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PubMed2001

Extramedullary hematopoiesis in a child with hereditary spherocytosis: an uncommon cause of an adrenal mass.

We report a case of extramedullary hematopoiesis presenting as an adrenal mass in a young male with hereditary spherocytosis. The unilateral adrenal mass was discovered during an abdominal ultrasound performed for jaundice. CT and MR imaging were subsequently performed, followed by an excisional biopsy at the time of splenectomy and cholecystectomy. Although extramedullary hematopoiesis is a rare cause of an adrenal mass, the diagnosis must be considered in any patient with a history of a congenital hemolytic disorder such as hereditary spherocytosis. In this regard, the morbidity of an unnecessary procedure may be avoided.

Adrenal Gland Neoplasms↗
PubMed2006

Impact of diagnostic laparoscopy on the management of chronic pelvic pain.

BACKGROUND: Diagnostic laparoscopy is a useful tool, especially when there is no definite anatomical abnormality visible on imaging modalities. We assess the role and clinical impact of diagnostic laparoscopy in the management of women with chronic pelvic pain. METHODS: Clinical data of 3,068 cases of diagnostic laparoscopy performed for chronic pelvic pain from June 1994 to August 2005 were analyzed. We compared the diagnoses after diagnostic laparoscopy and those after pelvic examination and imaging modalities such as ultrasound or computed tomography (CT), and we then checked the final pathologic diagnoses after operation. RESULTS: Pelvic endometriosis was the most common (60.2%) laparoscopic finding in patients with chronic pelvic pain in this study, followed by normal pelvic findings (21.2%) and pelvic congestion (13.0%). Diagnostic laparoscopy had an influence on correcting previous plans based on imaging modalities in 42.7% of patients such as discarding unnecessary procedures or introducing new diagnostic or therapeutic plans. There were 3 cases of major complications requiring immediate correction. CONCLUSIONS: Diagnostic laparoscopy is a useful diagnostic tool for of women with chronic pelvic pain and can be used as a guideline for individualized treatment.

Adolescent↗
PubMed2003

Foreign esophageal body impaction: multimodality imaging diagnosis.

We report a case of a portion of bran bread impacted in the cervical esophagus in an 88-year-old woman. A complete radiologic study including ultrasonography, computed tomography, and barium swallow was performed. These techniques confirmed and localized the foreign body, which was endoscopically removed. A complete radiologic assessment can guarantee the usefulness of esophagoscopy to avoid significant morbidity from unnecessary procedures in a patient in poor clinical condition. Ultrasonography and computed tomography are attractive and profitable options in these cases.

Aged↗
PubMed2006

Role of magnetic resonance in characterising extrahepatic cholangiocarcinomas.

PURPOSE: The purpose of this study was to evaluate the accuracy of magnetic resonance (MR) in correctly locating and characterising biliary strictures in patients affected by extrahepatic cholangiocarcinoma, identify findings suggestive of the disease, identify lesions with similar MR features and possible criteria for differential diagnosis and establish prospective MR accuracy in diagnosis of malignant obstruction of extrahepatic bile ducts. MATERIALS AND METHODS: We retrospectively reviewed the MR examinations of 39 patients affected by extrahepatic cholangiocarcinoma confirmed by histology or cytology. The studies were evaluated for the following parameters: site of obstruction (hilar, proximal or distal), presence of intra- or extrahepatic dilation of bile ducts, morphology of ductal stenosis (gradual tapering or abrupt ending), morphology of the lesion (mass like or circumferential), dimension, signal intensity before contrast medium administration and lesion enhancement after administration of contrast medium. Finally, we assessed the most useful sequence for the diagnosis. In order to evaluate MR accuracy in the diagnosis of malignant obstruction of extrahepatic bile ducts, we prospectively reviewed MR examinations of 74 patients affected by obstructive jaundice (55 malignant lesions and 19 inflammatory lesions). MR diagnosis was compared with histology or cytology considered as the gold standard. RESULTS: MR allowed identification and localisation of 41/41 extrahepatic cholangiocarcinomas. Fifty-four percent of the lesions showed gradual duct tapering; the remaining lesions showed an abrupt ending. Fifty-six percent of the lesions appeared as a circumferential thickening (infiltrative growth); the remaining lesions had a mass-like appearance (expansile growth). Most lesions were hypo- (49%) or isointense (49%) in T1-weighted sequences and hyper- (49%) or isointense (51%) in T2-weighted sequences. Ninety-five percent of the lesions did not enhance significantly in the arterial phase while 98% showed late enhancement (10 min). The most diagnostic sequence (in 76% of cases) was the late-phase gradient-echo (GRE) T1 fat-saturated sequence. MR had good sensitivity (91%) but poor specificity (47%) in characterising stenosis as malignant, given the large number (10/19) of benign lesions evaluated as neoplastic lesions. CONCLUSIONS: MR almost always identified the cause of stenosis and suggested its neoplastic nature if it exhibited a mass-like appearance (extraductal or growing into the choledochus). On the other hand, lesions with parietal thickening, particularly if smaller than 1 cm, require endoscopic cytology or histology because of the high risk of unnecessary procedures for benign lesions.

