Use Of Ancillary Tests Research Articles

Fine needle aspiration biopsy of the liver: Algorithmic approach and current issues in the diagnosis of hepatocellular carcinoma.

The role of fine needle aspiration biopsy (FNAB) in the evaluation of focal liver lesions has evolved. Guided FNAB is still useful to procure a tissue diagnosis if clinical, biochemical and radiologic findings are inconclusive. Major diagnostic issues include: (i) Distinction of benign hepatocellular nodular lesions from reactive hepatocytes, (ii) Distinction of well-differentiated hepatocellular carcinoma (WD-HCC) from benign hepatocellular nodular lesions, (iii) Distinction of poorly differentiated HCC from cholangiocarcinoma and metastatic carcinomas, (iv) Determination of histogenesis of malignant tumor, and (v) Determination of primary site of origin of malignant tumor. This review gives a general overview of hepatic FNAB; outlines an algorithmic approach to cytodiagnosis with emphasis on HCC, its variants and their mimics; and addresses current diagnostic issues. Close radiologic surveillance of high-risk cirrhotic patients has resulted in the increasing detection of smaller lesions with many subjected to biopsy for tissue characterization. The need for tissue confirmation in clinically obvious HCC is questioned due to risk of malignant seeding. When a biopsy is indicated, core needle biopsy is favored over FNAB. The inherent difficulty of distinguishing small/early HCC from benign hepatocellular nodular lesions has resulted in indeterminate reports. Changing concepts in the understanding of the biological behavior and morphologic evolution of HCC and its precursors; and the current lack of agreement on the morphologic criteria for distinguishing high-grade dysplastic lesions (with small cell change) from WD-HCC, have profound impact on nomenclature, cytohistologic interpretation and management. Optimization of hepatic FNAB to enhance the yield and accuracy of diagnoses requires close clinicopathologic correlation; combined cytohistologic approach; judicious use of ancillary tests; and skilled healthcare teams.

Rapid viral testing in the evaluation of the febrile infant and child

This review focuses on rapid viral testing in the febrile infant and child. Recent literature is reviewed regarding physician decision making, antibiotic use, ancillary testing use, and rate of serious bacterial infections concurrent with viral disease. Two recent studies detail the use of rapid testing of influenza. The impact on the use of ancillary testing and antibiotic prescribing practices based on the knowledge provided by rapid viral testing has been evaluated. Physician awareness of a rapid diagnosis of influenza significantly reduced the number of laboratory tests and radiographs ordered and their associated charges, decreased antibiotic use, increased antiviral use, and decreased length of time to discharge. The rate of serious bacterial infections coexisting with influenza illness has also been studied. Researchers concluded that the prevalence of serious bacterial infections is lower in febrile children with influenza A infection. Another two studies evaluated respiratory syncytial virus-positive febrile infants and their risk of serious bacterial infection. Both studies independently noted that febrile infants with respiratory syncytial virus infections are at significantly lower risk of serious bacterial infection than febrile infants without respiratory syncytial virus infection. The rate of urinary tract infections remained significant in febrile respiratory syncytial virus-positive infants, however. Various studies have documented the impact of rapid viral testing in the evaluation and management of febrile infants and children. There is insufficient evidence to change current clinical practice algorithms for young febrile infants and children. Continued research will affect future guidelines and algorithms in the management of febrile infants and children.

Treatment Effects in Pediatric Soft Tissue and Bone Tumors

Dramatic improvements in survival for children with cancer have led to increased numbers of posttreatment pathologic specimens, particularly in bone and soft tissue sarcomas. Current therapeutic protocols in North America require specific pathologic classification and stratify patients based on clinical, biologic, and pathologic features. For osteosarcoma, the pathologic response to therapy predicts prognosis and modifies the treatment regimen. Ongoing studies aim to assess the response to therapy and outcome in other types of soft tissue and bone tumors. The pathologic evaluation of pretreatment and posttreatment specimens is critical for therapeutic decisions and prognostic assessment. A standardized approach to posttherapy pathologic specimens, with attention to appropriate use of ancillary tests, and assessment of clinical and biologic significance of therapy-induced pathologic changes has significance for patient management and treatment protocols.

