Pathological Discharge Research Articles

242 The Provision of Diagnosis at Emergency Department Discharge: A Pilot Study

Study Objectives: Understanding the cause of patients' symptoms usually involves identification of a pathological diagnosis, without which effective treatment often cannot be initiated. Anecdotal reports suggest that emergency department (ED) providers do not prioritize giving pathological diagnoses to patients at time of discharge, and often reiterate the patient's symptom as the discharge “diagnosis.” No study has examined the proportion of patients who receive a pathological diagnosis at ED discharge that explains the likely cause of their symptoms. Our pilot study sought to identify the proportion of patients at a large teaching hospital who receive a symptomatic versus pathological diagnosis at ED discharge.Methods: We performed a chart review of all adult patients who were discharged from an urban ED with an emergency medicine residency and an annual visit volume of 88,000. All charts of patients presenting with the 3 most common ED chief complaints (chest pain, abdominal pain, and headache) were reviewed by a 4th-year medical student and a third-year emergency medicine resident. Charts were coded as either symptomatic or pathological diagnosis based on the discharge diagnosis provided by the attending physician. Those with both symptomatic and pathological discharge diagnosis (eg “chest pain” and “muscular chest pain”) were coded as pathological diagnosis. Those that received different coding by the 2 reviewers were subject to an analysis by a third adjudicator, an emergency medicine attending.Results: 797 charts met the inclusion criteria. Five charts (0.6%) were coded differently by the 2 reviewers; a discussion with the third reviewer resulted in consensus in all cases. The table below shows the number and percentage of symptomatic versus pathological discharge diagnosis for patients presenting with one of these 3 chief complaints:Tabled 1Conclusion: According to our pilot study at a large teaching hospital, it appears that most patients are discharged from the ED without a pathological diagnosis that explains the likely cause of their symptoms. Future studies will investigate whether this finding is consistent across institutions, and whether provision of a pathological diagnosis affects ED clinical outcomes, including patient satisfaction. Study Objectives: Understanding the cause of patients' symptoms usually involves identification of a pathological diagnosis, without which effective treatment often cannot be initiated. Anecdotal reports suggest that emergency department (ED) providers do not prioritize giving pathological diagnoses to patients at time of discharge, and often reiterate the patient's symptom as the discharge “diagnosis.” No study has examined the proportion of patients who receive a pathological diagnosis at ED discharge that explains the likely cause of their symptoms. Our pilot study sought to identify the proportion of patients at a large teaching hospital who receive a symptomatic versus pathological diagnosis at ED discharge. Methods: We performed a chart review of all adult patients who were discharged from an urban ED with an emergency medicine residency and an annual visit volume of 88,000. All charts of patients presenting with the 3 most common ED chief complaints (chest pain, abdominal pain, and headache) were reviewed by a 4th-year medical student and a third-year emergency medicine resident. Charts were coded as either symptomatic or pathological diagnosis based on the discharge diagnosis provided by the attending physician. Those with both symptomatic and pathological discharge diagnosis (eg “chest pain” and “muscular chest pain”) were coded as pathological diagnosis. Those that received different coding by the 2 reviewers were subject to an analysis by a third adjudicator, an emergency medicine attending. Results: 797 charts met the inclusion criteria. Five charts (0.6%) were coded differently by the 2 reviewers; a discussion with the third reviewer resulted in consensus in all cases. The table below shows the number and percentage of symptomatic versus pathological discharge diagnosis for patients presenting with one of these 3 chief complaints: Conclusion: According to our pilot study at a large teaching hospital, it appears that most patients are discharged from the ED without a pathological diagnosis that explains the likely cause of their symptoms. Future studies will investigate whether this finding is consistent across institutions, and whether provision of a pathological diagnosis affects ED clinical outcomes, including patient satisfaction.

