In-shoe biaxial shear force measurement: the Kent shear system

Involvement of the nail unit in pemphigus vulgaris is thought to be uncommon. However, trachyonychia, nail atrophy, onychomadesis, onycholysis, nail bed erosion, onychoschizia, subungual haemorrhage, nail pitting, nail plate discoloration, cross-ridging of nail plate, Beau's line and paronychia have been reported. These manifestations may be due either to secondary extension of the bulla adjacent to the nail or primary involvement of the nail bed, nail matrix and nail fold. We report four patients with pemphigus vulgaris who developed paronychia with a corresponding exacerbation of their cutaneous lesions. Nail fold biopsy and direct immunofluorescence revealed features of permphigus vulgaris. Treatment with immunosuppressive agents showed simultaneous improvement of both cutaneous and nail lesions.     

Statistical definition of nail fold capillary pattern in patients with systemic sclerosis

Image analysis of videographs of nail fold capillaries was performed in patients with systemic sclerosis (SS), and the capillary patterns were defined by canonical discriminant analysis. Forty-eight of 55 SS patients were significantly differentiated from patients with systemic lupus erythematosus and normal controls. Normal controls and patients with systemic lupus erythematosus showed identical nail fold capillary patterns; in patients with dermatomyositis the pattern was similar to that of SS. The canonical discriminant analysis revealed that only 5 of 55 (9%) SS patients showed a normal capillary pattern. The abnormal capillary pattern in SS patients correlated with microvascular disturbances such as Raynaud's phenomenon, digital pitting scars and low finger temperature. Our results indicate that quantitative analysis of the nail fold capillaries is useful in evaluating the microvascular disturbances in SS patients.     

The new temperance movement in the United States: what happened to macrostructural factors in alcohol problems?

BACKGROUND: Pulmonary tuberculosis can produce unusual radiographic appearances and negative results of sputum and bronchoscopic examinations are common. This study assessed the value of ultrasound guided aspiration biopsy in the diagnosis of pulmonary tuberculosis with unusual radiographic appearances. METHODS: Thirteen patients, ultimately diagnosed as having tuberculosis, underwent a chest ultrasonographic examination between June 1984 and August 1991. All had sputum available for examination and nine were also examined by bronchoscopy. Ten patients who had a negative sputum smear and negative bronchoscopic brushing smears underwent ultrasound guided aspiration or biopsy. Percutaneous aspiration was performed with a 22 gauge needle. If the smear did not reveal acid fast bacilli, a biopsy sample was taken with a 16 gauge Tru-cut needle to obtain a histological diagnosis. RESULTS: The ultrasonographic examination delineated the more complex nature of the lesions better than the chest radiograph. Ultrasound guided aspiration biopsy provided the diagnosis in nine of 10 patients, while the sputum smear and culture provided diagnosis in five of 13, and bronchoscopy in four of nine. In terms of rapid diagnosis, ultrasound guided aspiration biopsy gave the diagnosis in eight of 10 cases. No patient developed a major complication. CONCLUSION: Ultrasonography can direct the needle to the most suitable part of a lesion to obtain the relevant specimens. The diagnostic yield is high and the procedure is relatively safe. It is especially helpful in patients with negative results of sputum and bronchoscopic examinations.     

Lead, nickel and vanadium in seafood: an exposure assessment for Kuwaiti consumers

Approximately 20% of patients with the limited form of scleroderma will develop pulmonary hypertension which is generally a late stage fatal complication. Why pulmonary hypertension occurs in this subset of patients is unknown and it has not been possible to predict which patients are at risk. Nailfold capillary dilatation, distortion and drop occurs universally in patients with scleroderma and is generally an early finding. The present study was conducted to investigate whether quantitative nailfold capillaroscopy could distinguish those limited scleroderma patients who have established pulmonary hypertension. Quantitative nailfold capillaroscopy was performed by Visual Image Analysis in 10 healthy subjects and 20 patients with limited scleroderma (18 centromere +ve), of whom 8 had established pulmonary hypertension. It was found that scleroderma patients with pulmonary hypertension had a significant reduction in capillary density compared with patients lacking this complication (p < 0.01). Patients with scleroderma have significantly more dilated capillaries than controls although no significant differences were observe between the two patient subgroups. The finding of reduced nailfold capillary density in scleroderma patients with established pulmonary hypertension has possible pathogenic significance and may allow detection of this subgroup at an early stage in their disease progression.     