Treatment Effects in Pediatric Soft Tissue and Bone Tumors

Dramatic improvements in survival for children with cancer have led to increased numbers of posttreatment pathologic specimens, particularly in bone and soft tissue sarcomas. Current therapeutic protocols in North America require specific pathologic classification and stratify patients based on clinical, biologic, and pathologic features. For osteosarcoma, the pathologic response to therapy predicts prognosis and modifies the treatment regimen. Ongoing studies aim to assess the response to therapy and outcome in other types of soft tissue and bone tumors. The pathologic evaluation of pretreatment and posttreatment specimens is critical for therapeutic decisions and prognostic assessment. A standardized approach to posttherapy pathologic specimens, with attention to appropriate use of ancillary tests, and assessment of clinical and biologic significance of therapy-induced pathologic changes has significance for patient management and treatment protocols.

Prehospital Spine-Clearance Protocol: Not Ready for Prime Time

Spine immobilization to prevent worsening of potential spine injury in trauma patients is standard practice, with emergency medical services (EMS) providers using a low threshold “just in case.” Yet, immobilization is not without consequence: It is uncomfortable, increases the risk of aspiration, can restrict inspiration, and is associated with increased use of ancillary tests (such as x-rays) in the emergency department …

Comparison of two culture media and three sampling techniques for sensitive and rapid screening of vaginal colonization by group B streptococcus in pregnant women.

The Centers for Disease Control and Prevention (CDC) recommend universal screening of all pregnant women between 35 and 37 weeks of gestation for group B streptococci (GBS) by use of a selective broth medium. Recent reports suggest that Granada medium can be used for rapid and direct visual identification of GBS colonies. However, studies comparing the Granada medium method to the selective broth method are few, and while some report comparable sensitivities, others have found significant differences in detection rates between the two methods. This prospective study compared a method using Granada agar to a Todd-Hewitt broth method with subculture to blood agar in order to determine which GBS detection method is more sensitive and less labor-intensive and has a more rapid turnaround time. Detection rates for three sampling techniques (rectovaginal, vaginal only, and cervical only) were also compared. Consecutive specimens for GBS screening received over a 6-month period from 1,635 pregnant women were included. Overall, GBS was detected in 390 (23.8%) women. The Granada medium gave positive results for 348 of these women, and the selective broth gave positive results for 385, indicating sensitivities of 89.2% for the Granada medium and 98.7% for the selective broth. These findings show that the Granada medium method is less sensitive than the selective broth method and should not replace it as the only method for screening pregnant women for GBS. However, the Granada medium method reduced detection time to 1 day and also reduced the use of ancillary tests in approximately 90% of positive cases. Additionally, no significant differences were noted in the detection rates with rectovaginal, vaginal, and cervical specimens.

Clinical course and determination of brainstem death in a children's hospital

To study the aetiology and clinical course of children with brainstem death in a paediatric intensive care unit (ICU) and to determine whether current the practices that are used to declare brainstem death conform to accepted criteria. A retrospective review chart of all patients with brainstem death (n = 31) admitted to the paediatric ICU between January 1995 and December 1998 was drawn up. Mean age of the patients was 51.9 +/- 54.5 mo with the main diagnoses being head trauma in 11 children, anoxic encephalopathy in 7, brain tumour in 5, drowning in 4, CNS haemorrhage in 3 and CNS infection in 1 child; 32.3% of the children were given pre-ICU admission cardiopulmonary resuscitation. The average time from insult to suspected brainstem death was 27 h and suspected brainstem death to confirmation was 25 h, with an average of 1.6 examinations performed. EEG was done in 14 patients, with electrocerebral silence in 8 after the first examination and in a further 5 after repeat testing. Cerebral blood-flow scans were done in 3 children and evoked potentials in 1 child. Trauma remains the most common primary diagnosis leading to brainstem death. Intensivists in this large hospital for children mainly conform to accepted guidelines for determination of brainstem death although there is a wider use of ancillary tests to aid diagnosis. The study also showed a low rate of < 10% of organ procurement for transplantation.