The diagnostic value of nipple discharge cytology: Breast imaging complements predictive value of nipple discharge cytology

Papilloma is the most common finding associated with pathologic nipple discharge. In the absence of breast imaging abnormalities, the incidence of occult malignancy is <3%. To determine the predictive value of nipple discharge cytology in conjunction with breast imaging. Retrospective review of 160 charts; inclusion criteria of clinically pathologic nipple discharge, subsequent excisional biopsy, and absence of palpable abnormalities. Nipple discharge cytology categorized as negative, atypical, suspicious, and papillary. Breast imaging was analyzed. Preoperative tests were correlated to final surgical pathology. 89 patients identified. Sixty-five had positive cytology, with a false positive rate of 32.3%. They were associated with papillomas in 52%, benign non-papillary in 33% and malignant lesions in 9% of cases. Nipple discharge cytology was positive in 69.6% of papillomas and 92% of atypical/malignant lesions; 30% had abnormal breast imaging and positive cytology. Nipple discharge cytology had a sensitivity of 74.5%, specificity of 30%, and positive predictive value of 68%. The positive predictive value increased to 85% with associated abnormal breast imaging. Nipple discharge cytology is useful in evaluating pathologic discharge. However, negative cytology with negative imaging is not enough to avoid surgery in cases of suspicious clinical presentation.

脳深部刺激療法からみたパーキンソン病の生理

Remarkable effectiveness of deep brain stimulation (DBS) for Parkinson's disease (PD) has occupied the interest of many scientists and their efforts for elucidating its mechanism have given us a lot of clues for understanding of pathophysiology of PD. The early idea that DBS inhibits neuronal activity of the stimulated nucleus was based on the observation that it shows similar effects as lesions, standing behind the so-called firing rate model of PD pathophysiology. However, it has been also revealed that DBS induces changes indicative of activation of outputs from the stimulated structure, which is inconsistent with the firing rate model. On the other hand, recent studies have demonstrated abnormal discharge pattern in the subthalamic nucleus and the globus pallidus of parkinsonian state, such as burst and oscillation, and its suppression by DBS. These support an idea that the pathological discharge interrupts normal information flow in the basal ganglia. Taken together, changes of firing pattern in the basal ganglia may be crucial for the PD pathophysiology, not a simple increase or decrease in firing rates. Besides, since DBS seems to affect the entire system of the basal ganglia and more, it is necessary to approach its mechanism with a systems-wide view.

P3-S1.03 Mixed infections in women with Chlamydial genital infection

BackgroundTo study the prevalence and structure of mixed infection in women with Chlamydial genital infection.MethodsThe object of research was 80 women revealed to have Chlamydial genital infection. Age varied from...

Pathological basal ganglia activity in movement disorders

Our understanding of the pathophysiology of movement disorders and associated changes in basal ganglia activities has significantly changed during the last few decades. This process began with the development of detailed anatomical models of the basal ganglia, followed by studies of basal ganglia activity patterns in animal models of common movement disorders and electrophysiological recordings in movement disorder patients undergoing functional neurosurgical procedures. These investigations first resulted in an appreciation of global activity changes in the basal ganglia in parkinsonism and other disorders, and later in the detailed description of pathological basal ganglia activity patterns, specifically burst patterns and oscillatory synchronous discharge of basal ganglia neurons. In this review, we critically summarize our current knowledge of the pathological discharge patterns of basal ganglia neurons in Parkinson's disease, dystonia, and dyskinesias.

Zastosowanie izotonicznego roztworu NaCl u chorych z ostrym zapaleniem błony śluzowej nosa i zatok przynosowych

