Outpatient Biopsy Research Articles

Application of electronic laryngoscope combined with narrow band imaging endoscope and its classification in the diagnosis of vocal cord leukoplakia

Objective:To investigate the clinical value of electronic laryngoscope combined with narrow band imaging（NBI） endoscope and its classification in the diagnosis of vocal cord leukoplakia. Methods:A retrospective analysis was performed on 115 cases of patients treated in the Department of Otolaryngology, Head and Neck Surgery, Nanjing Drum Tower Hospital from September 2020 to November 2022. All 115 cases were diagnosed with vocal cord leukogramma using the electronic laryngoscopy and narrow band imaging endoscopy, followed by pathological examination in the outpatient tissue biopsy. The morphological characteristics of vocal cord leukoplakia and the correlation between narrow band imaging classification and pathological results were investigated. Results:Among 115 cases of vocal cord leukoplakia, 46 cases（40.00%） were diagnosed as benign lesions. Low grade intraepithelial neoplasia occurred in 29 cases（25.22%）. High-grade intraepithelial neoplasia（including carcinoma in situ） occurred in 22 cases（19.13%）. Invasive carcinoma（including suspected invasive carcinoma） was found in 18 cases（15.65%）. There were no statistical differences in the unilateral and bilateral distribution of vocal cord leukoplakia and pathological results（P>0.05）, but there were statistical differences in the size, thickness, lesion uniformity, clear boundary, pre-invasion commissure, symmetry,age over 55 years old, morphological classification, NBI classification and pathological results distribution（P<0.05）. The two-by-two comparison among the three groups of morphological classification（flat type, raised type, rough type） showed that P<0.017 was only compared between flat type and rough type, and P>0.017 was compared between the other two groups. The pairwise comparison among the three groups of NBI classification（Ⅲ, Ⅳ, Ⅴ） was statistically significant（P<0.017）. There was a high correlation between NBI classification and pathological diagnosis, and the correlation coefficient was 0.705（P<0.05）. The risk of high intraepithelial neoplasia and cancerization in type Ⅳ was 9.125 times higher than that in type Ⅲ, and the risk of high intraepithelial neoplasia and cancerization in type Ⅴ was 271.078 times higher than that in type Ⅲ. The area under the curve of morphological classification and NBI classification were 0.672 and 0.896, respectively. Conclusion:There is a high match and correlation between NBI classification and pathological diagnosis. Electronic laryngoscope combined with narrow band imaging endoscope has a high diagnostic value for vocal cord leukoplakia, and a strong predictive ability for malignant leukoplakia.

Shorter observation times and smaller gauge needles in outpatient kidney biopsies.

Controversy exists as to the optimal observational time (OT) after outpatient percutaneous kidney biopsy. Further, there is some uncertainty about the benefit of smaller (18-gauge) vs. larger (16-gauge) biopsy needles. At our institution, we have been lowering the OT after outpatient kidney biopsies. Initially in 2015, we were monitoring for 6 hours and gradually began to decrease the OT over time. From 2020, we have adopted an OT of less than 4 hours. During this time period (in 2018), we also began using a smaller gauge needle (18 gauge). We reviewed all outpatient kidney biopsies performed by the nephrology division at our institution since 2015. There were 137 biopsies reviewed. 63 had OT of 4-6 hours, and 74 had OT &lt;4 hours. There was a total of 4 significant complications (2.9%). Two complications, symptomatic retroperitoneal bleeds, were detected in less than 3 hours. The other 2 complications were seen at 9 hours (clot retention) and 72 hours (retroperitoneal bleed after anticoagulation restarted). 63% of the biopsies were done using 18-gauge needles with 1 complication in this group vs. 3 in the 16-gauge group. All cases had adequate tissue for interpretation based on the ability to make a kidney diagnosis. The number of glomeruli obtained in the 18-gauge group was 29 ± 13 glomeruli, and in the 16-gauge group was 25 ± 10, which did not differ between groups. In summary, in an outpatient population, all significant post-biopsy complications were evident either within the first 3 hours or after 9 hours, and this suggests the feasibility of using shorter than standard OT in outpatient kidney biopsies. Furthermore, an 18-gauge needle may lower the risk of complications and obtain adequate tissue.

High early mortality after percutaneous liver biopsy in metastatic cancer: national analysis

ObjectiveThe study aimed to assess outcomes in patients undergoing liver biopsy for metastatic cancer, focusing on mortality rates and chemotherapy following their biopsy.MethodsHospital Episode Statistics data from 2010 to 2019...

Assessing the Correlation between Allostatic Load and False-Positive Image-Guided Breast Biopsies.