Diagnosis of prostatic carcinoma: value of random transrectal sonographically guided biopsies

OBJECTIVE: We studied the efficacy of random, transrectal sonographically guided biopsies in the diagnosis of prostatic carcinoma in a high-risk population. SUBJECTS AND METHODS: During a 2-year period, 570 transrectal sonographically guided prostatic biopsies were done because of clinical findings suggestive of prostatic carcinoma. Biopsies of hypoechoic lesions that were suggestive of carcinoma and segmental random biopsies of normal-appearing lobes of the prostate were performed. Transrectal sonographic findings were correlated with results of pathologic examination of the biopsy specimen and with surgical results, when available. RESULTS: Of the 202 patients found to have carcinoma, the carcinoma was detected with directed biopsy in 145 patients (72%). One hundred twenty (71%) of 169 carcinomas were detected with random biopsy when that procedure was performed. Random biopsies were the only method of diagnosing 57 (28%) of the 202 carcinomas, increasing the yield by 39%. CONCLUSION: Yield of carcinoma on transrectal sonographically guided biopsies increases significantly when segmental random biopsies are performed. Transrectal sonographically guided biopsies should include cores through hypoechoic lesions that are suggestive of carcinoma and bilateral segmental random biopsies.     

Efficacy of sonographically guided biopsy of thyroid masses and cervical lymph nodes

OBJECTIVE: We performed a prospective study in 96 patients to determine accuracy of sonographically guided fine-needle aspiration biopsy of thyroid masses and cervical lymph nodes. MATERIALS AND METHODS: Real-time sonography was used to guide biopsy of 112 cervical masses in 96 patients (71 patients with impalpable masses, 16 with failed unguided attempts, patient's or physician's preference in nine). The diameters of all masses were less than 3 cm, with a mean of 1.5 cm and a median of 1.5 cm. Twenty-nine masses measured 1 cm or less in diameter, 60 masses between 1.1 and 2.0 cm, and 23 masses between 2.1 and 3.0 cm. Cervical masses that were sampled by biopsy included 75 thyroid masses and 37 lymph nodes. RESULTS: Diagnostic specimens were obtained in 102 (91%) of 112 masses sampled. Sixty-eight (91%) of 75 biopsies of thyroid tissue and 34 (92%) of 37 biopsies of lymph nodes were diagnostic. Nondiagnostic thyroid biopsies included four of complex cysts and three of solid nodules. Sonographic follow-up (1 year) revealed no change or decrease in size of those seven lesions. Sixty of 68 diagnostic thyroid biopsies showed benign processes: 42 macrofollicular adenomas, six colloid adenomas, five microfollicular adenomas, four probable cases of thyroiditis, and three hemorrhagic cysts. The remaining eight diagnostic thyroid biopsies showed malignant processes: seven papillary carcinomas and one metastatic small-cell carcinoma. Of 34 diagnostic biopsies of lymph nodes, 26 showed malignant processes and eight showed benign processes. Surgery in the three patients with nondiagnostic biopsies of lymph nodes revealed two recurrent medullary cancers and one benign node. CONCLUSION: Sonographically guided fine-needle aspiration biopsy of neck masses has a high sensitivity (91%) and should be routinely used to evaluate indeterminate masses in the neck.     