The mucous membrane of the nose and paranasal sinuses has several important physiological functions. Inflammation of the nose and paranasal sinuses impairs filtration, humidification and warming of the inhaled air. It also affects the beating of cilia and the mucociliary clearance within the nose and lumen of the sinuses. The result is impairment of the mechanism by which the removal of the stagnant pathological discharge from the paranasal sinuses and of foreign matter (environmental pollutants) from the nasal mucosa would be otherwise effected. The use of special products to cleanse the nasal mucosa may considerably improve its function. Day-to-day ENT practice offers evidence of beneficial effects of nasal douching with isotonic sea water solutions. Products which cleanse nasal mucosa are now used as an adjunct to treatment of rhinosinusitis and rhinitis co-existing with nasal polyps. was a retrospective assessment of symptoms in patients with acute rhinosinusitis depending on the therapeutic modality used, especially in a group of patients using an isotonic solution (0.9% NaCl) in addition to standard treatment. Medical records of 80 patients, males and females with symptoms of acute rhinosinusitis were included in the final evaluation. The following medical records including fully documented medical history and physical findings in compliance with the EP3OS were randomly selected from the medical records at the ENT Outpatient Clinic: 40 patients with acute rhinosinusitis treated symptom-relieving medication (Group A) and symptom-relieving medication with topical nasal corticosteroids (Group C); 40 patients with acute rhinosinusitis treated symptom-relieving medication plus isotonic NaCl solution twice a day (Group B) and symptom-relieving medication with topical nasal corticosteroids plus isotonic NaCl solution twice a day (Group D). Seven-days-treatment resulted in the decreasing of severity of the disease by 39.59% in control group and by 73.62% in patients using isotonic solution NaCl. The use of isotonic NaCl solutions as an adjunct to the treatment of acute rhinosinusitis results in highly statistically significant improvement of nasal patency (by 45.1% in control group and by 72.0% in patients using isotonic solutions) due to decreased swelling of the mucosa of the nasal turbinate. The use of isotonic NaCl solutions as an adjunct to the treatment of acute rhinosinusitis results in a highly statistically significant improvement in function of smell. Treatment with local nasal corticosteroids in combination with isotonic NaCl solutions produces a significant reduction in the severity of symptoms in patients with rhinosinusitis. The therapeutic effect in these patients is statistically significantly better than in patients treated with local nasal corticosteroids alone. The findings of the present study support the investigators' opinion that the isotonic solution (0.9% NaCl) should be recommended for nasal douching may be a valuable adjunct to the standard medical treatment of acute rhinosinusitis.

Diagnostik der pathologischen Mamillensekretion durch Duktoskopie

Fragestellung: Ist die selektive Duktektomie nach duktoskopischer Drahtmarkierung bei pathologischer Mamillensekretion sicher durchführbar? Stellt die Methode eine sinnvolle Alternative zur Reduktion des Resektionsvolumens zur Duktektomie nach Urban dar? Material und Methode: Bei 45 Patientinnen, mittleres Alter 52 Jahre (Range 21–71), wurde wegen einer pathologischen Sekretion eine selektive Duktektomie durchgeführt. Dazu wurden Duktoskope von 0,9 und 1,1 mm Durchmesser eingesetzt. Es wurden nur Patientinnen eingeschlossen, die sonografisch und mammografisch kein Korrelat für die Sekretion zeigten. Der pathologische Milchgang wurde duktoskopisch über einen Arbeitskanal drahtmarkiert und extirpiert. Die histologischen Ergebnisse wurden mit der Zytologie, Galaktografie und Duktoskopie verglichen. Ergebnisse: In 32 von 45 Fällen (71 %) wurde histologisch eine intraduktale, epitheliale Proliferation gefunden. Folgende Sensitivitäten konnten ermittelt werden: Zytologie 12 %, Galaktografie 70 %, Duktoskopie 79 %. Schlussfolgerung: Die Methode erlaubt eine selektive Duktektomie unter direkter Visualisierung des Milchgangs und der intraduktalen Proliferation. Subjektiv lässt sich damit das Resektionsvolumen gegenüber der unselektiven Duktektomie reduzieren.

Selective microdochectomy after ductoscopic wire marking in women with pathological nipple discharge

BackgroundTo investigate the diagnostic reliability of selective microdochectomy after direct ductoscopic wire marking of suspect lesions in patients with pathological nipple discharge.MethodsSelective microdochectomy due to pathological discharge was performed in 33 patients with mean age of 51.7 years. Ductoscopes of 0.9 and 1.1 mm in diameter with a channel for wire marking were used. Only patients without sonographic or mammographic correlation for the discharge were included. The pathologic mammary duct was wire marked and extirpated under direct visual guidance via the ductoscope. The histological results were compared with cytology, galactography and ductoscopy.ResultsIn 24 out of 33 cases (72%) an intraductal, epithelial proliferation was found histologically. The following sensitivities for intraductal, epithelial proliferations could be determined: cytology 4%, galactography 74%, and ductoscopy 78%.ConclusionThe method allows selective microdochectomy of the pathological duct and the intraductal proliferation under visual guidance. The resection volume can be reduced in contrast to the unselective ductectomy after injection of methylene blue.

