Overcoming the Limitations of Fine Needle Aspiration Biopsy: Detection of Lateral Neck Node Metastasis in Papillary Thyroid Carcinoma

Purpose

Ultrasound (US) and US-guided fine needle aspiration biopsies (FNAB) are considered the modalities of choice for assessing lymph nodes suspected of containing metastases, but the sensitivity of FNAB varies and is specific to the operator. We analyzed the risk of FNAB providing false negative results of lateral neck node metastasis, and evaluated diagnostic accuracy of FNAB, in patients with papillary thyroid cancer.

Materials and Methods

FNAB was performed in 242 patients suspected of having lateral neck node metastasis on preoperative imaging. Thyroglobulin in the fine-needle aspirate washout (FNA wash-out Tg) and computed tomography enhancement (Hounsfield units) were measured. Patients with negative results on FNAB were examined by intraoperative frozen section. The false negative and true negative groups were compared.

Results

Of the 242 patients, 130 were confirmed as having lateral neck node metastases. In 74 patients, the metastasis was identified by FNAB. False positive results were observed in 2 patients (0.8%) and false negatives in 58 (44.6%). Risk analysis showed that patient age <45 years (p=0.006), tumor size >1 cm (p=0.008) and elevated FNA wash-out Tg (p=0.004) were significantly associated with false negative results on FNAB. The accuracy of FNAB increased significantly when combined with FNA wash-out Tg (p=0.003).

Conclusion

To reduce the false negative rate of FNAB, patient age (<45 years), tumor size (>1 cm) and FNA wash-out Tg (>34.8 ng/mL) should be considered in preoperative planning. Accuracy may be improved by combining the results of FNAB and FNA wash-out Tg.     

Cytological results of ultrasound-guided fine-needle aspiration cytology for thyroid nodules: emphasis on correlation with sonographic findings

Purpose

To compare the cytological results of ultrasound-guided fine-needle aspiration (US-FNA) cytology of thyroid nodules to sonographic findings and determine whether US findings are helpful in the interpretation of cytological results.

Materials and Methods

Among the thyroid nodules that underwent US-FNA cytology, we included the 819 nodules which had a conclusive diagnosis. Final diagnosis was based on pathology from surgery, repeated FNA cytology or follow-up of more than one year. Cytological results were divided into five groups: benign, indeterminate (follicular or Hurthle cell neoplasm), suspicious for malignancy, malignant, and inadequate. US findings were categorized as benign or suspicious. Cytological results and US categories were analyzed.

Results

Final diagnosis was concluded upon in 819 nodules based on pathology (n=311), repeated FNA cytology (n=204) and follow-up (n=304), of which 634 were benign and 185 were malignant. There were 560 benign nodules, 141 malignant nodules, 49 nodules with inadequate results, 21 with indeterminate results, and 48 that were suspicious for malignancy. The positive and negative predictive values of the US categories were 59.1% and 97.0%, and those of the cytological results were 93.7% and 98.9%. The US categories were significantly correlated with final diagnosis in the benign (p=0.014) and suspicious for malignancy (p<0.001) cytological result groups, but not in the inadequate and indeterminate cytological results groups. The false positive and negative rates of cytological results were 1.9% and 3.2%.

Conclusion

Sonographic findings can be useful when used alongside cytological results, especially in nodules with cytological results that are benign or suspicious for malignancy.     

Focal Lymphocytic Thyroiditis Nodules Share the Features of Papillary Thyroid Cancer on Ultrasound

Purpose

It is often difficult to discriminate focal lymphocytic thyroiditis (FLT) or adenomatous hyperplasia (AH) from thyroid cancer if they both have suspicious ultrasound (US) findings. We aimed to make a predictive model of FLT from papillary thyroid cancer (PTC) in suspicious nodules with benign cytologic results.

Materials and Methods

We evaluated 214 patients who had undergone fine-needle aspiration biopsy (FNAB) and had shown thyroid nodules with suspicious US features. PTC was confirmed by surgical pathology. FLT and AH were confirmed through more than two separate FNABs. Clinical and biochemical findings, as well as US features, were evaluated.

