The meaning of equivocal pancreatic cytology in patients thought to have pancreatic cancer

INTRODUCTION: Fine needle aspirations (FNAs) and endoscopic retrograde cholangiopancreatography (ERCP)-guided brushings (BRUSH) are useful tools in the differentiation between malignant and benign disease of the pancreas. Once the decision to obtain a cytologic confirmation of one's clinical suspicion is made, the interpretation of the findings, especially an equivocal or negative cytology finding, can be unclear. This study seeks to evaluate the utility of cytologic studies in the evaluation of a patient with suspected pancreatic malignancy. METHODS: A retrospective review of 224 cytologic reports, including 174 FNAs and 50 BRUSHs, from all pancreatic FNAs and BRUSHs performed between January 1989 and June 1995, was performed. Subsequent confirmation of the cytologic diagnosis was made either by histologic or strict clinical criteria. RESULTS: Forty-three percent of the cytologic reports were read as malignant, all others reported as suspicious, atypical, or negative. All cytology studies read as malignant and all FNAs reported as suspicious were histologically or clinically confirmed to be malignant. Of those reported as atypical or negative, 55% and 49% were confirmed to be malignant. Both FNA and BRUSH were 100% specific, 75% sensitive, and 80% accurate. CONCLUSIONS: We conclude that a cytological diagnosis of malignant or suspicious is reliable and useful for further therapy planning in the patient suspected to have a pancreatic malignancy. The reason for the cytologic tests was a strong clinical suspicion, therefore, a high incidence of cancer was found in the patients with atypical or negative readings. A diagnosis of atypical or negative is equivocal and requires further diagnostic maneuvers, frequently including surgery, to make the definitive diagnosis.     

Foot dystonia and lumbar canal stenosis

We describe a patient who developed involuntary, painless, dystonic contraction of the toes of the right foot on standing or walking. The development of this abnormal movement had been preceded by sensory disturbance on the soles of both feet, triggered by dorsiflexion of the feet. Examination showed that weight bearing on the right foot and walking brought on clawing of the toes of the right foot, which was relieved within seconds of taking pressure off the right foot. There was sensory and reflex evidence of bilateral S1 root disturbance confirmed by electrophysiology. Magnetic resonance imaging of the lumbar spine showed marked stenosis of the lumbar canal with compression of the L5 and S1 nerve roots bilaterally. The patient underwent a lumbar laminectomy with nerve root exit foramina decompression, which abolished the foot dystonia and has considerably improved the sensory disturbance. This case demonstrates that lumbar canal stenosis and/or nerve root compression, may be responsible for foot dystonia. Amelioration of the abnormal movement by surgical decompression argues strongly in favour of this hypothesis.     

Effect of propofol and thiopentone on free radical mediated oxidative stress of the erythrocyte

Propofol has free radical scavenging properties similar to those of recognized phenol-based antioxidants. We have examined these properties in an in vitro model of radical-induced cellular injury, comparing its activity with that of thiopentone (which has also been shown to have radical scavenging activity). Haemolysis of human erythrocytes was induced using the azo compound 2,2'-azo-bis(2-amidinopropane) dihydrochloride (ABAP). This was achieved by incubating a 10% suspension of erythrocytes with ABAP 100 mmol litre-1 at 37 degrees C. For propofol, at concentrations of 12.5, 25 and 50 mumol litre-1, the times to achieve 50% haemolysis were mean 126 (SEM 7) min (95% confidence interval 108-144 min), 150 (8) (129-170) min and 182 (12) (160-180) min, respectively (Intralipid control 107 (7) (90-125) min, ANOVA P < 0.0001). For thiopentone, at concentrations of 62.5, 125 and 250 mumol litre-1, the values were 117 (2) (112-121) min, 126 (3) (119-133) min and 138 (2) (132-144) min, respectively (saline control 109 (2) (104-113) min, ANOVA P < 0.0001). Spectroscopic analysis in the visible and ultraviolet spectra demonstrated a steady increase in the proportion of methaemoglobin during haemolysis, with the highest concentrations in the propofol-containing flasks. The formation of methaemoglobin was preceded by the generation of ferrylhaemoglobin (a Fe4+ haemoglobin species). Further experiments examining oxidation of purified methaemoglobin to ferrylhaemoglobin by hydrogen peroxide suggested that propofol, but not Intralipid or thiopentone, reduced ferrylhaemoglobin back to the met- state, and thereby explained the higher concentrations of methaemoglobin in the propofol-containing erythrocyte suspensions. We conclude that propofol is a more potent free radical scavenger in this model of oxidant stress than thiopentone, and that reduction of high oxidation states of haemoglobin may contribute to such activity.     

Hemorrhagic gastritis in free-living rodents in Idaho

Between February 1992 and March 1994, four species of rodent from the Snake River Birds of Prey Area near Boise, Idaho (USA) were necropsied. Hemorrhagic gastritis was observed in 16 of 131 Townsend's ground squirrels (Spermophilus townsendii), one of 11 Ord's kangaroo rats (Dipodomys ordii) and the one Great Basin pocket mouse (Perognathus parvus) evaluated. No lesions were observed in 14 white-footed deer mice (Peromyscus maniculatus). Tissue from one Townsend's ground squirrel was negative for Helicobacter sp.-like bacteria.     

Assessment of the nutritional state of dialysis patients

Obstructive sleep apnea syndrome (OSAS) has been associated with a higher than normal cardiovascular morbidity and mortality. Some OSAS patients lack the sleep-related, nocturnal decrease, or "dip," in blood pressure which is seen in normal individuals. These subjects, called "non-dippers," may be at greater risk for cardiovascular problems. We studied 40 OSAS patients (including 3 women) and 6 control subjects, all identified by polysomnography, for nocturnal blood pressure "dipping." We performed a second nocturnal polysomnogram to determine their apnea and hypopnea indices, (A + H)I, and oxygen saturation levels at the beginning of the study and then initiated 48 hours of ambulatory blood pressure monitoring, with data points collected every 30 minutes. Controls, which included one hypertensive subject, were all dippers. Nineteen OSAS subjects (48% of OSAS individuals) were systolic non-dippers and only 9 of them (22.5%) were diastolic non-dippers. We considered the following clinical variables as potential predictors of non-dipping: age, body mass index, respiratory disturbance index, years of reported loud snoring by bed partners, lowest oxygen saturation during nocturnal sleep, and percentage of sleep time spent with oxygen saturation below 90%. Multiple regression analyses indicated respiratory disturbance index as the only significant variable for systolic (p = 0.04) and diastolic (p = 0.03) blood pressure non-dipping. When we forced the following two nonsignificant variables into the model, they showed a very meager impact: number of years with reported loud snoring (p = 0.4 and p = 0.5, respectively for systolic and diastolic blood pressure non-dipping) and age (p = 0.5 and p = 0.6). The calculated model explained only a low percentage of the variance with an r2 of 0.25 and 0.26 for systolic and diastolic blood pressure non-dipping, respectively. Analysis of hypertension/normotension and dipping/non-dipping failed to show a significant relationship in the studied population. Fifty percent of the normotensive OSAS subjects were non-dippers and 43% of the hypertensive OSAS subjects were also non-dippers. We found a relationship between increasing respiratory disturbance index and increasing average 24-hour systolic blood pressure only when OSAS subjects were non-dippers and hypertensive.