Short communication: Haptoglobin as an early indicator of metritis

The purpose of this study was to determine whether haptoglobin (Hp) could be used as a predictive measure for metritis. Cattle were grouped into 3 health categories based on the condition of vaginal discharge and body temperature after calving: severe metritis (n=12), mild metritis (n=32), and healthy (n=23). Blood was collected and analyzed for Hp concentration on d −20±5, −6±2, −2±1, and d 0 relative to calving, and then every 3 d after calving until d +21. Cows with mild and severe metritis had greater Hp concentrations than healthy cows between d 0 and d +12. Mean (±SE) Hp concentrations peaked on d +3 in the cows with mild metritis (1.06±0.15g/L) and on d +6 in cows with severe metritis (1.62±0.47g/L). Mean concentrations for the healthy group were 0.58±0.12g/L and 0.31±0.08g/L on d +3 and d +6, respectively. Clinical signs of pathological discharge for the mildly and severely metritic cows did not occur until, on average, 8.6±3.9 d and 5.3±1.9 d after calving, respectively. Cows with Hp concentrations ≥1g/L on d +3 were 6.7 times more likely to develop severe or mild metritis; this predictive threshold has a sensitivity of 50% and specificity of 87%. These results indicate that an acute phase inflammatory response precedes clinical metritis and that Hp screening may assist in the early detection of metritis, providing increased opportunities for early treatment and prevention.

Suivi de l'activité cancérologique au CHU de Dijon : intérêt du PMSI

This work aimed to assess the feasibility of coalescing data sources to follow up on the management and delivery of cancer patient care using both anatomical-pathological data and a medical record information system based on the "Medicalisation of Information Systems Programme" which is administered by an independent source. The study group was comprised of all hospitalised cancer patients in the Dijon university teaching hospital during the first quarter of 2001. Data were obtained from a cross-analysis of medical records with pathological information and standard discharge files. A manual validation was then carried out to ensure a valid synthesis. Overall, 1377 abstracts were created and selected for cancer patients hospitalized for the first time. Among these, 60% were validated by the compatibility and concordance of data between the medical record discharge issued and the pathological record, less than 5% were identified only through looking at the anatomical-pathological data in the medical record, and 24% identified by exploring the patient discharge forms. These results demonstrate the difficulty and challenge as well as the benefits of crossing multiple sources of patient information and combine them to more thoroughly and appropriately assess the hospital's activity for caring for cancer patients.

Breast MR for the Evaluation of Occult Nipple Discharge

Pathologic nipple discharge often presents a diagnostic and therapeutic dilemma for clinicians. We present two patients with pathologic nipple discharge in whom breast MR facilitated preoperative identification of and management of otherwise occult index lesions. Breast MR should be considered in the toolbox for evaluation of occult nipple discharge when other available strategies have failed to demonstrate an underlying etiology for the pathologic discharge. The use of breast MR in this setting may permit directed evaluation and management of potentially malignant lesions.

The role of major duct excision and microdochectomy in the detection of breast carcinoma

BackgroundThe association of nipple discharge with breast carcinoma has resulted in numerous women undergoing exploratory surgery to exclude malignancy. The aim of this study was to determine whether pre-operative factors can identify those patients that are most at risk of carcinoma.MethodsAll patients over a 14-year period (1991–2005) who had a microdochectomy or subareolar exploration for the evaluation of nipple discharge were assessed. Patient characteristics, pre-operative imaging and pathological findings were analysed.ResultsOf the 211 patients included in this study, 116 patients had pathological (unilateral, uniductal serous or bloody) discharge. On excision, 6% (n = 7) of patients with pathological discharge and 2.4% (n = 2) of patients with non-pathological discharge were diagnosed with carcinoma. Overall, major duct excision resulted in the diagnosis of carcinoma in 4.3% (n = 9), ADH/LCIS in 4% (n = 8), papilloma in 39% (n = 83), and duct ectasia or non-specific benign disease in 53% (n = 111) of patients. In the patients determined to have malignancy, 44% (n = 4) were premenopausal. No patient with a non-bloody discharge in the total population analysed (28%; n = 59/211), or in the population with a pathological discharge (21%; n = 24/116) was found to have carcinoma upon excision.ConclusionMicrodochectomy or major duct excision performed for nipple discharge resulted in a low rate of malignancy on excision. Conservative management of non-bloody nipple discharge can be considered in patients with no other clinical or radiological signs of malignancy.