Results

Of 214 patients, 100 patients were diagnosed with PTC, 55 patients with FLT, and 59 patients with AH. The proportion of elevated thyrotropin (TSH) levels (p=0.014) and thyroglobulin antibody (Tg-Ab) or thyroid peroxidase antibody (TPO-Ab) positivity (p<0.001) in the FLT group was significantly higher than that in the PTC group. Regarding US features, absence of calcification (p=0.006) and "diffuse thyroid disease" (DTD) pattern on US (p<0.001) were frequently seen in the FLT group. On multivariate analysis, Tg-Ab positivity, presence of a DTD pattern on US, and absence of calcification in nodules were associated with FLT with the best specificity of 99% and positive predictive value of 96%. In contrast, a taller than wide shape of nodules was the only variable significant for differentiating AH from PTC.

Conclusion

Suspicious thyroid nodules with cytologic benign results could be followed up with US rather than repeat FNAB, if patients exhibit Tg-Ab positivity, no calcifications in nodules, and a DTD pattern on US.     

Treatment and clinical outcome of needle-track seeding from hepatocellular carcinoma

Background/Aims

Needle-track seeding is a rare but important complication of diagnostic and therapeutic ultrasound (US)-guided procedures in hepatocellular carcinoma (HCC). We examined the frequency of needle-track seeding after US-guided percutaneous ethanol injection (PEI), fine-needle aspiration biopsy (FNAB), and percutaneous transhepatic biliary drainage (PTBD) in order to determine the appropriate treatment for needle-track seeding and its clinical outcome.

Methods

We analyzed the clinical characteristics and treatment outcomes in eight patients who experienced needle-track seeding from HCC after an US-guided procedure (FNAB, PEI, or PTBD) between January 1990 and July 2004.

Results

Seven (0.14%) of 5,092 patients who experienced needle-track seeding (2 after PEI, 4 after FNAB, and 1 after PTBD) during the study period and 1 other patient who experienced needle-track seeding recently were recruited for this study. Two of the eight patients underwent mass excision and the other six patients underwent en-bloc wide excision for the needle-track seeding. Tumors recurred in the needle-tracks in both patients who underwent mass excision but not in the six patients who underwent en-bloc wide excision. Mortality occurred in three patients who experienced the recurrence and progression of intrahepatic HCC.

Conclusions

The incidence of needle-track seeding after US-guided procedures in HCC was 0.14%. En-bloc wide excision seems to be the optimal treatment for minimizing the probability of tumor recurrence due to needle-track seeding.     

International comparison of clinicians' ability to identify depression in primary care: meta-analysis and meta-regression of predictors

Background

There are international differences in the epidemiology of depression and the performance of primary care physicians but the factors underlying these national differences are uncertain.

Aim

To examine the international variability in diagnostic performance of primary care physicians when diagnosing depression in primary care.

Design of study

A meta-analysis of unassisted clinical diagnoses against semi-structured interviews.

Method

A systematic literature search, critical appraisal, and pooled analysis were conducted and 25 international studies were identified involving 8917 individuals. A minimum of three independent studies per country were required to aid extrapolation.

Results

Clinicians in the Netherlands performed best at case finding (the ability to rule in cases of depression with minimal false positives) (AUC+ 0.735) and this was statistically significantly better than the ability of clinicians in Australia (AUC+ 0.622) and the US (AUC+ 0.653), who were the worst performers. Clinicians from Italy had intermediate case-finding abilities. Regarding screening (the ability to rule out cases of no depression with minimal false negatives) there were no strong differences. Looking at overall accuracy, primary care physicians in Italy and the Netherlands were most successful in their diagnoses and physicians from the US and Australia least successful (83.5%, 81.9%, 74.3%, and 67.0%, respectively). GPs in the UK appeared to have the lowest ability to detect depression, as a proportion of all cases of depression (45.6%; 95% CI = 27.7% to 64.2%). Several factors influenced detection accuracy including: collecting data on clinical outcomes; routinely comparing the clinical performance of staff; working in small practices; and having long waits to see a specialist.