Clinical course and determination of brainstem death in a children's hospital

Aim: To study the aetiology and clinical course of children with brainstem death in a paediatric intensive care unit (ICU) and to determine whether current the practices that are used to declare brainstem death conform to accepted criteria. Methods: A retrospective review chart of all patients with brainstem death (n= 31) admitted to the paediatric ICU between January 1995 and December 1998 was drawn up. Results: Mean age of the patients was 51.9 ± 54.5 mo with the main diagnoses being head trauma in 11 children, anoxic encephalopathy in 7, brain tumour in 5, drowning in 4, CNS haemorrhage in 3 and CNS infection in 1 child; 32.3% of the children were given pre-ICU admission cardiopulmonary resuscitation. The average time from insult to suspected brainstem death was 27 h and suspected brainstem death to confirmation was 25 h, with an average of 1.6 examinations performed. EEG was done in 14 patients, with electrocerebral silence in 8 after the first examination and in a further 5 after repeat testing. Cerebral blood-flow scans were done in 3 children and evoked potentials in 1 child. Conclusions: Trauma remains the most common primary diagnosis leading to brainstem death. Intensivists in this large hospital for children mainly conform to accepted guidelines for determination of brainstem death although there is a wider use of ancillary tests to aid diagnosis. The study also showed a low rate of < 10% of organ procurement for transplantation.

Human papillomavirus reporting: impact on Bethesda cytology reports.

In 2001, the Bethesda Committee revised the terminology for reporting Papanicolaou tests. One of the 2001 Bethesda forum groups addressed the use of ancillary tests, and the most commonly used ancillary test is for human papillomavirus (HPV). The Bethesda Ancillary Testing Forum presented terminology related to HPV testing. The Ancillary Testing Forum recommended that the specific HPV test method be presented and the results reported as positive or negative for HPV of a certain type or class. The Papanicolaou test and the HPV test should be reported together or should refer to each other if possible. A number of reporting schema currently are used to report HPV results; these schema include probabilistic reporting, integrated reporting, reporting as a result, and reporting with clinical management recommendations. Few data currently are available to support an optimal reporting method.

“medical clearance” of psychiatric patients without medical complaints in the Emergency Department

This study was conducted to evaluate the benefit of comprehensive “medical clearance” (history, physical examination, vital signs, laboratory, radiography) in patients presenting to the Emergency Department (ED) with isolated psychiatric complaints. All patients 16 years and older who presented with a psychiatric complaint and required a psychiatric evaluation before discharge from the ED were included in the study. Data, obtained in a 5-month consecutive, retrospective chart review, included patient age, sex, initial complaint, past medical and psychiatric history, initial vital sign measurement, physical examination findings, laboratory analysis (electrolytes, complete blood count, toxicology screen), chest X-ray study results, and final disposition. The number of patients who could have been referred to a psychiatric unit after a history, physical examination, and stable vital signs, without additional laboratory or radiographic studies, was determined. There were 212 patients who met the inclusion criteria, and all their charts were available for review. Eighty patients (38%) presented with isolated psychiatric complaints coupled with a documented past psychiatric history. All received a comprehensive “medical clearance” in the ED followed by a psychiatric consultation. None of the patients had positive screening laboratory or radiographic results. All were either dispositioned home or to the psychiatric ED. The remaining 132 patients (62%) presented to the ED with medically based chief complaints or past medical history requiring further evaluation in the ED before discharge. The initial complaints of these patients correlated directly with the need for laboratory and radiographic “medical clearance” in the ED. Patients with a primary psychiatric complaint coupled with a documented past psychiatric history, negative physical findings, and stable vital signs who deny current medical problems may be referred to psychiatric services without the use of ancillary testing in the ED.