Background: Allostatic load (AL) is the accumulation of physiological dysregulation attributed to repeated activation of the stress response over a lifetime. We assessed the utility of AL as a prognostic measure for high-risk benign breast biopsy pathology results. Method: Eligible patients were women 18 years or older, with a false-positive outpatient breast biopsy between January and December 2022 at a tertiary academic health center. AL was calculated using 12 variables representing four physiological systems: cardiovascular (pulse rate, systolic and diastolic blood pressures, total cholesterol, high-density lipoprotein, and low-density lipoprotein); metabolic (body mass index, albumin, and hemoglobin A1C); renal (creatinine and estimated glomerular filtration rate); and immune (white blood cell count). Multivariable logistic regression was used to assess the association between AL before biopsy and breast biopsy outcomes controlling for patients' sociodemographics. Results: In total, 170 women were included (mean age, 54.1 ± 12.9 years): 89.4% had benign and 10.6% had high-risk pathologies (radial scar/complex sclerosing lesion, atypical ductal or lobular hyperplasia, flat epithelial atypia, intraductal papilloma, or lobular carcinoma in-situ). A total of 56.5% were White, 24.7% Asian, and 17.1% other races. A total of 32.5% identified as Hispanic. The mean breast cancer risk score using the Tyrer-Cuzick model was 11.9 ± 7.0. In multivariable analysis, with every one unit increase in AL, the probability of high-risk pathology increased by 37% (odds ratio, 1.37; 95% confidence interval, 1.03, 1.81; p = 0.03). No significant association was seen between high-risk pathology and age, ethnicity, breast cancer risk, or area deprivation index. Conclusion: Our findings support that increased AL, a biological marker of stress, is associated with high-risk pathology among patients with false-positive breast biopsy results.

Prostate cancer detection rate with MRI-targeted biopsy alone using outpatient transperineal prostate biopsy.

We aimed to compare the detection rate of prostate cancer (PCa) and clinically significant (cs) PCa by magnetic resonance imaging-guided targeted biopsy (MTBx) alone and MTBx plus systematic biopsy (SBx) using an outpatient transperineal (TP) approach under local anesthesia. A retrospective study of patients who underwent outpatient TP prostate biopsy under local anesthesia at our tertiary institution between 2019 and 2022 was performed. To compare the proportions of PCa and csPCa in both pathways, McNemar's tests were used. Multivariable logistic regression model was fitted to determine the predictors of csPCa. Of 255 men included, 177 (69%) underwent MTBx alone. MTBx had similar detection rate for PCa (56%) and csPCa (47%) compared to the combination of MTBx and SBx (PCa 61%; csPCa 49%; p=0.1 and p=0.3, respectively). MTBx had lower median number of biopsy cores compared to the combination of MTBx and SBx (6 vs. 11, p<0.001). At multivariable logistic regression analysis, age (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.04-1.13, p<0.001), prior negative biopsy (OR 0.19, 95% CI 0.09-0.44, p<0.001), prostate-specific antigen density cutoff ≥0.15 (OR 3.17, 95% CI 1.67-6.01, p<0.001), and prostate imaging reporting and data system ≥4 (OR 12.2, 95% CI 4.21-35.6, p<0.001) were independent predictors of csPCa. MTBx showed similar diagnostic performance to the combination of MTBx and SBx in patients undergoing outpatient TP prostate biopsy. Future studies are needed to evaluate the role of MTBx in avoiding unnecessary biopsies.

1232 Outpatient Stereotactic Needle Biopsy Is a Cost-effective Strategy for Brain Tumor Patient Decision-making That Enhances Clinical Trial Accrual

INTRODUCTION: Although neuroradiological techniques have expanded, stereotactic needle biopsy is a simple, ubiquitous,and immediate strategy for established or potential brain tumor patients with atypical clinical and/or radiographic findings. METHODS: Outpatient stereotactic needle biopsies performed by a single surgeon from August 2020 through November 2022 were retrospectively reviewed. Electronic medical records were queried for clinical, perioperative, and tumor demographics. Financial records were queried for insurance and payment reports. Descriptive statistics were used to characterize comparisons among collected variables. RESULTS: 107 consecutive stereotactic needle biopsy procedures were conducted in adult brain tumor patients. All biopsies were performed using a single needle-pass in the outpatient setting, targeting supratentorial lesions in 89.7% of cases. Tissue diagnosis was established in 96% of procedures, with glioma being the most common histology. No intraoperative or perioperative complications occurred. Four patients (3.7%) were admitted overnight due to urinary retention (n = 2) and asymptomatic tract hemorrhage (n = 2), respectively. Insurance approval was sought preoperatively from non-commercial (31.7%) and commercial (68.3%) payors and approved in all cases. Postoperatively, 30.8% of patients received an experimental therapeutic on the basis of tissue analysis. CONCLUSIONS: We report the largest experience to date with outpatient stereotactic needle biopsy in newly-diagnosed and recurrent brain tumor patients. Our findings identify this strategy as a cost-effective alternative to advanced imaging that facilitates clinical trial accrual through tissue acquisition.