Conclusion

Assuming these differences are representative, there appear to be international variations in the ability of primary care physicians to diagnose depression, but little differences in screening success. These might be explained by organisational factors.     

Improved Automated Perimetry Performance in Elderly Subjects after Listening To Mozart

PURPOSE:

To evaluate the performance of automated perimetry of elderly subjects naïve to AP after listening to a Mozart sonata.

INTRODUCTION:

Automated perimetry (AP) is a psychophysical test used to assess visual fields in patients with neurological disorders and glaucoma. In a previous study, Fiorelli et al. showed that young subjects who listened to a Mozart sonata prior to undergoing AP performed better in terms of reliability than those who did not listen to the sonata.

METHODS:

Fifty-two AP-naïve, normal subjects underwent Automated perimetry (SITA 24-2). The study group (25 subjects) underwent AP after listening to Mozart’s Sonata for Two Pianos in D Major, and the control group (27 subjects) underwent Automated perimetry without prior exposure to the music.

RESULTS:

The study group had significantly lower false negative rates and a lower visual field reliability score than the controls (P=0.04 and P=0.04, respectively). The test time was shorter for the study group (P=0.03).

DISCUSSION:

This study shows that elderly subjects, when exposed to the Mozart sonata immediately before AP testing, have lower false negative rates and lower visual field reliability scores when compared with an age- and gender-matched control group. Our results differ from those of Fiorelli et al. who found lower false positive rates and less fixation loss in addition to lower false negative rates.

CONCLUSION:

Listening to a Mozart sonata seems to improve automated perimetry reliability in elderly subjects.     

Mixed echoic thyroid nodules on ultrasound: approach to management

Purpose

To evaluate malignancy risk according to ultrasound (US) features and size change on follow-up US in mixed echoic thyroid nodules and to suggest management guidelines thereof.

Materials and Methods

Among patients who underwent US-guided fine needle aspiration biopsy, 316 mixed echoic nodules in 303 patients were included after excluding the patients with pure solid or cystic nodules or without further cytopathologic evaluation. We evaluated malignancy risk according to US features and changes in size and shape on follow-up US.

Results

The malignancy rate was 31.6% (6 of 19) for nodules with suspicious US features and 2.7% (8 of 297) for nodules without suspicious US features (p<0.001). Among 265 nodules with no suspicious US features and initial benign cytology, 15 nodules with suspicious US change and decreased size, 25 nodules with no suspicious US change and increased size, and 225 nodules with no suspicious US change and no change in size were observed on follow-up USs. The malignancy risk thereof was 0%, 0% and 0.4%, respectively (p=1.000).

Conclusion

Mixed echoic nodules with no suspicious US features and benign cytology can be followed up using US, as they revealed very low malignancy rates, even if they showed growth on follow-up US.     

Accuracy of sonographic criteria in the decision for surgical treatment in infantile hypertrophic pyloric stenosis

Introduction

Abdominal ultrasonography has replaced barium studies in establishing the diagnosis in difficult cases of infantile hypertrophic pyloric stenosis (IHPS). The aim of this retrospective study was to establish sonographic criteria of qualification for surgical treatment in children with IHPS.

Material and methods

Hundred and fifteen infants (98 boys and 17 girls) with suspected IHPS were treated between 2000 and 2009. Pyloric muscle thickness, pyloric diameter and pyloric length were measured in US scans in all patients. Results were compared with US results of 19 infants with negative diagnosis and 29 children of the reference group.

Results

Diagnosis of IHPS was confirmed by US examination in 96 children (83.5%). There were 86 boys in the group with male prevalence 8.6 : 1. The remaining 19 infants (16.5%) had a negative ultrasound. The mean PL (20.89 vs. 12.73), PMT (5.41 vs. 2.24), and PD (14.1 vs. 7.42) differed significantly between patients with and without pyloric stenosis (p < 0.0001). The mean PL (12.34), PMT (2.2), and PD (7.48) in the reference group did not differ statistically from values obtained in patients with negative IHPS diagnosis and were significantly lower than in children from the IHPS group (p < 0.0001). US imaging had a sensitivity of 98%, specificity of 100%, with a positive and negative predictive value of 100% and 90% respectively.