Effect of chrysotile-asbestos and zeolites dust on generations of reactive oxygen species by alveolar macrophages and granulocytes

OBJECTIVE: To evaluate the discrepancy index between the clinical and histological diagnosis and the prevalence of epithelial dysplasia and carcinoma in 45 patients with potentially malignant epithelial oral lesions (PMEL). PATIENTS AND METHODS: We submitted 45 patients with PMEL to clinical examination and obtained a biopsy from each. The results of histological diagnosis were compared to the clinical diagnosis. RESULTS: Clinical diagnosis showed that the most common PMEL was leukoplakia followed by lichen planus and by actinic cheilitis associated with leukoplakia. The most common site was the buccal mucosa. Histological diagnosis revealed that 46.7% of the PMEL were lichen planus. The discrepancy index between clinical and histological diagnosis was 24.4%. The higher discrepancy index occurred among leukoplakias. The prevalence of epithelial dysplasia and carcinoma was 17.8%. CONCLUSIONS: We conclude that all PMEL should be submitted to a microscopic analysis because the discrepancy between clinical and histological diagnosis was present in a quarter of these lesions. Otherwise, the epithelial dysplasia and carcinoma were more frequent in the leukoplakias.     

Clinical value of endoscopic ultrasound-guided transesophageal fine needle puncture of mediastinal lesions

BACKGROUND AND OBJECTIVE: As the mediastinum has been a region difficult to access for biopsy, mediastinoscopy has been required in most cases. In a prospective study the value of transoesophageal endoscopic ultrasound (TEUS) guided aspiration biopsy was assessed as an alternative. PATIENTS AND METHODS: TEUS-guided fine-needle aspirations were performed between May 1995 and March 1998 in 35 patients with mediastinal space-occupying lesions. In all cases the conventional endoscopic method or percutaneous puncture-sonography had been impossible or had failed. In one patient it had been performed after a negative mediastinoscopy. RESULTS: In 34 patients (97%) the aspirated tissue cylinder could be evaluated histologically. There were no complications. Malignancy was demonstrated in 24 patients, and there were one case each of sarcoidosis, silicoanthracosis and two cases of retrosternal goitre. In four of seven patients the negative preoperative diagnosis was confirmed at operation or by follow-up. There were two false-negative results and in one patient there has been no definitive diagnosis. The accuracy of the method was thus 91.4%, the positive predictive value for malignancy 88.9% and the negative predictive value for malignancy 72.7%. Ultrasound alone was a poor predictor of malignancy in lymph node enlargement. CONCLUSION: TEUS-guided fine-needle aspiration of space-occupying mediastinal lesions is an effective and low-risk method that can in selected cases shorten the diagnostic process and avoid methods that are expensive or lead to complications such as transpulmonary biopsy guided by computed tomography or mediastinoscopy.     

Sonographic guidance of mediastinal biopsy: an effective alternative to CT guidance

OBJECTIVE: Our objective was to determine the diagnostic and cost efficacy of sonographically guided mediastinal biopsy as an alternative to CT-guided mediastinal biopsy and to review our biopsy triage experience in switching from CT to sonography. CONCLUSION: Sonography is as safe and accurate as CT and is 25% less costly than CT. Sonography proved particularly valuable for identifying vessels and perfused tissue and for permitting upright biopsy positions in dyspneic patients. When using our triage criteria, radiologists should find sonographically guided mediastinal biopsy to be an attractive alternative to CT-guided mediastinal biopsy in most patients.     

Stereotactic and ultrasound core needle breast biopsy performed by surgeons

BACKGROUND: The authors evaluated outcomes and treatment costs of stereotactic core needle biopsy (SCNB) and ultrasound core needle biopsy (UCNB), and needle localization biopsy (NLB) in managing patients with mammographic abnormalities presenting to the surgeon. METHODS: Data for all patients with mammographic lesions who underwent SCNB or UCNB since their introduction at this institution were prospectively collected over 17 months. Mean inclusive costs of the three procedures were accumulated and compared. RESULTS: Stereotactic core needle biopsy was performed for 342 lesions in 319 women, for a malignancy rate of 19%; UCNB was performed for 157 lesions in 144 patients, yielding a malignancy rate of 17%. With a mean follow-up of 13.5 months, 1 patient with in situ carcinoma was diagnosed late. Absolute cost savings for the period studied was $721,963. CONCLUSIONS: Minimally invasive breast biopsy procedures can safely and reliably be performed by surgeons in clinical practice with increased patient convenience and decreased costs.     