Office-based Magnetic Resonance Imaging–guided Transperineal Prostate Biopsy Without Antibiotic Prophylaxis: A Real-world Clinical Utility Study

Background and objectiveAdvances in for magnetic resonance imaging (MRI)-guided transperineal biopsy (TPBx) techniques have facilitated outpatient prostate biopsies under local anaesthesia to lower postbiopsy infection rates. However, there is debate regarding antibiotic prophylaxis because of concerns regarding antibiotic resistance and interactions. Our objective was to assess the transition from office-based transrectal biopsy to TPBx performed under local anaesthesia without antibiotic prophylaxis despite potential risk factors for infectious complications. MethodsWe conducted a prospective assessment of 665 men undergoing office-based MRI-guided TPBx. The primary outcome was the rate of urosepsis or febrile urinary tract infections requiring hospitalisation and/or antibiotics within 2 wk after biopsy. Secondary outcomes included patient-reported procedure tolerability and the prostate cancer detection rate. Key findings and limitationsTPBx using a median of nine cores per patient (range 4–15) detected prostate cancer in 534/665 men (80%). Only four men (0.6%) were hospitalised for suspected postbiopsy infection; no patient experienced urosepsis. The TPBx procedure was well tolerated, with low pain scores (median Visual Analogue Scale score of 2, interquartile range [IQR] 1–3) and positive patient ratings (median rating 1 [no problem], IQR 1–2). Limitations include the single-centre analysis and lack of randomisation for antibiotic prophylaxis. Conclusions and clinical implicationsAn office-based TPBx strategy under local anaesthesia without antibiotic prophylaxis is well tolerated and has a very low risk of side effects. This approach should be considered as the standard of care. Further studies may determine if a subgroup of predisposed men could benefit from antibiotic prophylaxis. Patient summaryFor prostate biopsy the sampling needle can be inserted through the rectum or through the perineum, which is the skin between the rectum and the scrotum. Our study confirms that in everyday clinical practice, prostate biopsy via the perineum can be carried out under local anaesthetic and without routine use of antibiotics because of its lower risk of infection. Patients reported low pain scores and positive ratings for the overall experience.

THU505 Severe Acute Hypercortisolism From Stable Pre-existing Lung Nodule

Abstract Disclosure: N. Raza: None. S. Wagle: None. R.N. Kiani: None. K. Kaput: None. A 63-year-old male with uncontrolled hypertension and Rheumatoid arthritis was admitted for acute psychosis, progressive asthenia, and severe refractory hypokalemia. He was afebrile on admission and blood pressure was 151/99 mmHg. Physical examination lacked typical Cushingoid appearance of moon facies, central obesity, or purple striae. Labs showed a potassium of 1.8 (ref: 3.3-5 mmol/L), HbA1c 6.0% (ref&amp;lt;=5.6 %), 24-hour urinary free cortisol of 9438 (ref&amp;lt;=60.0 ug/d) and random ACTH level of 229 (ref:7.7-63.3pg/ml). The presentation was felt to be consistent with ectopic ACTH dependent Cushing's syndrome. He was treated with ketoconazole 400 mg BID, Deep veinous thrombosis prophylaxis and trimethoprim-sulfamethoxazole daily for PJP prophylaxis. CT chest/abdomen/pelvis was performed and showed a 1.9 cm right middle lobe pulmonary nodule. Past records were reviewed and showed a stable lung nodule from 2020 (2.5 years earlier). Elective lung biopsy was discussed, and the patient was discharged home with plan for outpatient biopsy. Prior to his biopsy, he was readmitted with worsening agitation, hypertension, and extremity edema. After extensive discussion with CT surgery, a decision was made to perform robotic-assisted thoracoscopic resection of the right middle lobe with mediastinal lymph node dissection. Post-surgery his BP improved, agitation resolved, and cortisol level declined to 3.4 (ref: 6.0 - 18.4 ug/dL). Final pathology showed a well differentiated neuroendocrine tumor, low grade. Lymphovascular invasion was present, and one lymph node was positive for tumor. ACTH immunostaining was performed and was also positive. Ectopic ACTH dependent Cushing syndrome represents a rare condition, contributing to 5-20% of Cushing’s cases. Lung carcinoid tumor is one of the major causes of ectopic ACTH syndrome and typically resolves with surgery. Unusual in our case is the stability of the lung lesion prior to his acute decompensation and lymph node positivity. To date, we have not identified a reason for the indolent nature of his tumor. He is currently on a hydrocortisone taper and is actively undergoing treatment planning with our multidisciplinary peer review process. Essential to his management is the coordination of multiple providers, which includes complex medical decision making and treatment decisions. In the future, lung carcinoid should be considered in the differential for persons with difficult to control hypertension and a stable pulmonary nodule Presentation: Thursday, June 15, 2023