Conclusions

This study confirmed that ultrasonography is the first choice of diagnostic method in an infant with suspected hypertrophic pyloric stenosis. In cases with an uncertain clinical diagnosis of IHPS the examination can be easily repeated.     

Recognition of Depressive Symptoms by Physicians

OBJECTIVE:

To investigate the recognition of depressive symptoms of major depressive disorder (MDD) by general practitioners.

INTRODUCTION:

MDD is underdiagnosed in medical settings, possibly because of difficulties in the recognition of specific depressive symptoms.

METHODS:

A cross-sectional study of 316 outpatients at their first visit to a teaching general hospital. We evaluated the performance of 19 general practitioners using Primary Care Evaluation of Mental Disorders (PRIME-MD) to detect depressive symptoms and compared them to 11 psychiatrists using Structured Clinical Interview Axis I Disorders, Patient Version (SCID I/P). We measured likelihood ratios, sensitivity, specificity, and false positive and false negative frequencies.

RESULTS:

The lowest positive likelihood ratios were for psychomotor agitation/retardation (1.6) and fatigue (1.7), mostly because of a high rate of false positive results. The highest positive likelihood ratio was found for thoughts of suicide (8.5). The lowest sensitivity, 61.8%, was found for impaired concentration. The sensitivity for worthlessness or guilt in patients with medical illness was 67.2% (95% CI, 57.4–76.9%), which is significantly lower than that found in patients without medical illness, 91.3% (95% CI, 83.2–99.4%).

DISCUSSION:

Less adequately identified depressive symptoms were both psychological and somatic in nature. The presence of a medical illness may decrease the sensitivity of recognizing specific depressive symptoms.

CONCLUSIONS:

Programs for training physicians in the use of diagnostic tools should consider their performance in recognizing specific depressive symptoms. Such procedures could allow for the development of specific training to aid in the detection of the most misrecognized depressive symptoms.     

Uninfected Para-Anastomotic Aneurysms after Infrarenal Aortic Grafting

Purpose

This single-institution retrospective review examines the management of uninfected para-anastomotic aneurysms of the abdominal aorta (PAAA), developed after infrarenal grafting.

Materials and Methods

From October 1979 to November 2005, 31 PAAA were observed in our Department. Twenty-six uninfected PAAA of degenerative etiology, including 24 false and 2 true aneurysms, were candidates for intervention and retrospectively included in our database for management and outcome evaluation. Six (23%) patients were treated as emergencies. Surgery included tube graft interposition (n = 12), new reconstruction (n = 8), and graft removal with extra-anatomic bypass (n = 3). Endovascular management (n = 3) consisted of free-flow tube endografts.

Results

The mortality rate among the elective and emergency cases was 5% and 66.6%, respectively (p = 0.005). The morbidity rate in elective cases was 57.8%, whereas 75% in emergency cases (p = 0.99). The survival rate during the follow-up was significantly higher for elective cases than for emergency cases.

Conclusion

Uninfected PAAA is a late complication of aortic grafting, tends to evolve silently and is difficult to diagnose. The prevalence is underestimated and increases with time since surgery. The mortality rate is higher among patients treated as an emergency than among patients who undergo elective surgery, therefore, elective treatment and aggressive management in the case of pseudoaneurysm are the keys to obtain a good outcome. Endovascular treatment could reduce mortality. Patients who undergo infrarenal aortic grafting require life-long surveillance after surgery.     

The Prevalence of Short Sleep Duration by Industry and Occupation in the National Health Interview Survey

Study Objectives:

To explore whether employment in industries likely to have non-standard work schedules (e.g., manufacturing and service) and occupations with long work-weeks (e.g., managerial/ professional, sales, and transportation) is associated with an increased risk of short sleep duration.