Surgical treatment of extratemporal epilepsy: clinical, radiologic, and histopathologic findings in 60 patients

PURPOSE AND METHODS: The aim of this study was to analyze clinical, radiologic, and histopathologic findings in 60 consecutive patients with medically intractable extratemporal epilepsy who were operated on between November 1987 and May 1993. RESULTS: Histologically, there were distinct structural abnormalities in 50 (83%) of the surgical specimens. Signal abnormalities on magnetic resonance imaging (MRI) were present in all patients with neoplastic lesions (n = 17) and in 94% of patients with nonneoplastic focal lesions (n = 32). Overall, structural abnormalities were detected by MRI in 47 (96%) of 49 patients with focal lesions. During a mean follow-up of 4 years, 30 (54%) patients remained completely seizure free, 11 (20%) had < or = 2 seizures per year, seven (12%) showed a seizure reduction of > or = 75%, and eight (14%) had < 75% reduction in seizure frequency. The fraction of seizure-free patients was 12 (80%) of 15 in patients with neoplastic lesions, 16 (52%) of 31 in patients with nonneoplastic focal lesions, and two (20%) of 10 for those without histopathologic abnormalities. The differences in seizure outcome between patients with and without focal lesions were statistically significant (p < 0.05), if seizure-free outcome was compared with persistent seizures. CONCLUSIONS: Focal lesions and particularly neoplasms are associated with improved postoperative seizure control compared with patients without histopathologic abnormalities. We advise caution in considering surgery to treat extratemporal epilepsy in patients who have normal MRI scans, because the outcome with the approach described in this study is poor in such cases.     

A case-control and nerve biopsy study of CREST multiple mononeuropathy

From 536 patients with the CREST syndrome (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasis), seven were identified as having peripheral neuropathy not attributable to another cause. Peripheral neuropathy developed 0 to 25 years after their first symptoms of scleroderma. Unexplained neuropathy in CREST patients (seven patients) was more frequent than in control subjects (two patients) matched for age, sex, time of evaluation, and geographic referral region. Multiple mononeuropathy occurred significantly more frequently in the CREST group (six patients) than in the control group (0 patients). Four sural nerve biopsy specimens from the CREST patients demonstrated multifocal fiber loss and perivascular inflammation; one was diagnostic for necrotizing vasculitis and two others were highly suggestive for necrotizing vasculitis. The density of myelinated fibers in three nerves from CREST patients was significantly decreased, whereas the index of dispersion (a measure of multifocal fiber loss) was increased, and the frequency of axonal degeneration was significantly increased. Based on these clinical and pathologic findings, we conclude that in the CREST syndrome multiple mononeuropathy, although occurring infrequently, occurs more frequently than by chance and necrotizing vasculitis is the cause of this multiple mononeuropathy.     

Diagnostic framework of nonpalpable lesions of the breast

Mammography is the most sensitive test for non-palpable lesions, but its specificity is quite limited. When a decision for biopsy is based only on the mammographic appearance the benign/malignant biopsy ratio (B/M) is around 3:1. The B/M varies according to the radiological pattern being favourable for stellate opacities, high for regular opacities, and intermediate for distortions and microcalcifications. Aspiration cytology of non-palpable lesions, either sonographically or stereotaxically guided, is highly accurate. When the decision for surgical biopsy is taken also on the basis of cytology, B/M may be reduced by up to 0.5:1. As false negatives are expected for cytology, lesions which are strongly suspicious at mammography must be biopsied anyway. Sonography guided aspiration is possible in about a half of mammographically detected non-palpable lesions, particularly for opacities, whereas distortions and microcalcification are seldom visualized at sonography. Cytology should be routinely performed in the presence of questionable non-palpable lesions.     