Impact of emergency medicine residents on ancillary test utilization

The effect of the addition of emergency medicine residency on the use of ancillary testing in a teaching hospital's emergency department (ED) staffed previously by emergency medicine board-certified physicians was studied. Prospectively, the utilization of three common ancillary tests (electrolyte levels, X-ray, or electrocardiogram) for four common chief complaints of patients eventually discharged from the ED was evaluated. A 12-month period before and a 15-month period after introduction of an emergency medicine residency program were compared. The mean number of ancillary tests utilized by the ED attending physicians working with residents was compared with the mean number of tests generated by the same physicians (all emergency medicine board-certified) for the same complaints in the year before the residents' arrival. There was no significant difference in test use before and after introduction of the residency ( P = .66). Faculty use of tests was also unaffected by the concurrent presence of residents ( P = .068). These results show that the use of testing for a sample of common ED complaints was not affected by the introduction of emergency medicine residents to a previously emergency medicine board-certified staff in one community teaching hospital.

Use of ancillary tests in the differential diagnosis of psychotic psychiatric inpatients

Use of ancillary tests in the differential diagnosis of psychotic psychiatric inpatients

Combined Posterior Cruciate Ligament Injuries

Management of posterior cruciate ligament injuries combined with other ligamentous knee injuries must begin with an understanding of the normal anatomy and biomechanics of the knee. Careful physical examinations and judicious use of ancillary tests allow delineation of the extent of knee injury. Each combined injury can then be approached with an organized and specific plan for reconstruction, optimizing knee stability and function.

Medical problems in a sports medicine setting

Becoming reliant on a diagnostic repertoire limited to common sports-related problems can result in delayed diagnoses and potential disservice to the athlete. Remaining aware of other conditions that can mimic the common disorders and maintaining an index of suspicion for their occurrence can aid both the primary care physician and the specialist when challenged with a refractory or atypical presentation in an athlete. Reliance on a thorough history and physical examination, with judicious use of ancillary testing, is the cornerstone for any medical evaluation and no less important in this scenario. When equipped with such knowledge and skills, the physician caring for athletes can provide the best possible service, insuring not only the individuals' overall health, but also their safe and complete return to their chosen sport.

A survey of neurological diseases in horses.

Case records of 450 horses with signs of neurological disease are reviewed. One hundred and nineteen horses with neurological disease due to trauma were examined, of which 60 were due to spinal cord trauma, 47 to brain or cranial nerve trauma and 12 to peripheral nerve trauma. Cervical vertebral fractures/trauma were the most common injury. Basisphenoid/basioccipital bone fractures were the most common form of cranial trauma and facial nerve paralysis the most common cranial nerve injury. Eighty-nine horses with neurological disease due to malformation were examined. Cervical vertebral malformation occurred in 83 horses and congenital defects in 6 foals. Neurological disease due to inflammation or infection occurred in 30 horses. The most common disease of this type was meningitis, which occurred in 11 horses and foals. Neoplasms in the CNS caused neurological disease in 8 horses. The final category was miscellaneous neurological disease, which was diagnosed in 204 horses. Diseases in this category included neonatal (28 cases), toxic/metabolic (27 cases), idiopathic (133 cases), degenerative (3 cases) and other neurological diseases (13 cases). The most common condition was idiopathic laryngeal hemiplegia (116 cases). Where possible, diagnosis relied on a thorough neurological examination with use of ancillary tests in selected cases including rhinolaryngoscopy, radiography, myelography, ophthalmoscopy and cerebrospinal fluid analysis when indicated. In many cases necropsy and histopathological confirmation or diagnosis was necessary.

A New Guideline for Cataract

O'Day's editorial 1 regarding the new clinical practice guidelines on cataract management published by the Agency for Health Care Policy and Research is a harbinger of a new era in medical care. For centuries, physicians have considered themselves a class of professionals above observing the basic tenets of good business and marketing. Ophthalmologists, in their rush to provide what they consider the standard of care, have perfected the use of ancillary tests and statistics to convince patients with early visual alterations due to cataracts that they need surgery imminently. In an environment in which health care costs are rising much faster than inflation and many citizens are underinsured, it is definitely time that the old practices be reconsidered. Japanese industrial leaders and the more successful American entrepreneurs have discovered that there is only one measure that will guarantee survival against tough competition: putting the customer first. 2 This is