Design:

Cross-sectional epidemiologic survey.

Setting:

Household-based face-to-face survey of civilian, non-institutionalized US residents.

Participants:

Sample adults interviewed for the National Health Interview Survey in 1985 or 1990 (N = 74,734) or between 2004 and 2007 (N = 110,422). Most analyses focused on civilian employed workers interviewed between 2004 and 2007 (N = 66,099).

Interventions:

N/A

Measurements and Results:

The weighted prevalence of self-reported short sleep duration, defined as ≤6 h per day, among civilian employed workers from 2004-2007 was 29.9%. Among industry categories, the prevalence of short sleep duration was greatest for management of companies and enterprises (40.5%), followed by transportation/warehousing (37.1%) and manufacturing (34.8%). Occupational categories with the highest prevalence included production occupations in the transportation/warehousing industry, and installation, maintenance, and repair occupations in both the transportation/warehousing industry and the manufacturing industry. In the combined sample from 1985 and 1990, 24.2% of workers reported short sleep duration; the prevalence of short sleep duration was significantly lower during this earlier time period compared to 2004–2007 for 7 of 8 industrial sectors.

Conclusions:

Self-reported short sleep duration among US workers varies by industry and occupation, and has increased over the past two decades. These findings suggest the need for further exploration of the relationship between work and sleep, and development of targeted interventions for specific industry/occupation groups.

Citation:

Luckhaupt SE; Tak S; Calvert GM. The prevalence of short sleep duration by industry and occupation in the National Health Interview Survey. SLEEP 2010;33(2):149-159     

Causes of shoulder pain in women with breast cancer-related lymphedema: a pilot study

Purpose

To inform on shoulder pathology and to identify the disabilities and level of quality of life (QOL) associated with shoulder pain in patients with breast cancer-related lymphedema (BCRL).

Materials and Methods

Using patient history, physical examination, and ultrasound (US), we classified patients with BCRL into the following three groups: no pain with normal ultrasound (US), pain with normal US, and pain with abnormal US. We evaluated shoulder pathology using US, pain intensity using a visual analogue scale (VAS), and functional disability using the Korean version of the Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire. For assessment of QOL, we used the Korean version of the brief form of the World Health Organization Quality of Life Assessment Instrument (WHOQOL-BREF).

Results

28.9% of patients had no pain and normal US, 31.6% had pain with normal US, and 39.5% had pain with abnormal US. The US findings for those with pain and abnormal US revealed the following: 53.3% had a supraspinatus tear, 13.3% had biceps tenosynovitis, 13.3% had acromioclavicular arthritis, 13.3% had subdeltoid bursitis, and 53.3% had adhesive capsulitis. Patients with shoulder pain and abnormal US findings had significantly higher mean DASH and pain scores. Pain scores were positively correlated with DASH scores and negatively correlated with QOL.

Conclusion

We found that BCRL with shoulder pain and evidence of shoulder pathology on US was associated with reduced QOL and increased disability. Proper diagnosis and treatment of shoulder pain are necessary to improve QOL and decrease disability in patients with BCRL.     

Nonrestorative Sleep as a Distinct Component of Insomnia

Study Objectives:

Explore characteristics of nonrestorative sleep (NRS) in prospectively defined subgroups of individuals with NRS symptoms, investigate whether NRS can occur independently of difficulties initiating and maintaining sleep (DIS/DMS), and determine its effect on waking function.

Design:

Cross-sectional and longitudinal population-based study comparing patterns of daytime symptoms, and their persistence, in cohorts of subjects with NRS symptoms grouped according to presence or absence of DIS and DMS.

Setting:

28 sleep centers in the US.

Participants:

Subjects reporting awakening unrestored or unrefreshed at least 3 times weekly over the previous 3 months were classified, based on self-reported sleep problems, to DIS (n = 138), DMS (n = 44), DIS+DMS (n = 125), and NRS-only (no DIS or DMS; n = 192) cohorts. Eighty healthy volunteers formed a control group.

