Is cytokeratin immunoreactivity useful in the diagnosis of short-segment Barrett's oesophagus in Korea?

BACKGROUND: Cytokeratin 7/20 staining has been reported to be helpful in diagnosing Barrett's oesophagus and gastric intestinal metaplasia. However, this is still a matter of some controversy. OBJECTIVE: To determine the diagnostic usefulness of cytokeratin 7/20 immunostaining for short-segment Barrett's oesophagus in Korea. METHODS: In patients with Barrett's oesophagus, diagnosed endoscopically, at least two biopsy specimens were taken from just below the squamocolumnar junction. If goblet cells were found histologically with alcian blue staining, cytokeratin 7/20 immunohistochemical stains were performed. Intestinal metaplasia at the cardia was diagnosed whenever biopsy specimens taken from within 2 cm below the oesophagogastric junction revealed intestinal metaplasia. Barrett's cytokeratin 7/20 pattern was defined as cytokeratin 20 positivity in only the superficial gland, combined with cytokeratin 7 positivity in both the superficial and deep glands. RESULTS: Barrett's cytokeratin 7/20 pattern was observed in 28 out of 36 cases (77.8%) with short-segment Barrett's oesophagus, 11 out of 28 cases (39.3%) with intestinal metaplasia at the cardia, and nine out of 61 cases (14.8%) with gastric intestinal metaplasia. The sensitivity and specificity of Barrett's cytokeratin 7/20 pattern were 77.8 and 77.5%, respectively. CONCLUSION: Barrett's cytokeratin 7/20 pattern can be a useful marker for the diagnosis of short-segment Barrett's oesophagus, although the false positive or false negative rate is approximately 25%.     

Is the diagnosis of asthma different in elderly?

Asthma is mis-diagnosed, under-diagnosed and under-treated in older populations but has a high mortality rate. The physiological changes due to aging of lung, the co-morbid situations and poly pharmacy may change the typical presentation of asthma in older people and cause diagnostic difficulties. But it therefore should be diagnosed properly by taking of all differential situations especially chronic obstructive pulmonary disease into consideration since the appropriate management of the disease will alter the morbidity and mortality.     

Is early endoscopic retrograde cholangiopancreatography useful in the management of acute biliary pancreatitis?: A meta-analysis of randomized controlled trials

AIMS: To compare early endoscopic retrograde cholangiopancreatography with conservative management for the treatment of acute biliary pancreatitis: a meta-analysis of prospective randomized trials. METHOD: Pertinent studies were selected from the Medline, Embase, and the Cochrane Library Databases, references from published articles and reviews. Conventional meta-analysis according to DerSimonian and Laird method was used for the pooling of the results. The rate difference (95% CI) and the number needed to treat were used as a measure of the therapeutic effect. RESULTS: Five prospective randomized trials including 702 patients were selected. Overall complications and mortality rates were 31% and 6%, respectively. In predicted severe pancreatitis the pooled rate difference for complications in early endoscopic retrograde cholangiopancreatography was 38.5% (95% CI -53% to -23.9%); p < 0.0001; number needed to treat = 3. In predicted mild pancreatitis the pooled rate difference for complications in early endoscopic retrograde cholangiopancreatography was 1.8% (95% CI -5.6% to 9.3%); p = 0.6. No mortality was observed in predicted mild pancreatitis. In predicted severe pancreatitis the pooled rate difference for mortality in the early endoscopic retrograde cholangiopancreatography group was 4.3% (95% CI -16% to 7.5%); p < 0.24. CONCLUSIONS: Early endoscopic retrograde cholangiopancreatography reduces pancreatits-related complications in patients with predicted severe pancreatitis although mortality rate is not affected. In predicted mild pancreatitis early endoscopic retrograde cholangiopancreatography has no advantage compared to conservative management.     

Induced sputum for the diagnosis of pulmonary tuberculosis: Is it useful in clinical practice?