Aged↗
PubMed2004

Intraoral neuropathy.

Chronic nonodontogenic toothache has been reported in the literature since the 1700s. This problem has followed a similar scenario since those first reports. The patient typically is misdiagnosed and then subjected to multiple unnecessary procedures, ultimately resulting in tooth extractions because of dentists and physicians being unaware of the existence of atypical odontalgia and other types of intraoral neuropathic pain that are treatable without sacrificing the teeth. This paper reviews the medications and procedures used to treat nonodontogenic toothache.

Anticonvulsants↗
PubMed2004

Prevention or Surgical Treatment of Gallstones in Patients Undergoing Gastric Bypass Surgery for Obesity.

It is well known that obesity is a risk for gallstone formation and biliary sludge. Additionally, it has been clearly shown that rapid weight loss following bariatric surgery is a risk factor for cholesterol cholelithiasis. Multiple serious complications from gallstones such as cholecystitis, cholangitis, gallstone pancreatitis, and cholecystenteric fistulae may occur. Thus, it is necessary to employ medical or surgical methods to prevent or treat gallstones in this group. Therapy should be individualized. Although there is a high incidence of gallstones in this group, only a minority of individuals will develop symptomatic disease. When used in patients who are compliant, ursodeoxycholic acid therapy can be effective to prevent gallstone formation during rapid weight loss. The cost effectiveness of routine ursodeoxycholic acid therapy compared with the potential costs of complicated gallstone disease needs to be further investigated. Combined cholecystectomy with Roux-en-Y gastric bypass surgery is a safe and appropriate therapeutic option in those with preoperatively known gallstones, biliary sludge, and prior episodes of cholecystitis. However, routine cholecystectomy at the time of gastric bypass surgery is not warranted for all patients because of the increased time of operation and postoperative hospitalization, as well as all the potential complications after cholecystectomy. The approach of routine cholecystectomy in this setting subjects many patients to an unnecessary procedure because the majority will not develop symptoms or complications of gallstones. Furthermore, cholecystectomy is technically easier to perform after weight loss occurs.

Journal Article↗
PubMed1990

Hyperkalemia after irradiation of packed red blood cells: possible effects with intravascular fetal transfusion.

Plasma potassium, calcium, and albumin concentrations in irradiated blood, and in fetal blood before and after transfusion, were measured. Dangerously high plasma potassium levels were observed in some units of irradiated packed red blood cells (range, 13.9 to 66.5 mEq/L; mean, 44.7 mEq/L) and could be one possible explanation for the high incidence of fetal arrhythmia associated with fetal intravascular transfusion. There are many factors operative in the preparation of irradiated packed red blood cells that may predispose to high potassium levels: the age of the red blood cells, the number of procedures used to concentrate the blood, the duration of time elapsed from concentration, the duration of time elapsed from irradiation, and the hematocrit. Use of fresh blood, avoidance of multiple packing procedures, limiting the hematocrit in the donor unit to less than or equal to 80%, and minimizing the time between concentration, irradiation and transfusion may minimize the potassium levels, and therefore making an additional washing procedure unnecessary.

Arrhythmias, Cardiac↗
PubMed1991

Efficiency in pathology laboratories: a survey of operations management in NHS bacteriology.

In recent years pathology laboratory services in the U.K. have experienced large increases in demand. But the extent to which U.K. laboratories have introduced controls to limit unnecessary procedures within the laboratory was previously unclear. This paper presents the results of a survey of all 343 NHS bacteriology laboratories which records the extent to which such operations management controls are now in place. The survey shows large differences between laboratories. Quality controls over inputs, the use of screening tests as a culture substitute, the use of direct susceptibility testing, controls over routine antibiotic susceptibility testing, and controls over reporting of results all vary widely. The survey also records the prevalence of hospital antibiotic policies, the extent to which laboratories produce antibiograms for user clinicians, the degree of computerisation in data handling, and the degree of automation in processing specimens. Finally, the survey uncovers a large variation between NHS labs in the percentage of bacteriology samples which prove positive and lead to antibiotic susceptibility tests being carried out.

Bacteriological Techniques↗
PubMed1993

Inadvertent intubation of the left mainstem bronchus.