Interventions:

None.

Measurements and Results:

Polysomnography confirmed DIS and/or DMS in 56/138 (41%), 18/44 (41%), and 37/125 (30%) subjects in DIS, DMS, and DIS+DMS cohorts, respectively; and absence of DIS or DMS in 115/192 (60%) NRS-only subjects and 52/80 (65%) healthy volunteers. Multiple subject-reported endpoints including the Endicott Work Productivity Scale, Pittsburgh Insomnia Rating Scale, Restorative Sleep Questionnaire, and SF-36, showed that NRS-only subjects had significantly impaired daytime function relative to healthy volunteers, comparable to impairment affecting subjects with DIS and/or DMS. Symptoms persisted over 3 months.

Conclusions:

This study confirms that NRS can occur independently of other components of insomnia. Daytime symptoms were as severe in individuals with NRS-only as those whose NRS symptoms were combined with DIS or DMS.

Citation:

Roth T; Zammit G; Lankford A; Mayleben D; Stern T; Pitman V; Clark D; Werth JL. Nonrestorative sleep as a distinct component of insomnia. SLEEP 2010;33(4):449-458.     

Prediction of Coronary Atherosclerotic Ostial Lesion with a Damping of the Pressure Tracing during Diagnostic Coronary Angiography

Purpose

When performing coronary angiography (CAG), diagnostic catheter intubation to the ostium can cause damping of the pressure tracing. The aim of this study was to determine the predictors of atherosclerotic ostial stenosis in patients showing pressure damping during CAG.

Materials and Methods

In total, 2926 patients who underwent diagnostic CAG were screened in this study. Pressure damping was defined as an abrupt decline of the coronary blood pressure with a blunted pulse pressure after engagement of the diagnostic catheter. According to CAG and intravascular ultrasound (IVUS), we divided damped ostia into two groups: atherosclerotic ostial lesion group (true lesion group) and non-atherosclerotic ostium group (false lesion group). Clinical and angiographic characteristics were compared between the two groups.

Results

The overall incidence of pressure damping was 2.3% (68 patients and 76 ostia). Among the pressure damped ostia, 40.8% (31 of 76 ostia) were true atherosclerotic ostial lesions (true lesion group). The true lesion group had more frequent left main ostial damping and more percutaneous coronary interventions (PCIs) performed on non-ostial lesions, compared to the false lesion group. On multivariate logistic regression analysis, left main ostial damping [hazard ratio (HR) 4.11, 95% confidence interval (CI) 1.24-13.67, p=0.021] and PCI on non-ostial lesion (HR 5.34, 95% CI 1.34-21.27, p=0.018) emerged as independent predictors for true atherosclerotic ostial lesions in patients with pressure damping.

Conclusion

Left main ostial damping and the presence of a non-ostial atherosclerotic lesion may suggest a significant true atherosclerotic lesion in the coronary ostium.     

Insomnia with Short Sleep Duration and Mortality: The Penn State Cohort

Study Objectives:

Because insomnia with objective short sleep duration is associated with increased morbidity, we examined the effects of this insomnia subtype on all-cause mortality.

Design:

Longitudinal.

Setting:

Sleep laboratory.

Participants:

1,741 men and women randomly selected from Central Pennsylvania.

Measurements:

Participants were studied in the sleep laboratory and were followed-up for 14 years (men) and 10 years (women). “Insomnia” was defined by a complaint of insomnia with duration ≥ 1 year. “Normal sleeping” was defined as absence of insomnia. Polysomnographic sleep duration was classified into two categories: the “normal sleep duration group” subjects who slept ≥ 6 h and the “short sleep duration group” subjects who slept < 6 h. We adjusted for age, race, education, body mass index, smoking, alcohol, depression, sleep disordered breathing, and sampling weight.