Ultrasonographically guided percutaneous biopsy of gastric, small bowel, and colonic abnormalities: efficacy and safety

The purposes of this study were to evaluate the efficacy of sonographically guided percutaneous biopsy of gastric and bowel lesions and to document any associated complications. A retrospective review of all patients undergoing ultrasonographically guided biopsy of gastric, small bowel, or colonic lesions was performed. Cases were evaluated for size of lesion, location, efficacy in obtaining a diagnostic specimen, and any procedure-related complications. A total of 46 biopsies were performed in 44 patients over a 6 year period. Fifteen gastric, four duodenal, seven small bowel, 16 right colonic, and two left colonic lesions were identified. Histologic diagnosis included 20 adenocarcinomas, seven lymphomas, 10 mesenchymal tumors, and two cases of candidal enteritis. In 18 (41%) patients the initial fine-needle aspirate was negative, although 10 of these patients subsequently underwent ultrasonographically guided core biopsy with a diagnosis of neoplasm established in all 10. Two patients with an initial negative result on fine-needle aspiration underwent repeat aspiration, demonstrating malignancy. Two additional false-negative aspirates were obtained; these patients did not undergo repeat biopsy but were subsequently found to have lymphoma. Two of the patients with aspirates that were negative for malignancy were believed to have inflammatory changes secondary to pancreatitis. One patient was lost to follow-up evaluation. No complications were recorded. Percutaneous fine-needle aspiration of gastric and bowel lesions is a simple and safe procedure and may be particularly useful with poor candidates for endoscopy or for lesions that are difficult or impossible to reach endoscopically. Diagnostic yield is high, particularly in documenting malignancy, although in suspected stromal tumors a core biopsy often is required.     

Solute focusing techniques for bioseparations

BACKGROUND: Hepatic lesions in sickle cell disease have been studied essentially in autopsy series. Previous reports on living patients are rare and concern a limited number of cases. The aim of the present study is to report the clinical, biochemical, and hepatic histological findings in 26 living patients with sickle cell disease and hepatobiliary disease. PATIENTS AND METHODS: Twenty-six of 510 patients with sickle cell disease, in whom liver tissue was available for histological analysis, were selected. In 21 patients, biopsy was obtained during laparotomy for cholecystectomy; 5 patients underwent needle biopsy for hepatomegaly and/or liver test abnormalities. RESULTS: Twenty of the 21 cholecystectomized patients, as well as the 5 other patients, had liver vascular lesions consisting of sinusoidal dilatation (23 cases), perisinusoidal fibrosis (19 cases), and acute ischemic necrosis (5 cases). It is of interest that the 21 cholecystectomized patients had clinical signs of complicated cholelithiasis, and that 20 of them had gallbladder stones, with common bile duct lithiasis in only 1 case. In the 25 patients without common bile duct obstruction, symptoms might have been due to vascular lesions, but it must also be noted that in the cholecystectomized patients they did not persist or recur following surgery. In one cirrhotic patient, marked sinusoidal lesions might have favored severe hepatocellular failure that led to liver transplantation. In another patient, fatal hepatocellular insufficiency was possibly due to ischemia. The nonvascular lesions that were observed, ie, chronic persistent or mildly active hepatitis (11 cases) and cirrhosis (2 cases), were always associated with vascular lesions. CONCLUSION: These results suggest that in sickle cell disease: (1) hepatic lesions are mainly vascular; (2) these lesions can be responsible for acute and/or chronic ischemia that may be severe; (3) symptoms suggestive of acute cholecystitis and/or biliary tract obstruction might be, at least in part, explained by vascular lesions; and (4) biliary tract surgery indications should be considered more carefully.     