This is a case report of a previously healthy 61-year-old white male who was emergently intubated in the field by paramedical personnel and transported to the emergency department. Physical examination revealed minimal-to-absent breath sounds over the right hemithorax associated with cyanosis of the head, face, and upper extremities. Emergency needle decompression of the right lung was accomplished without improvement. A postmortem chest radiograph revealed a left mainstem bronchus intubation. Use of the physical examination, the endotracheal tube depth, and an awareness of the possible--but rare-complication of left mainstem bronchus intubation may lead to accurate diagnosis and treatment and avoid unnecessary procedures.

Aortic Rupture↗
PubMed1995

One framework, two systems: flexible abductive methods in the problem-space paradigm applied to antibody identification and biopsy interpretation.

Our goal is to build flexible knowledge-based systems which can use a variety of problem-solving methods and additional task knowledge, without altering the method or task representation. For this purpose, we use a problem-space architecture which allows opportunistic adaptation of problem-solving methods based on the particular goal, situation and knowledge available. Within this framework, we have developed an opportunistic problem-solving method for flexible abductive problem solving. The basic method was specified in terms of potential subgoals and preferences regarding the order of subgoals. This technique avoids specification of any unnecessary procedural commitments, making the resulting method very general and robust. We then developed two systems using this basic abductive method with additional domain-dependent search-control and task knowledge. The additional knowledge alters/overrides some of the minimal knowledge provided by the basic method. Behavior of these systems can change quite dramatically depending on the added increments of knowledge. Knowledge available at runtime shapes the method and hence the behavior. Moreover, even in the absence of strong domain knowledge, due to the wide coverage of the basic abductive method and the general architecture it is based on, the systems are always able to perform some problem solving--they are not brittle. The specific systems implemented are RedSoar and LiverSoar in the domain of red blood cell antibody identification and liver biopsy interpretation, respectively. We discuss the designs, implementations and evaluations of these systems, emphasizing the role the flexible abductive problem-solving method plays.

Antibodies↗
PubMed2004

[Nasal ciliary investigations for the diagnosis of primary ciliary dyskinesia in children].

Primary ciliary dyskinesia (PCD) is an autosomal recessive disorder, characterized by chronic infections of the upper and lower airways, associated in 50% of cases with situs inversus, therefore, corresponding to Kartagener's syndrome. PCD is suspected on clinical features, including bronchitis, rhinosinusitis and chronic otitis media beginning in early childhood. The recurring infections eventually lead to bronchiectasis. The clinical features of PCD have been ascribed to primary defects in cilia, which lead to impairment of mucociliary clearance. Ciliary investigations looking for abnormalities in ciliary motion and ultrastructure can be easily performed at nasal level. Quantitative ultrastructural study of cilia is performed in cases of abnormal ciliary motion and/or clinical symptoms highly suggestive of PCD. In PCD, all or most of the cilia are abnormal, all bearing the same ultrastructural defects, mainly concerning dynein arms. In older children, the detection of a very low nasal NO output could also be useful for the diagnosis of PCD. As soon as the ciliary investigations are easy to perform at the nasal level, they could help for a better detection of PCD. This strategy could be especially useful in cases of atypical presentations, which are underestimated as a cause of recurrent airway infections. Diagnosis of PCD is important in order to prevent the development of bronchiectasis and to avoid any unnecessary procedure.

Age Factors↗
PubMed2006

How to clamp the main pulmonary artery during video-assisted thoracoscopic surgery lobectomy.

We sometimes run across difficulty in dissection of the pulmonary arteries due to dense pleural adhesions and bleeding from the pulmonary artery during the video-assisted thoracoscopic surgery (VATS) lobectomy. In these cases, conversion of the VATS approach to open thoracotomy is a requisite. The presence of an easy and safe technique for pulmonary artery clamping will make the switch of the surgical procedure unnecessary. We developed the new technique for pulmonary artery clamping using 1-0 silk suture. This may become one of the standard techniques for pulmonary artery clamping not only in VATS but also in open thoracotomy, as well.

Constriction↗
PubMed2004

Ovarian pregnancy-a 12-year experience of 19 cases in one institution.

