multi-planar CT Reconstruction to Diagnose Lemierre Syndrome Mona Shete, MDa; Jorge Salazar, MDa, b; Merry Sebelik, MD, FACSa, b aUniversity of Tennessee Health Science Center Department of Otolaryngology, bVeterans Administration Medical Center-Memphis

Recommendations from the Association for European Paediatric Cardiology for training in diagnostic and interventional cardiac catheterisation

IN PATIENTS WITH congenital cardiac disease includes both diagnostic studies and interventional treatment. Diagnoses include a wide range of congenital and acquired cardiac lesions. The patients range from neonates to adulthood. With the introduction of non-invasive diagnostic techniques such as echocardiography, computed tomography, and magnetic resonance imaging, the need for invasive diagnostic studies has decreased. At the same time, treatment by catheter intervention techniques has steadily increased. At present, diagnostic invasive studies are mostly limited to more complex cases. As opposed to echocardiography and MRI, cardiac catheterisation and catheter intervention are unique for their invasive nature and the fact that in many cases, treatment is part of the procedure. 1,2 These trends have implications for doctors in training for cardiac catheterisation and catheter intervention. This document summarises the requirements for training in diagnostic and interventional cardiac catheterisation, which should be provided at three levels, basic, intermediate, and advanced and should include both knowledge and skills. 3–5 It does not include recommendations for invasive electrophysiology.

The Use of Endobronchial Ultrasonography With Transbronchial Needle Aspiration To Sample a Solitary Substernal Thyroid Nodule

Solitary thyroid nodules (STNs) are frequently encountered in clinical practice. When sampling of an STN is deemed necessary, ultrasound-guided fine needle aspiration biopsy (US-FNAB) is the procedure of choice. In substernal STNs, US-FNAB is not feasible, and the patients are usually offered either more invasive diagnostic testing (mediastinoscopy or surgical excision) or follow-up imaging studies based on the clinical suspicion of malignancy. We report a case in which a substernal STN was sampled using endobronchial ultrasonography with transbronchial fine needle aspiration (EBUS-TBNA). Our patient is a 74-year-old woman who was admitted with an asthma exacerbation. She underwent a chest CT scan with intravenous contrast (CTA) to rule out pulmonary embolism (PE). The CTA was negative for PE but showed a substernal STN that was successfully sampled by EBUS-TBNA without complications. The cytology was consistent with a colloid adenoma. EBUS-TBNA can sample substernal STNs that are not amenable to US-FNAB.

Dermatologic findings of ankyloblepharon‐ectodermal defects‐cleft lip/palate (AEC) syndrome

Hay-Wells syndrome, caused by mutations in the p63 gene, is an autosomal dominant ectodermal dysplasia with the main features of ankyloblepharon filiforme adnatum, ectodermal defects, and cleft lip/palate, from which the disorder's other name, AEC syndrome, is derived. The National Foundation for Ectodermal Dysplasias convened the International Research Symposium for AEC Syndrome on November 8-10, 2006, at Texas Children's Hospital/Baylor College of Medicine, Houston, TX with appropriate IRB approval. This multidisciplinary conference was the largest gathering of such patients to date and allowed us to further characterize dermatologic features of AEC syndrome, which included: sparse and wiry hair, nail changes, past or present scalp erosions, decreased sweat production, palmar/plantar changes, and unique pigmentary anomalies. Early recognition of the features of AEC syndrome and subsequent early diagnosis is important in minimizing invasive diagnostic studies, improving morbidity and mortality, and providing genetic counseling. Skin erosions, especially those of the scalp, were identified as the most challenging cutaneous aspect of this syndrome. Although the reasons for the skin erosions and poor healing are not known, mutations of p63 may lead to a diminished store of basal cells capable of replenishing the disrupted barrier. Therapeutic strategies currently under exploration include gene therapy, as well as epidermal stem cell therapy. Until then, gentle wound care and limiting further trauma seem to be the most prudent treatment modalities.

A Ruptured Pancreaticoduodenal Artery Aneurysm Repaired by Combined Endovascular and Open Techniques