Successful pregnancy in a female with embryonal rhabdomyosarcoma of the cervix who received biopsy and chemotherapy alone without recurrence after 16 years: a case report and literature review

BackgroundEmbryonal rhabdomyosarcoma (ERMS) of the uterine cervix is rare, but the population affected is mostly underage females. The scope of surgery has now evolved from extensive to limited, and organ-preserving surgery combined with chemotherapy is recommended to preserve the patient’s fertility. However, reports of birth outcomes are rare.CaseA minor woman with cervical ERMS who underwent only an outpatient biopsy of the lesion had no residual lesion on subsequent multipoint cervical biopsy and refused radical surgery or cervical conization, after which the patient received a nonclassical regimen of chemotherapy. The patient stopped the chemotherapy on her own, but the patient conceived spontaneously 16 years later with a good pregnancy outcome and no recurrence.ConclusionsThis case suggests that preservation of reproductive function is often feasible in immature women with cervical ERMS, and the prognosis is usually good as long as the primary tumour can be surgically removed and the lesion is free of residual disease. We also look forward to reports of subsequent growth and pregnancy outcomes in other children with reproductive tract RMS. In cervical ERMS, accurate evaluation of the disease and development of an individualized treatment plan are crucial, and the protection of reproductive function and psychological well-being deserves special attention.

National survey sampling exercise on current practice in channelled local anaesthetic biopsy in suspected head and neck cancer.

Out-patient channelled endoscopic local anaesthetic biopsy reduces the time to diagnosis and wider use may improve cancer pathway times. This study aimed to assess the practice of ENT surgeons using channelled local anaesthetic biopsy. A survey was distributed nationally, containing questions about out-patient local anaesthetic biopsy. In total, 58 responses were returned; only 12 per cent of respondents (n = 7) used general anaesthetic biopsy. The advantages of local anaesthetic biopsy were: the avoidance of general anaesthetic for patients with poor performance scores (95 per cent, n = 55) and faster cancer pathway times (91 per cent, n = 53). Disadvantages were: clinics running late (29 per cent, n = 17) and complications (24 per cent, n = 14). The main barrier to using local anaesthetic was access to channelled flexible endoscopy (38 per cent, n = 22), with 43 per cent (n = 25) reporting they were not using out-patient channelled endoscopes but would be interested in using them. Surgeons are interested in using channelled endoscopic local anaesthetic biopsy, but they are limited by access to equipment. Increased use of channelled endoscopes may improve national cancer pathway times and avoid challenging general anaesthetics.

Monitoring Practices After Pediatric Liver Transplantation.

This study sought to understand the current monitoring practices after pediatric liver transplantation (LT), specifically regarding follow-up clinic visits, outpatient laboratory testing, protocol biopsies, and diagnostic imaging, and to identify potential center and provider characteristics associated with such practices. A cross-sectional survey of pediatric LT providers at centers participating in the Society of Pediatric Liver Transplantation (SPLIT) registry was conducted from February 2020 to April 2021. The overall response rate was 79% (38/48 SPLIT centers), with the majority representing large volume centers (>10 LTs per year). Frequency of clinic visits and laboratory monitoring varied by center, but all centers decreased frequency after the first post-transplant year. The most common practice included an annual clinic visit and laboratory sampling every 2-3 months. Surveillance liver biopsy is seldom done during the first post-transplant year, while being routinely performed by 50% of centers after this time period. Centers forgoing surveillance biopsies assert that the results would likely not change management. Only 39% of centers have a hepatologist perform the liver biopsy while the remaining centers consult interventional radiology. Most diagnostic imaging is obtained only as needed. Routine abdominal ultrasounds were obtained by only 50% of responding centers after the first year post-transplant. SPLIT centers vary widely in the routine management of LTs after the first year post-transplant. While common themes emerge, future studies will be needed to connect protocols to outcomes to determine best practice.

중년 여성의 중비갑개에서 기원한 혈관섬유종 1예

Angiofibroma which is rare benign tumor found in the nasal cavity is often called juvenile nasopharyngeal angiofibroma because it occurs mainly in the posterior lateral wall of the nasopharynx of adolescent males. It is known that outpatient biopsy is contraindicated due to its hypervascularity which has the potential for massive bleeding. It is difficult to recognize in advance when it is observed as a form originating outside the nasopharynx. We report a case of successfully treated angiofibroma without preoperative embolization originating from the middle turbinate in a 63-year-old woman with nasal obstruction, along with a literature review.