Twenty-Year Outcome Following Central Duct Resection for Bloody Nipple Discharge

Patients found with pathologic nipple discharge present a diagnostic dilemma to surgeons. No one diagnostic test, including cytology or radiologic imaging, has proved superior to any other in the differentiation of benign versus malignant sources of pathologic nipple discharge. Ductoscopy has been introduced as a way to assist with identification of potential sources of pathologic nipple discharge. Ductoscopy is also useful in the resection of deep or peripheral masses that may be missed with standard blind resection. This report evaluates the risk of missed malignancy following central duct resection (CDR). Records of 56 patients who underwent CDR for pathologic nipple discharge greater than 15 years previous were reviewed. Data including type of nipple discharge, future biopsy, and pathology reports were all examined. Of the 56 patients, 36 had bloody, 18 serous, and 2 green initial discharges. Fifty-seven percent were found to have intraductal papilloma as the source of discharge, with fibrocystic disease and ductal ectasia providing the next most common causes. One woman was found to have ductal cancer and one lobular carcinoma in situ at time of CDR. Patients were followed for a mean period of 22 years. Fourteen women required future biopsy. Of these, 10 had benign disease and 4 had cancer, 3 on the ipsilateral side. The 3 women with breast cancer were 9, 13, and 17 years from initial resection. CDR for pathologic nipple discharge is an effective way to diagnose and treat pathologic nipple discharge without missing underlying cancers.

The Influence of Nietzsche in Wang Guowei's Essay "On the Dream of the Red Chamber "

There are numerous traces of Nietzsche's influence in Wang Guowei's "On the Dream of the Red Chamber " even though there is not a single mention of Nietzsche's name in that seminal essay. Nietzschean thought looms large where Wang openly disagrees with or quietly departs from the views of Schopenhauer and, to a lesser extent, those of Kant and Aristotle. His questioning of Schopenhauer's "no-life-ism" harks back to Nietzsche's challenge to Schopenhauer's life-negating ethics. His portrayal of Bao Yu reveals three distinctive character traits of the Nietzschean overman. In particular, the praise of Bao Yu's rebellious character reveals Wang's preference for the iconoclastic Nietzschean overman over the passive Schopenhauerian saint. A strong influence of Nietzsche's views of tragedy may also be observed in Wang's discussion of the tragic form. His modification of Aristotle's catharsis seems to have been made in the spirit of Nietzsche's criticism of its "pathological discharge." His stress on the ultimate salvational function of the Dream strongly reminds us of what Nietzsche has said about the life-saving role of the Dionysian tragedy in the Birth. Finally, in his conditional endorsement of "live-life-ism" we can see a thinly disguised repudiation of the extreme Darwinian tendency he mistakenly reads into Nietzsche's works. It should not be surprising that there are so many echoes of Nietzschean thought in "On the Dream." While writing this essay Wang was deeply occupied with the study of Nietzsche's aesthetic and ethical theories through comparisons with Schopenhauer's. If this influence of Nietzsche can be established on the basis of the evidence given above, there is then a need to reassess Nietzschean thought as a catalyst more important than hitherto thought for the rethinking of traditional Chinese literary and cultural traditions-a broad twentiethcentury critical and intellectual trend initiated by none other than Wang's "On the Dream."

Wavelet analysis of epileptic spikes.

Interictal spikes and sharp waves in human EEG are characteristic signatures of epilepsy. These potentials originate as a result of synchronous pathological discharge of many neurons. The reliable detection of such potentials has been the long standing problem in EEG analysis, especially after long-term monitoring became common in investigation of epileptic patients. The traditional definition of a spike is based on its amplitude, duration, sharpness, and emergence from its background. However, spike detection systems built solely around this definition are not reliable due to the presence of numerous transients and artifacts. We use wavelet transform to analyze the properties of EEG manifestations of epilepsy. We demonstrate that the behavior of wavelet transform of epileptic spikes across scales can constitute the foundation of a relatively simple yet effective detection algorithm.