Aneurysms of the pancreaticoduodenal arteries (PDA) are rare, accounting for <2% of all visceral aneurysms. An association with celiac artery stenosis has been reported. Many present with rupture, and a high mortality can be expected. Treatment is therefore challenging. Arterial ligation, anuerysmectomy, or bypass has been the mainstay of treatment. We recently treated a patient (who had no celiac axis) with a ruptured PDA aneurysm with combined open and endovascular techniques. A 46-year-old man was transferred to our hospital with a 1-day history of abdominal pain and syncope. On admission, an abdominal and pelvis computerized tomographic (CT) scan identified a large mesenteric hematoma, a 1.9 cm PDA aneurysm, and an occluded celiac axis. Mesenteric angiography revealed no active aneurysm leak and a stenotic superior mesenteric artery (SMA) origin. All hepatic blood flow originated from the stenotic SMA via markedly enlarged PDA collaterals. The patient was brought to the operating room, where absence of the celiac axis was confirmed. An aorto-to-proper hepatic and SMA bypass was performed using a bifurcated polyester graft. The next day, the patient was brought to the angiography suite, where the PDA aneurysm was coiled. Postprocedure CT scans confirmed thrombosis of the aneurysm. Ruptured mesenteric artery aneurysms are a challenging problem for the vascular surgeon. PDA aneurysms are rare and often occur in an unfavorable location. There appears to be an association with anatomic anomalies of the mesenteric circulation. Prompt invasive and noninvasive diagnostic studies aid in the definitive management of this often fatal problem. Combined endovascular and open techniques can be used for successful treatment.

Chest pain of esophageal origin

Chest pain of esophageal origin is the most common atypical/extraesophageal manifestation of gastroesophageal reflux disease (GERD). We are increasingly recognizing the important role of the cardiologist in making the diagnosis. Studies continue to focus on the mechanisms of pain in this challenging group of patients. Factors that determine the development and persistence of visceral hypersensitivity are currently under investigation. Invasive diagnostic studies have been replaced by therapeutic trials or empirical therapies. Proton pump inhibitors have been demonstrated to be the most effective treatment for GERD-related noncardiac chest pain (NCCP). Pain modulators remain the primary therapy for non-GERD-related NCCP. Sertraline is the first selective serotonin reuptake inhibitor to demonstrate a significant improvement in chest pain symptoms.

Endoscopic ultrasound-guided fine needle aspiration in the diagnosis of mediastinal masses of unknown origin

OBJECTIVES: The ability of endosonography to diagnose a variety of gastrointestinal pathology has been significantly advanced with the introduction of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy. EUS-FNA technology can also be applied to the evaluation of non-GI disorders. The role of EUS-FNA to establish the diagnosis of unexplained mediastinal masses has not been previously described. The aim of this study was to determine the diagnostic accuracy, impact on subsequent workup, and role of EUS-FNA in treating mediastinal masses of unknown cause. METHODS: A total of 26 patients (15 men and 11 women, mean age 61 yr, range 39–77 yr) underwent EUS-FNA in patients presenting with unexplained mediastinal masses at four tertiary referral centers. Presenting symptoms included: chest pain (10 patients), dysphagia (eight), cough (seven), fever (six), night sweats (three), and no symptoms/abnormal x-ray (five patients). Five of 26 patients had prior history of cancer (three lung, one tracheal, and one esophageal). RESULTS: Final diagnosis using EUS-FNA, surgery, autopsy, other diagnostic study, or long-term follow-up was available in all patients. EUS-FNA results were classified under three disease categories: 1) infectious, 2) benign/inflammatory, and 3) malignant. Final diagnosis included infectious in five patents, benign/inflammatory in nine, and malignant in 12. EUS-FNA was successful in 21 of 26 patients (81%) for all disease categories (infectious 60%, benign/inflammatory 78%, and malignant 92%). EUS-FNA was successful in directing subsequent workup in 77% (20 of 26) and therapy in 73% (19 of 26). Mean EUS-FNA passes for adequate tissue sampling was lower of nonmalignant disease categories (3.0 and 3.4) versus malignant disease (4.4). No complications were seen during the course of this study. CONCLUSIONS: EUS-FNA in patients presenting with idiopathic mediastinal masses establishes the diagnosis in the vast majority of cases, particularly for those with malignant disease. The emergence of transesophageal EUS-FNA of the mediastinum provides the ability to alter subsequent workup and therapy, obviating the need for more invasive diagnostic studies such as thoracotomy.

Endoscopic ultrasound-guided fine needle aspiration in the diagnosis of mediastinal masses of unknown origin.