Determination of IgA- and IgM-rheumatoid factors in patients with rheumatoid arthritis with and without nephropathy

OBJECTIVE: To clarify the characteristics and pathogenesis of renal disorders in patients with rheumatoid arthritis (RA). METHODS: In this study, 143 patients with RA were included, from whom 43 with urinary abnormalities were biopsied. Serum rheumatoid factor (RF) concentrations of IgA and IgM isotypes were also measured in these patients by enzyme linked immunosorbent assay. RESULTS: Light microscopy of renal biopsy specimens showed minor glomerular abnormalities in six patients, mesangial proliferative glomerulonephritis (GN) in 21, membranous nephropathy in seven, renal amyloidosis in seven, and tubulointerstitial nephritis in two. Twelve patients with mesangial proliferative GN and one with minor glomerular abnormalities were found by immunofluorescence microscopy to have abnormalities consistent with IgA GN. Although the concentrations of IgA-RF in patients with IgA GN were slightly raised compared with those with glomerulopathy established by biopsy but not associated with IgA GN, the concentrations of IgA-RF were higher in patients with RA with vasculitis or interstitial pneumonia than those with RA complicated by IgA GN. CONCLUSIONS: Mesangial proliferative GN, including IgA GN, may be a frequent renal lesion in Japanese patients with RA. IgA-RF may play little pathogenetic part in the development of IgA GN in RA.     

Ultrasound-controlled stereotactic breast biopsy--description and initial clinical results of a new breast biopsy device

The aim of this prospective study was first to describe a new dedicated 3D-ultrasound guided stereotaxic breast biopsy unit and second its specificity, sensitivity, accuracy and positive predictive value (concerning malignant and benign lesions). Technical considerations are noted and discussed. SUBJECTS AND METHODS: 45 women (aged between 20 and 77 years; mean age: 49.73 years) with sonographically suspect breast lesions were assigned to the new biopsy device (Sonopsy, NeoVision Corporation, Seattle). All biopsies were performed by an experienced radiologists (G. Wolf) and the results compared to the surgical biopsies. RESULTS: Sensitivity and accuracy was 93.3%, specificity 100%, the positive predictive value (concerning malignant lesions) 95.4% and (concerning benign lesions) 97.8%. In 9/45 biopsies (20%) complications were noted (1 hematoma, 2 collapses, 5 vasovagale reactions). In 13/45 Cases (28.9%) the suspect lesions were more distinctively, respectively more clearly defined on the conventional/dedicated sonography unit. CONCLUSION: This dedicated unit combines all advantages of sonographic and stereotaxic guided core biopsies. Our results show that this technique is a promising new method for breast biopsy.     

Increased capillary permeability in systemic rheumatoid vasculitis: detection by dynamic fluorescence nailfold videomicroscopy

OBJECTIVE: Several histological studies suggest a vascular involvement in rheumatoid arthritis (RA). We evaluated morphological and functional changes of skin capillaries in patients with RA. METHODS: We studied capillary permeability by nailfold fluorescence videomicroscopy in patients with RA with and without systemic vasculitis to establish the sensitivity, specificity, and the prognostic value of the technique for the diagnosis of systemic rheumatoid vasculitis (SRV). Nine patients with SRV, 22 patients with active RA without signs of vasculitis, and 16 controls were evaluated. RESULTS: No difference in conventional capillaroscopy was observed when we compared patients with SRV and RA. Using fluorescence videomicroscopy after intravenous injection of fluorescein sodium, we observed an increase of transcapillary dye diffusion in 9/9 patients with SRV, in 13/22 patients with RA without vasculitis and in 4/16 control patients. Our results give a sensitivity of 100% in SRV, a specificity of 44%, a positive predictive value of 34% and a negative predictive value of 100%. CONCLUSION: Our present study points out the functional alteration of the capillary wall in patients with RA with or without vasculitis and suggests the usefulness of dynamic fluorescence nailfold capillaroscopy in patients with RA when systemic vasculitis is suspected, not as a diagnostic tool, but because of the high negative predictive value of the technique.