Clinical significance of measuring hepatic venous pressure gradient on transjugular liver biopsy for patients with pre-cirrhotic bridging fibrosis liver disease

PurposeTo demonstrate that patients with pre-cirrhotic bridging fibrosis (Meta-analysis of Histological Data in Viral Hepatitis, METAVIR stage F3) and clinically significant portal hypertension (CSPH, Hepatic Venous Pressure Gradient ≥10 mmHg) experience a higher rate of clinical decompensation than patients without CSPH. Materials and methods128 consecutive patients with pathology proven bridging fibrosis without cirrhosis between 2012 and 2019 were reviewed. Inclusion criteria were patients with HVPG measurement obtained during the same outpatient transjugular liver biopsy and clinical follow up of at least two years. Primary endpoint included rate of overall complication related to portal hypertension including evidence of either ascites, presence of varices on imaging or endoscopy, or evidence of hepatic encephalopathy. ResultsAmong 128 patients with bridging fibrosis (67 females and 61 males; average age 56 years), 42 (33%) and 86 (67%) were with and without CSPH (HVPG ≥10 mmHg). Median follow-up time was 4 years. Rate of overall complication (either ascites, varices or hepatic encephalopathy) in patients with and without CSPH was 36/42 (86%) and 39/86 (45%) (p < .001) respectively. Rate of developing ascites, varices and hepatic encephalopathy in patients with and without CSPH was 21/42 (50%) vs 26/86 (30%) (p = .034), 32/42 (76%) vs 26/86 (30%) (p ≤ .001) and 18/42 (43%) vs 12/86 (14%) (p = .001) respectively. ConclusionPatients with pre-cirrhotic bridging fibrosis and CSPH were associated with higher rates of developing ascites, varices and hepatic encephalopathy. Measuring HVPG during transjugular liver biopsy provides additional prognostic value in anticipating clinical decompensation in patients with pre-cirrhotic bridging fibrosis.

Contribution of Outpatient Ultrasound Transvaginal Biopsy and Puncture in the Diagnosis and Treatment of Pelvic Lesions: A Bicenter Study.

The use of transvaginal ultrasound guided biopsy and puncture of pelvic lesions is a minimally invasive technique that allows for accurate diagnosis. It has many advantages compared to other more invasive (lower complication rate) or non-invasive techniques (accurate diagnosis). Furthermore, it offers greater availability, it does not radiate, enables the study of pelvic masses accessible vaginally with ultrasound control in real time, and it is possible to use the colour Doppler avoiding puncturing large vessels among others. The main aim of the work is to describe a standardized ambulatory technique and to determine its usefulness. This is a retrospective study of ultrasound transvaginal punctures (core needle biopsies and cytologies) and drainages of pelvic lesions performed on an outpatient basis during the last two years. The punctures were made with local anesthesia, under transvaginal ultrasound guidance with an automatic or semi-automatic 18G biopsy needle with a length of 20-25 cm and a penetration depth of 12 or 22 mm. The material obtained was sent for anatomopathological, cytological and/or microbiological study if necessary. A total of 42 women were recruited in two centers. Fifty procedures (nine punctures, seven drains, and 34 biopsies) were performed. In five cases the punction and drain provided clinical relief in benign pelvic masses. Regarding material of the biopsies performed, 15 were vaginal in women previously histerectomized, finding 10 carcinomas, eight were ovarian tumours in advanced stages or peritoneal carcinomatosis obtaining the appropriate histology in each case, seven were suspicious cervical biopsies finding carcinomas in five of them, three were myometrial biopsies including one breast carcinoma metastasis in the miometrium and a benign placental nodule, and a periurethral biopsy was performed on a woman with a history of endometrial cancer confirming recurrence. The pathological diagnosis was satisfactory in all cases, confirming the nature of the lesion (25 malignant-ten vaginal recurrences of previous gynaecological cancers, eight cases of primary ovarian/peritoneal carcinoma, four new diagnosis of cervical malignant masses, one cervical metastasis of lymphoma, one periurethral recurrence of endometrial carcinoma and one recurrence of breast cancer in the myometrium-and 23 benign). The tolerance was excellent and no complications were detected. The ambulatory ultrasound transvaginal puncture and drainage technique is useful for obtaining a sample for pathological and microbiological diagnosis with excellent tolerance that can be used to rule out the recurrence of malignant lesions or progression of the disease, diagnose masses not accessible to gynecological exploration (vaginal vault, myometrium or cervix) and for early histologic diagnosis in cases of advanced peritoneal carcinomatosis or ovarian carcinoma as well as drainage and cytological study of cystic pelvic masses.