Surgical decision making and factors determining a diagnosis of breast carcinoma in women presenting with nipple discharge.

There is no consensus about the use of the various diagnostic tests and surgical procedures available to confirm or rule out breast cancer in patients presenting with nipple discharge. This study was designed to identify patient and nipple-discharge characteristics associated with the diagnosis of breast cancer and to determine the utility of mammography, sonography, ductography, and cytology in surgical decision making in patients presenting with pathologic nipple discharge. We reviewed the medical records of all patients who presented with nipple discharge at our institution between August 1993 and September 2000. Patient and nipple-discharge characteristics and findings on imaging studies and cytologic examination were analyzed. A total of 146 patients presented at our institution with nipple discharge during the study period. Of these, 52 had clinically benign discharge and were managed without surgical intervention; 94 patients had pathologic discharge and underwent a biopsy procedure for histologic diagnosis, treatment, or both. Logistic regression analysis identified mammographic (relative risk [RR] = 10.47, 95% confidence interval [CI] 2.36 to 46.39, p = 0.0002) and sonographic (RR = 5.54, 95% CI 1.27 to 25.40, p = 0.028) abnormalities as independent factors associated with a malignant diagnosis. Nineteen cancers, 62 papillomas, and 13 other benign lesions were identified among the patients with pathologic discharge. In 3 patients with cancer (15.8%) and 30 patients with a papilloma (48.4%), ductography was the only means of identifying lesions to be resected. Patients who underwent ductography-guided operation (n = 42, 50%) or any surgical procedure including a localization study (n = 66, 78.6%) were significantly more likely than patients who underwent central duct excision alone to have a specific underlying lesion identified (p = 0.045 and p = 0.033, respectively). Abnormalities on mammography and sonography in patients with nipple discharge should alert physicians to the possibility of a breast cancer diagnosis. In patients with pathologic discharge with normal findings on physical examination and other imaging studies, ductography might be the only means of localizing and resecting breast lesions associated with nipple discharge.

Is a one-step operation for breast cancer patients presenting nipple discharge without palpable mass feasible?

Although spontaneous nipple discharge without mass is a common complaint, only about 5–15% of patients with nipple discharge have cancer. The standard preoperative evaluations, including mammography, physical examination, ultrasonography and squeezing cytology, do not provide enough definite data to make a decision for surgery. We have investigated whether preoperative intraductal aspiration cytology and galactography supply sufficient information about the location and nature of the lesion, and have carried out a one-step operative procedure by adding frozen section diagnosis during surgery. A retrospective review of Kaohsiung Medical University Hospital patients presenting symptoms of nonpalpable mass was conducted from January 1989 to June 2000. The medical charts, pathology and cytology reports, and imaging studies were reviewed. Of 487 patients with spontaneous nipple discharge, 190 with pathologic discharge had complete preoperative galactography and intraductal aspiration cytology, and 176 received surgery. Fourteen cases with negative cytology and normal galactography, who had not had an operation, did not develop cancer during an average 7 years follow-up. The diagnostic accuracy rates of 35 cancer patients using galactography and cytology were 91.4% and 88.6%, respectively, and 97.1% in combination, which is better than those of 141 patients with benign lesions (77.3% and 84.4%, and 90.0% in combination, P<0.05). The results show a 91.5% preoperative diagnostic accuracy rate in all patients with nipple discharge, and can be used to discuss the diagnosis with the patient during the preoperative period. All 35 cases with cancer received the one-step procedure under general anesthesia. Sixteen patients received mastectomies, and the other 19 cases had ductolobular resections, depending on their preoperative evaluations and frozen section in pathology. There were no false positives or false negatives in frozen section when comparing permanent histology and residual cancer in mastectomy specimens. There were no symptoms of recurrence in any of the patients who had undergone the two different procedures during 7 years of follow-up. In patients with spontaneous nipple discharge without palpable mass, the preoperative intraductal cytology and galactography were reliable methods to evaluate intraductal lesions. The one-step procedure will be selected for those patients if the frozen section is added. The ductolobular resection with an adequate surgical margin should be the first choice for those nonpalpable breast cancers with nipple discharge. Due to the limited number of breast cancer cases studied, more cases and a long follow-up period are necessary in future.