The ability of endosonography to diagnose a variety of gastrointestinal pathology has been significantly advanced with the introduction of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy. EUS-FNA technology can also be applied to the evaluation of non-GI disorders. The role of EUS-FNA to establish the diagnosis of unexplained mediastinal masses has not been previously described. The aim of this study was to determine the diagnostic accuracy, impact on subsequent workup, and role of EUS-FNA in treating mediastinal masses of unknown cause. A total of 26 patients (15 men and 11 women, mean age 61 yr, range 39-77 yr) underwent EUS-FNA in patients presenting with unexplained mediastinal masses at four tertiary referral centers. Presenting symptoms included: chest pain (10 patients), dysphagia (eight), cough (seven), fever (six), night sweats (three), and no symptoms/abnormal x-ray (five patients). Five of 26 patients had prior history of cancer (three lung, one tracheal, and one esophageal). Final diagnosis using EUS-FNA, surgery, autopsy, other diagnostic study, or long-term follow-up was available in all patients. EUS-FNA results were classified under three disease categories: 1) infectious, 2) benign/ inflammatory, and 3) malignant. Final diagnosis included infectious in five patents, benign/inflammatory in nine, and malignant in 12. EUS-FNA was successful in 21 of 26 patients (81%) for all disease categories (infectious 60%, benign/inflammatory 78%, and malignant 92%). EUS-FNA was successful in directing subsequent workup in 77% (20 of 26) and therapy in 73% (19 of 26). Mean EUS-FNA passes for adequate tissue sampling was lower of nonmalignant disease categories (3.0 and 3.4) versus malignant disease (4.4). No complications were seen during the course of this study. EUS-FNA in patients presenting with idiopathic mediastinal masses establishes the diagnosis in the vast majority of cases, particularly for those with malignant disease. The emergence of transesophageal EUS-FNA of the mediastinum provides the ability to alter subsequent workup and therapy, obviating the need for more invasive diagnostic studies such as thoracotomy.

Chest pain of esophageal origin

Chest pain of esophageal origin is the most common atypical/extraesophageal manifestation of gastroesophageal reflux disease (GERD). We are increasingly recognizing the important role of the cardiologist in making the diagnosis. Studies continue to focus on the mechanisms of pain in this challenging group of patients. Factors that determine the development and persistence of visceral hypersensitivity are currently under investigation. Invasive diagnostic studies have been replaced by therapeutic trials or empirical therapies. Proton pump inhibitors have been demonstrated to be the most effective treatment for GERD-related noncardiac chest pain (NCCP). Pain modulators remain the primary therapy for non-GERD-related NCCP. Sertraline is the first selective serotonin reuptake inhibitor to demonstrate a significant improvement in chest pain symptoms.

Diagnostic Workup of Neoplastic Lesions in the Cirrhotic Liver: The Case for Minimizing Invasive Diagnostic Studies

The development of low-density lesions in the liver of patients with known cirrhosis raises the question of the clinical pathway for the diagnostic workup. Primary hepatocellular carcinoma (HCC) an...

Computed tomography in the evaluation of penetrating neck trauma: a preliminary study.

Penetrating neck trauma has traditionally been evaluated by surgical exploration and/or invasive diagnostic studies. We hypothesized that computed tomography (CT), used as an early diagnostic tool to accurately determine trajectory, would direct or eliminate further studies or procedures in stable patients with penetrating neck trauma. Retrospective case series. Academic, urban, level I trauma center. Hemodynamically stable patients without hard signs of vascular injury or aerodigestive violation who had sustained penetrating trauma to the neck. Patients underwent a spiral CT as an initial diagnostic study after initial evaluation in the trauma bay. Further invasive studies were directed by CT findings. Number of invasive studies performed. Twenty-three patients were identified during the 30-month period. Nineteen patients sustained gunshot wounds; 3, shotgun wounds; and 1, a stab wound. One patient died of a cranial gunshot wound. Three isolated zone I, 1 isolated zone II, 9 isolated zone III, and 10 multiple neck zone trajectories were evaluated. Thirteen patients were identified by CT to have trajectories remote from vital structures and required no further evaluation. Ten patients underwent angiography. Only 2 underwent bronchoscopy and esophagoscopy. Four patients were discharged from the emergency department; 7 other patients were discharged within 24 hours. No adverse patient events occurred before, during, or after CT scan. Computed tomography in stable selected patients with penetrating neck trauma appears safe. Invasive studies can often be eliminated from the diagnostic algorithm when CT demonstrates trajectories remote from vital structures. As a result, efficient evaluation and early discharge from the trauma bay or emergency department can be realized. Further prospective study of CT scan after penetrating neck trauma is needed.

Nicht-invasive und invasive Pränataldiagnostik und psychische Beanspruchung der Schwangeren

Die Methoden der Pränataldiagnostik haben sich in den letzten Jahren beträchtlich weiterentwickelt. Die hochauflösenden Ultraschallgeräte erlauben aufgrund des Nachweises bestimmter Fehlbildungen und Marker, am bekanntesten „nuchal translucency“, unter Einbeziehung des maternalen Alters und eventuell auch biochemischer Parameter, die Abschätzung eines empirischen Risikos für einen auffälligen Karyotyp. Wir untersuchen die psychische Beanspruchung der Schwangeren vor und nach invasiver und nicht-invasiver Pränataldiagnostik.