Research Letter-Outcomes of Outpatient Native Kidney Biopsies at the McGill University Health Center: A Quality Assurance Audit.

Percutaneous kidney biopsies are essential for diagnosis and management of kidney diseases. However, post-procedural bleeding is a significant risk associated with biopsies. At the McGill University Health Center, the 2 main hospitals, the Royal Victoria Hospital and the Montreal General Hospital, have different observation protocols for outpatient native kidney biopsies. Currently, patients are admitted for a 24-hour inpatient observation at the Montreal General Hospital, whereas patients biopsied at the Royal Victoria Hospital are discharged after 6 to 8 hours of observation at the end of the day. Most Canadian centers do not admit patients for an overnight observation, and it was unclear why this practice continued at the Montreal General Hospital. Our objective was to determine the incidence of complications post-renal biopsy over the past 5 years at both hospital sites, and compare them to each other, as well as to established rates in the available literature. This assessment was designed as a quality assurance audit. This audit was conducted from a local registry of renal biopsies performed at the McGill University Health Center between January 2015 to January 2020. We included all adult patients (between the ages 18 and 80) with outpatient native kidney biopsies performed at the McGill University Health Center between 2015 and 2020. We collected the included patients' baseline demographics and risk factors at the time of biopsy, including age, BMI, creatinine, estimated glomerular filtration rate, pre- and post-biopsy hemoglobin, platelet, urea, coagulation profile, blood pressure, kidney side/size as well as needle size, and number of passes made. We compared the incidence of both minor and major bleeding complications at the Montreal General and the Royal Victoria Hospital. Variables that were measured included hemoglobin before and after biopsy, incidence of minor bleeding complications (defined by hematomas and gross hematuria), and incidence of major complications (defined by post-biopsy bleeding requiring either transfusions or another procedure to stop the bleeding), as well as the incidence of admissions post-biopsy. The incidence of major complications was 2.87% over 5 years (5/174 patients), which is comparable with that reported in the literature. Our transfusion incidence was 1.72% (3/174 patients) and our embolization incidence was 2.3% (4/174 patients) over the 5 study years. Our total number of major events was low and the patients who had major events had significant risk factors for bleeding. All events occurred within 6 hours of observation. This was a retrospective study with a low event number. Additionally, since the events included only those recorded at the McGill University Health Center, it is possible that the events of interest may have occurred at other hospital sites without the author's knowledge. Based on the results of this audit, all major bleeding events occurred within 6 hours of a percutaneous kidney biopsy, suggesting that patients should be monitored for 6 to 8 hours following biopsy. The next step after this quality assurance audit is a quality improvement project and a cost-effectiveness analysis to assess whether post-biopsy practices should be amended at the McGill University Health Center.

Risk and Timing of Major Bleeding Complications Requiring Intervention of the Percutaneous Kidney Biopsy With a Short Observation Protocol: A Retrospective Chart Review

Background: We previously published a retrospective study of kidney biopsies performed in a tertiary care hospital in London, Ontario from 2012 to 2017. This study resulted in a change of practice in our institution to shorter postbiopsy monitoring for outpatients as well as the development of a risk calculator to predict serious bleeding complications. Objective: The primary objective of this study was to determine whether this shorter monitoring time is adequate in the outpatient setting. A secondary objective was to validate the bleeding risk calculator in both inpatients and outpatients. Design: This was a retrospective chart review. Setting: This study was performed at a tertiary academic hospital in London, Ontario, Canada. Participants: This was a retrospective study of 400 adult patients who underwent kidney biopsy between April 30, 2018 and February 25, 2022 at a tertiary academic hospital in London, Canada. Methods: We retrospectively assessed frequency and timing of major bleeding complications in patients who underwent kidney biopsy. In secondary analyses, we examined the prediction performance of the risk calculator in discrimination and calibration. Results: Major bleeding occurred in 7 patients (1.8%). Five of these patients required blood transfusions (1.3%) and 2 required embolization (0.5%). In the outpatient setting, any major bleeding events were identified immediately (1 patient) or on the routine 2-hour ultrasounds (1 patient). The risk calculator showed good discrimination (C-statistic, 0.91, 95% confidence interval [CI] = [0.84 to 0.95]) and calibration (slope, 1.10, 95% CI = [0.47 to 1.74]; intercept, 95% CI = −0.02 [−0.79 to 0.75]), but with much uncertainty in the estimates. Limitations: The occurrence of only a few major bleeding events limits the reliability of our assessment of our risk calculator. Conclusions: There appears to be little yield in extending observation beyond 2 hours after an outpatient kidney biopsy with the use of immediate and 2-hour postbiopsy ultrasounds. The bleeding risk calculator ( http://perioperativerisk.com/kbrc ) warrants further validation.