OBJECTIVES: To report the prevalence, presentation, diagnostic modalities, and treatment of ovarian pregnancy in one institution. STUDY DESIGN: Retrospective case control study of 19 cases of ovarian pregnancy treated between 1990 and 2001 at Assaf Harofeh Medical Center, Zerifin, Israel. MAIN OUTCOME MEASURES: Prevalence, presentation, diagnostic modalities, surgical treatment, and relation to intrauterine device (IUD) use. RESULTS: Nineteen ovarian pregnancies, diagnosed between 1990 and 2001, comprised (19/694) 2.7% of all ectopic pregnancies, 1:3000 of all live births leading to a mean ovarian pregnancy per year of 1.6. Presenting symptoms were similar to those of tubal pregnancies including circulatory collapse which was present in 4/19 (21%) of patients. Culdocentesis for diagnostic purposes, has become an unnecessary procedure. Wedge resection by laparotomy was the treatment of choice in the past, and from 1994, it was performed exclusively by laparoscopy. When an ovarian pregnancy was diagnosed, intrauterine device was present in 68% of the patients and in 76% of the fertile women. CONCLUSIONS: The absolute number of ovarian pregnancies between 1900 and 2001 increased but the prevalence rate per delivery was stable. Despite modern diagnostic modalities patients still present in circulatory collapse-conservative approach may underestimate the potential risk of bleeding. Culdocentesis has no clinical diagnostic benefits. Laparoscopy is invaluable, as diagnosis and treatment can be carried out as a single treatment. Laparoscopic wedge resection is the treatment of choice. The relation between IUD use and ovarian pregnancies is still strong.

Adult↗
PubMed2006

Efficacy of PET/CT in the accurate evaluation of primary colorectal carcinoma.

AIM: This study was performed to assess in the accurate evaluation of primary colorectal carcinoma using PET/CT. METHODS: One hundred patients with primary colorectal carcinoma were evaluated during 2004. All patients underwent PET/CT when their preoperative serum carcinoembryonic antigen was >or=10 ng/mL or when CT showed equivocal findings. The appropriateness of PET/CT-induced changes was noted by subsequent operative findings and follow-up. RESULTS: PET/CT more detected 15 intra-abdominal metastatic lesions than abdomino-pelvic CT scan. PET/CT showed true negative findings in 13 patients and false positive or negative findings in 10. Due to PET/CT results, management plans were altered in 27 patients; 9 had inter-modality changes, 10 received more extensive surgery, and 8 avoided unnecessary procedures. CONCLUSIONS: PET/CT altered management plan in 24% of patients with primary colorectal carcinoma in correct direction. These findings suggest that PET/CT should be considered a part of standard work up for preoperative evaluation in a subset of patients with colorectal carcinoma.

Adult↗
PubMed2004

Traumatic acute subdural hygroma mimicking acute subdural hematoma.

Subdural hygroma is a frequent delayed complication of head trauma. Most hygromas are clinically 'silent' and a few cases have shown slow deterioration in the chronic stage. We report a case of subdural hygroma showing unique radiological findings and rapid deterioration. A 74-years-old female presented with a mild headache and consciousness disturbance after head injury. Computed tomography showed a midline shift as a result of two components piling up in the subdural space; the outer components showed low density, the inner components high density. Magnetic resonance imaging demonstrated that these two subdural components were subdural hygroma and subarachnoid hematoma. Simple burr hole irrigation, rather than large craniotomy, was thought to be more appropriate treatment to reduce the mass effect. Simple burr hole irrigation was performed to remove the subdural hygroma and the patient showed an excellent recovery. Careful examination of the radiological findings prevented an unnecessary procedure in this case. A possible mechanism of this phenomenon is discussed.

Acute Disease↗
PubMed2006

Routine gallbladder screening not necessary in patients undergoing laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Management of the gallbladder in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) is controversial. We reviewed our experience in patients undergoing LRYGBP without routine gallbladder screening. METHODS: The data of 644 patients who underwent LRYGBP at our institution were analyzed. Preoperative ultrasonography was routinely obtained early in our series and selectively thereafter in patients with suspected symptomatic biliary disease. Cholecystectomy at LRYGBP was performed in symptomatic patients with positive ultrasound findings. Postoperatively, patients with intact gallbladders were prescribed ursodiol for 6 months. RESULTS: Of the 644 patients, 155 (24%) had history of cholecystectomy. A total of 104 patients underwent preoperative ultrasonography. Of the 104 patients, 20 had positive ultrasound findings and symptoms consistent with biliary disease and underwent concomitant cholecystectomy. Twelve patients had positive ultrasound findings and no biliary symptoms and did not undergo cholecystectomy. At a mean follow-up of 26.4 months, only 1 (8.3%) of the 12 patients had required cholecystectomy. Of the 104 patients, 72 had negative ultrasound findings. At a mean follow-up of 21.2 months, 5 of them (6.9%) had required cholecystectomy. The remaining 385 patients did not undergo any gallbladder screening. At a mean follow-up of 14 months, 32 (8.3%) of 385 patients had required cholecystectomy. Compliance with ursodiol for >4 months was only 39%. A time-to-event analysis did not reveal a significant difference in the cholecystectomy rate between asymptomatic patients with preoperative gallbladder screening and patients with no screening. CONCLUSION: Omission of gallbladder screening in asymptomatic patients undergoing LRYGBP is a reasonable approach that spares the patient a potentially unnecessary procedure with all its associated risks.

Adolescent↗