Is a one-step operation for breast cancer patients presenting nipple discharge without palpable mass feasible?

Although spontaneous nipple discharge without mass is a common complaint, only about 5–15% of patients with nipple discharge have cancer. The standard preoperative evaluations, including mammography, physical examination, ultrasonography and squeezing cytology, do not provide enough definite data to make a decision for surgery. We have investigated whether preoperative intraductal aspiration cytology and galactography supply sufficient information about the location and nature of the lesion, and have carried out a one-step operative procedure by adding frozen section diagnosis during surgery. A retrospective review of Kaohsiung Medical University Hospital patients presenting symptoms of nonpalpable mass was conducted from January 1989 to June 2000. The medical charts, pathology and cytology reports, and imaging studies were reviewed. Of 487 patients with spontaneous nipple discharge, 190 with pathologic discharge had complete preoperative galactography and intraductal aspiration cytology, and 176 received surgery. Fourteen cases with negative cytology and normal galactography, who had not had an operation, did not develop cancer during an average 7 years follow-up. The diagnostic accuracy rates of 35 cancer patients using galactography and cytology were 91.4% and 88.6%, respectively, and 97.1% in combination, which is better than those of 141 patients with benign lesions (77.3% and 84.4%, and 90.0% in combination, P<0.05). The results show a 91.5% preoperative diagnostic accuracy rate in all patients with nipple discharge, and can be used to discuss the diagnosis with the patient during the preoperative period. All 35 cases with cancer received the one-step procedure under general anesthesia. Sixteen patients received mastectomies, and the other 19 cases had ductolobular resections, depending on their preoperative evaluations and frozen section in pathology. There were no false positives or false negatives in frozen section when comparing permanent histology and residual cancer in mastectomy specimens. There were no symptoms of recurrence in any of the patients who had undergone the two different procedures during 7 years of follow-up. In patients with spontaneous nipple discharge without palpable mass, the preoperative intraductal cytology and galactography were reliable methods to evaluate intraductal lesions. The one-step procedure will be selected for those patients if the frozen section is added. The ductolobular resection with an adequate surgical margin should be the first choice for those nonpalpable breast cancers with nipple discharge. Due to the limited number of breast cancer cases studied, more cases and a long follow-up period are necessary in future.

Anatomic correlates of painful tonic spasms in multiple sclerosis.

Painful tonic spasms (PTS) are now regarded as a typical symptom of multiple sclerosis but pathologic or radiologic findings rarely have been described. We report clinical and magnetic resonance imaging records of five original cases. In all of them, lesions likely responsible for unilateral PTS involved the motor pathway at the level of the posterior limb of the internal capsule or the cerebral peduncle on the opposite side. Closeness of motor fibers seems to be the most important underlying anatomic factor because it enables involvement of a higher proportion of axons by a single demyelinating lesion and radial spread of ephaptic activation. In turn, preservation of the underlying pyramidal-spinal tract could make it easier for the pathologic discharge to reach the peripheral effectors and generate PTS.

Ductography for nipple discharge: No replacement for ductal excision

Background: Current management of nipple discharge depends on clinical history to distinguish pathologic from physiologic discharge. We investigated whether ductography supplied additional information in the decision for surgery and/or the localization of pathologic lesion. Methods: A retrospective review of patients with a presenting complaint of nipple discharge seen at the Lynn Sage Breast Center was conducted from January 1995 to June 1996. Medical records, pathology, and ductograms were reviewed. Results: Of 91 patients with nipple discharge, 49 met the criteria for physiologic discharge and 42 had pathologic discharge. Eleven with physiologic discharge had ductograms; none were abnormal. Four of 20 preoperative ductograms were normal but showed intraductal papillomas at the time of surgery; 6 of 20 (30%) had multiple lesions. Four lesions on ductograms did not demonstrate corresponding lesions in the surgical specimen. It is uncertain whether this is due to a missed lesion or a false-positive ductogram. Conclusions: Modern ductography does not reliably exclude intraductal pathology and is not a substitute for surgery in patients with pathologic discharge. Its utility is in identifying multiple lesions or those with lesions in the periphery of the breast. (Surgery 1998;124:685-91.)