Results:

The mortality rate was 21% for men and 5% for women. In men, mortality risk was significantly increased in insomniacs who slept less than 6 hours compared to the “normal sleep duration, no insomnia” group, (OR = 4.00, CI 1.14-13.99) after adjusting for diabetes, hypertension, and other confounders. Furthermore, there was a marginally significant trend (P = 0.15) towards higher mortality risk from insomnia and short sleep in patients with diabetes or hypertension (OR = 7.17, 95% CI 1.41-36.62) than in those without these comorbid conditions (OR = 1.45, 95% CI 0.13-16.14). In women, mortality was not associated with insomnia and short sleep duration.

Conclusions:

Insomnia with objective short sleep duration in men is associated with increased mortality, a risk that has been underestimated.

Citation:

Vgontzas AN; Liao D; Pejovic S; Calhoun S; Karataraki M; Basta M; Fernández-Mendoza J; Bixler EO. Insomnia with short sleep duration and mortality: the Penn State Cohort. SLEEP 2010;33(9):1159-1164.     

Diagnostic performance of thyroglobulin value in indeterminate range in fine needle aspiration washout fluid from lymph nodes of thyroid cancer

Purpose

The purpose was to compare the frequency of metastatic and nonmetastatic lymph nodes diagnosed by fine needle aspiration biopsy cytology (FNAC) and thyroglobulin concentration from fine needle aspiration biopsy washout fluid (FNAB-Tg) in an indeterminate range (0.2-100 ng/mL), and to evaluate the most appropriate threshold value of FNAB-Tg in an indeterminate range.

Materials and Methods

We performed ultrasound-guided FNAB and FNAB-Tg in suspicious metastatic cervical lymph nodes of papillary thyroid carcinoma and performed surgery. Ninety-five lymph nodes with indeterminate values of FNAB-Tg ranging from 0.2-100 ng/mL in ninety-two patients were included in this study. The diagnostic performances in multiple Tg levels (0.7, 1.0, 5.0, 10.0, 20.0, 50.0) were evaluated to compare with FNAB cytology using sensitivity, specificity, and accuracy with area under the curve (AUC) analysis.

Results

Forty-two were metastatic lymph nodes and fifty three were nonmetastatic lymph nodes. FNAB-Tg ranged from 0.22 to 90.9 ng/mL in metastatic lymph nodes (mean; 34.3±33.3 ng/mL) and 0.20 to 56.7 ng/mL in nonmetastatic lymph nodes (mean; 4.9±11.1 ng/mL) (p<0.001). The most excellent diagnostic performance was displayed in 5 ng/mL of FNAB-Tg with AUC of 0.76, sensitivity, specificity, accuracy, 69.0, 83.0, and 76.8, respectively. However, there was no significant difference from 10 ng/mL FNAB.

Conclusion

We ascertained that 5 ng/mL yielded the most excellent diagnostic performance among FNAB-Tg levels in the present setting with a large series with the indeterminate range (0.2-100 ng/mL) of FNAB-Tg values. These results need additional confirmation under different laboratory conditions.     

Quality of prescribing in care homes and the community in England and Wales

Background

Care home residents are vulnerable to the adverse effects of prescribing but there is limited monitoring in the UK.

Aim

To compare prescribing quality in care homes in England and Wales with the community and with US nursing homes.

Design and setting

Cross-sectional analysis of a UK primary care database and comparison with the US National Nursing Home Survey including 326 general practices in 2008–2009 in England and Wales, with 10 387 care home and 403 259 community residents aged 65 to 104 years.

Method

Comparison of age- and sex-standardised use of ‘concern’ and common drug groups in the last 90 days and potentially inappropriate prescribing based on a consensus list of medications best avoided in older people (Beers criteria).

Results

Compared to the community, care home residents were more likely to receive ‘concern’ drugs, including benzodiazepines (relative risk (RR) = 2.05, 95% confidence interval (CI) = 1.90 to 2.22), anticholinergic antihistamines (RR = 2.78, 95% CI = 2.38 to 3.23), loop diuretics (RR = 1.47, 95% CI = 1.41 to 1.53), and antipsychotics (RR = 22.7, 95% CI = 20.6 to 24.9). Use of several common drug groups, including laxatives, antidepressants, and antibiotics, was higher, but use of cardiovascular medication was lower. Thirty-three per cent (95% CI = 31.7% to 34.3%) of care home residents in England and Wales received potentially inappropriate medication, compared to 21.4% (95% CI = 20.9% to 21.8%) in the community. The potentially inappropriate prescribing rate in US nursing homes was similar to England and Wales.