Clinical Value of a Routine Urine Culture Prior to Transrectal Prostate Biopsy

BackgroundInfectious complications after a transrectal prostate biopsy may be severe. In Sweden, a routine culture prior to all prostate biopsies was introduced to enable targeted antimicrobial prophylaxis and reduce postbiopsy infections. ObjectiveTo investigate whether a clinical routine with a urine culture prior to a prostate biopsy and targeted prophylactic antibiotic therapy reduces postbiopsy infections. Design, setting, and participantsIn 2015, a site-specific antimicrobial stewardship programme with a urine culture prior to a prostate biopsy was initiated in Region Kronoberg. To evaluate this routine, we designed a population-based register study including all men who had an outpatient prostate biopsy in 2015–2019 and a control period including all men who had a biopsy in 2010–2014, when a urinary culture was obtained only on clinical suspicion. Outcome measurements and statistical analysisThe primary outcome was infectious complications within 10 d and the secondary outcome was a change in antibiotic prophylactic treatment. An infectious complication was defined as prescription of antibiotics for urinary tract infections or admission to hospital for urinary tract infections or sepsis after a biopsy. Results and limitationsThe urine culture period included 2971 prostate biopsy procedures, of which 2684 (90%) were preceded by a urine culture. The control period included 2818 procedures, of which 135 (4.8%) were preceded by a urine culture. Infectious complications were slightly more common during the urine culture period (5.0%) than during the control period (4.3%, p = 0.17), as was inpatient care for infections (3.5% vs 2.2%, p = 0.002). The routine identified 5.4% men with asymptomatic bacteriuria. Despite targeted antibiotic treatment (1.5% received a nonfluoroquinolone treatment), the rate of infectious complications (6.3%) was similar to that in the control period. ConclusionsPrebiopsy urine culture did not lead to fewer postbiopsy infections. Other measures are needed to reduce infectious complications after a prostate biopsy. Patient summaryIn this report, we evaluated a routine with urine culture prior to a transrectal prostate biopsy and found that it did not lead to fewer infectious complications.

355: RHINOVIRUS-ASSOCIATED ANCA VASCULITIS: A RARE ASSOCIATION

Introduction: The anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitides (AAV) are immune mediated diseases, associated with antigen exposure and host immune response. Approximately 52–80% of patients with AAV have pulmonary abnormalities on chest CT, mainly interstitial lung disease (ILD), granuloma, or alveolar hemorrhage. Myeloperoxidase (MPO) antineutrophil cytoplasmic antibody (ANCA) has been particularly associated with interstitial lung disease and the majority of patients present with pulmonary symptoms prior to the diagnosis of ANCA vasculitis. ILD is a relatively uncommon manifestation of MPO-ANCA, but signifies a poor prognosis. We present a patient with rhinovirus infection associated ANCA vasculitis. Description: A 42-year-old female with a past medical history of COPD, bipolar disorder, and intravenous drug use presented to the emergency department in acute respiratory distress. Computed tomography of the chest revealed bilateral diffuse, patchy ground glass opacities. Respiratory PCR testing was positive for rhinovirus. The patient was admitted to the ICU for acute hypoxic respiratory failure. Her respiratory status continued to decline during the ICU stay. Serum studies including DsDNA, SSA, SSB, anticentromere, myositis, aldolase and ANCA were obtained. The studies were positive for MPO-ANCA. The patient was treated with high dose methylprednisolone. Subsequently, the oxygen demand improved and the patient made a full recovery, with plan for outpatient biopsies. Discussion: MPO-ANCA is a marker which may be induced by various drugs, dust inhalation, smoking, heavy metal exposure, or silica exposure. The hypothesized mechanism involves cytokines produced by antigens to induce MPO expression within the neutrophil cell membrane. The ANCA component binds to MPO to induce neutrophil activation which then activates the inflammatory cascade. The overproduction of cytokines causes vascular endothelial cell damage and ultimately vasculitis. One proposed mechanism of MPO-ANCA involves the alteration in degradation of neutrophil extracellular traps (NETs) likely due to infections. This mechanism leads to an increase in MPO-ANCA binding. NETs have a proliferative effect on lung fibroblasts, and thus are seen alongside fibroblasts in patients with MPO-ANCA interstitial pneumonia.

Training Hematology and Medical Oncology Fellows in Performing Bone Marrow Biopsies- a Quality Improvement Initiative

Background Bone marrow biopsies are frequently performed in the evaluation of many benign and malignant hematologic disorders and occasionally utilized in the diagnostic evaluation of fever of unknown origin. 1 2 Guidelines for bone marrow biopsy samples vary. A size of 20mm for lymphoma , 15 mm for myeloproliferative disease , 16 mm for malignant neoplasms in general is considered to be a rough guide3. Bone marrow samples can be altered during the processing which may lead to shrinkage of up to 25% from the size obtained 5. Awareness and strict adherence to recommended bone marrow biopsy sample sizes seems limited. Type of bone marrow biopsy needle such as manual or motorized needles, operator skill and patient body habitus lead to variability in size, hemodilute aspirates and crush artifacts5. Suboptimal samples due to inadequate size or aspiration artifact can lead to delays in diagnosis, need for repeat procedures with physical, emotional and financial consequences4 . In our institution, we undertook a quality improvement initiative to improve upon the sample sizes and minimize artifacts of bone marrow biopsies and herein we report the results of this project. Methods: We collected data from the outpatient bone marrow biopsy clinic on all the bone marrow biopsies done by a class of hematology and oncology fellows between the months of July 2021 and January 2022 . Data was collected for 70 bone marrow biopsy encounters. Each encounter was analyzed for size , type of artifact if present, patient diagnosis, age, gender, BMI, number of attempts and use of sedation to assess meaningful correlations and potential contributing factors. We then performed individual one on one intervention sessions with each fellow participating in the project to review their individual operator data and discuss areas of improvement. A best practices handout with the steps to a successful biopsy and common pitfalls with useful tips was given to all the fellows and was placed in the bone marrow biopsy clinic for reference. A post procedure checklist was added and included a measuring aid to ensure that the bone samples were of the desired size which allowed practitioners to be more aware of the quality of their collected samples and intervene again if needed to get better samples in the same encounter. A survey was also utilized to understand the personal experiences and knowledge barriers that may be contributing to inferior outcomes and allow for anonymous feedback. Data was then collected again over a 6-month period post intervention to screen for improvement in percentage of adequate biopsies, average size of sample obtained and presence of artifacts. Results: Data obtained pre-intervention showed a 39.4% inadequate samples. The average bone marrow biopsy size was 1.2 cm, 95% CI ( 1.05- 1.35). There was a 22.5% aspiration artifact in the tested samples along with 16.9% and 1.4% fragmentation and crush artifacts respectively. Interestingly the size of adequate samples in this pre-intervention cohort of biopsies was 1.23cm 95% CI (1.04-1.42) , indicating that the percentage of inadequate samples was mostly influenced by high degree of artifacts in the obtained samples. In addition, patient age, BMI and diagnosis did not correlate with percentage of inadequate samples suggesting operator skill and technique as the main factor in determining outcomes. Of the 49 post intervention samples analyzed, the average size of the sample was 1.2cm, 95% CI ( 1.03- 1.37) which was similar to the pre intervention samples . but there was a difference in the size of the adequate samples at 1.43cm 95% CI ( 1.27-1.59) , . 8.1% of samples had aspiration artifact . 8.1%of samples had fragmentation. Overall, this intervention resulted in a decrease in the inadequate sample rate from 39.4% to 26.5% Conclusion: Bone marrow biopsies are an important part of investigating a wide array of diseases , personal skill and experience are important factors in determining adequacy of samples , there is merit behind a combined approach of individualized feedback along with tools such as post-procedure checklists for self-evaluation to improve the quality of collected bone marrow biopsy samples in new Hematology and Oncology fellowship trainees. Novel approaches such as utilization of image guidance or ultrasound may be worth exploring to further improve sampling yield.

A multicenter interventional study aimed to assess the effectiveness of Lavanda aroma in reducing anxiety and pain in patients undergoing PROstatic BIOpsy (LA-BIOPRO): Study protocol

Background: A prostatic biopsy is a diagnostic test used in cases of suspected prostate cancer. The patient expresses significant levels of anxiety from the very first outpatient visits; anxiety and pain management is essential for a successful outcome of the procedure. Lavender oil is one of the essential oils that is commonly used in aromatherapy to reduce anxiety and pain, its low toxicity and side effects have made it the preferred treatment in complementary medicine. Aim: To assess the 'effectiveness of lavender scent in decreasing the levels of anxiety and pain in patients undergoing a prostatic biopsy. Methods: An interventional non-pharmacological, randomized, two-arm, multi-center, nonprofit study. The SS Antonio e Biagio e Cesare Arrigo Hospital and the City of Alessandria Clinic, Monza Polyclinic of Alessandria, will enroll consecutively all adult patients undergoing outpatient prostatic biopsy from April 1, 2022, to October 1, 2022. The Numerical Rating Scale and Hamilton Anxiety Rating Scale will be used for assessments. Conclusion: Lavender oil aromatherapy could have a clinically significant effect on reducing pain and anxiety during prostatic biopsy procedures; its simple use, safety, and low cost provide a therapeutic option to be considered, complementary to other medical interventions in certain clinical settings.