Conclusion

Care home prescribing has the potential for improvement. High use of anticholinergic and psychotropic medication may contribute to functional and cognitive decline. The targeting and effectiveness of medication reviews in care homes needs to be improved.     

Risk of hepatitis B and C infections in Tehranian wrestlers

Context:

Although bloodborne infections are among the most important global health issues, limited data are available on bloodborne infections in athletes.

Objective:

To determine and compare the prevalence of markers of hepatitis B (HBV) and hepatitis C (HCV) viruses and the risk factors for these infections among wrestlers in Tehran and among a control group of athletes in the same geographic area who took part in low- to moderate-contact sports (ie, volleyball and soccer).

Design:

Case-control study.

Setting:

Laboratory.

Patients or Other Participants:

A total of 420 male wrestlers were randomly selected from 28 wrestling clubs in Tehran using a cluster-sample–setting method. The control group (205 volleyball players from 21 clubs and 205 soccer players from 16 clubs) was selected from the same geographic area.

Main Outcome Measure(s):

The risk factors for HBV and HCV and serum levels of anti-HBcAg (antibodies to the HBV core antigen), HBsAg (HBV surface antigen), and anti-HCV (antibodies to HCV) in both groups.

Results:

The prevalence of anti-HBcAg was 13.4% (95% confidence interval [CI] = 10.2%, 16.7%) in wrestlers and 10.9% (95% CI = 7.9%, 14.0%) in the control group. The prevalence of HBsAg was 1.2% (95% CI = 0.2%, 2.2%) in wrestlers and 0.5% (95% CI = −0.2%, 1.2%) in the control group. The prevalence of anti-HCV was 0.5% (95% CI = −0.2%, 1.1%) in wrestlers and 0 in the control group. Some risk factors for bloodborne infections were more common in the wrestlers than in the control group.

Conclusions:

Within the limits of our study, we found no evidence that participation in Tehranian wrestling increased HBV or HCV transmission when compared with transmission in athletes participating in low- to moderate-contact sports. Prevention of bloodborne infections in Tehranian wrestlers should be focused not only on appropriate care for bleeding injuries but also on general risk factors for these conditions.     

Clinical Significance of Microcalcifications Detection in Invasive Breast Carcinoma

Background

Recently, a lot of cases with microcalcifications of the breast are pointed by the images of mammography (MG), because breast screening using MG become common. Although MG is a gold standard modality for detecting microcalcifications, images of ultrasonography (US) are now feasible to detect microcalcifications with recent improvements to ultrasound diagnostic devices. In this report, we analyzed clinical significance of microcalcifications detected with US images in invasive breast carcinoma.

Methods

Eighty-eight patients with invasive breast carcinoma who underwent MG and US before surgery at the Division of Breast and Endocrine Surgery of Tottori University Hospital between January 2012 and August 2013. After reviewing US images, the association between the presence of echogenic spots that indicate microcalcifications and images of MG or pathological findings was assessed.

Results

Patients without microcalcifications on US images were significantly more likely to have the Luminal A subtype and a lower nuclear grading. Conversely, patients with microcalcifications on US images were significantly more likely to have higher level of MIB-1 index, lymphovascular invasion, comedonecrosis and lymph node metastasis. The rate of detecting microcalcifications on US images was relatively good, with 81.8% of sensitivity, 94.5% of specificity and 89.8% of diagnostic accuracy. Among the calcifications detected by MG images, detected rate of calcifications with US images was higher in necrotic type (92.6%) than secretory type (33.3%).

Conclusion

This study suggest that microcalcifications of tumors detected by US images could serve as an useful prediction to evaluate the degree of malignancy for patients with invasive breast carcinoma.