BACKGROUND:

Diagnosing pulmonary tuberculosis (PTB) is challenging in patients who are unable to spontaneously expectorate. Published evidence suggests that induced sputum (IS) is the least invasive and most cost-effective method of diagnosis, and should be used before fibre-optic bronchoscopy (FOB).

METHODS:

The medical records of 337 adults treated for PTB in northern Alberta between 1997 and 2007 were reviewed to determine whether local practice patterns reflect the evidence. Microbiological data were collected from the Provincial Laboratory for Public Health. Demographic information was collected from the patients’ charts.

RESULTS:

A total of 8.5% (26 of 307) of PTB patients had IS collected, whereas 35.8% (110 of 307) underwent FOB. Among FOB patients, 56.4% (62 of 110) had no sputum sent before the procedure and 29% (18 of 62) of these patients were smear positive. Only five patients referred for FOB had IS sent previously. There were no demographic factors predictive of IS use, whereas being an inpatient at a teaching facility or having a nodule or mass on chest x-ray was predictive of FOB referral. Because so few IS samples were available, not all patients had spontaneously expectorated sputum, IS and FOB tests performed; thus, the calculated yields were not comparable with one another.

CONCLUSIONS:

Despite published evidence recommending IS collection before FOB referral in suspected PTB patients, clinicians in our health region appeared to prefer early FOB over IS by a large margin. This practice pattern is less cost effective and exposes patients and health care workers to greater risk. Further research is needed to identify the reasons for the underuse of sputum induction.     

Ultrasonography: is it useful in the diagnosis of cancer in thyroid nodules?

The role of ultrasonography (US) in the diagnosis of cancer in thyroid nodules is not well-established. The aim of the present study was to evaluate US performance in predicting cancer in thyroid nodules using a novel approach. Two hundred and eighty-nine patients with thyroid nodular disease were evaluated with clinical, biochemical and cytopathological examinations. Eighty patients with palpable solitary thyroid nodules or multinodular goiters who were to undergo surgery were included, and had a US exam performed by one of us. Some US characteristics of thyroid nodules were associated to cancer: absent halo, hypoechogenicity and microcalcifications, with sensitivity, respectively, of 56, 44 and 56%, and specificity of, respectively, 80, 83 and 94%. These findings were considered positive and were studied in two different combinations: simultaneous, when two or more were positive, and parallel, when any positive finding was present. When positive findings were studied simultaneously, sensitivity ranged 25 to 38% and specificity ranged 89 to 97%. Microcalcifications, associated or not to other findings, were highly specific for thyroid cancer, but they were only present in half of the malignancies. When positive findings were studied in parallel, sensitivity ranged 69 to 81% and specificity ranged 70 to 81%. The parallel combination of hypoechogenicity or microcalcifications or absent halo improved US sensitivity to 81% with an acceptable specificity (70%). This method is potentially useful to help us select patients for surgery when fine-needle aspiration biopsy is repetitively non-diagnostic or select for biopsy incidentally discovered non-palpable nodules.     

Is it really myositis? A consideration of the differential diagnosis

PURPOSE OF REVIEW: The idiopathic inflammatory myopathies are an important and treatable group of disorders. However, the potential toxicity associated with the immune therapeutic regimens used to treat these disorders may be significant; therefore, accurate diagnosis before such treatment is essential. The differential diagnosis is potentially large. Accurate diagnosis usually depends on a combination of careful clinical assessment in conjunction with detailed laboratory investigations. Muscle biopsy remains essential in achieving an accurate diagnosis that will then guide treatment. This review describes the diagnostic approach used. RECENT FINDINGS: There has been debate over the requirements for an accurate diagnosis of inflammatory myopathy (i.e., polymyositis and dermatomyositis). It is increasingly recognized that there can be clinical and muscle histopathologic overlap between the features of inflammatory myopathies and those of other muscle disorders, in particular, the genetic muscular dystrophies. Pathologic findings of inflammation and major histocompatibility complex upregulation, although typical of inflammatory myopathies, have been shown to occur in some muscular dystrophies, complicating the diagnostic process. Inclusion body myositis is much less responsive to immunotherapy and is now recognized as the most common acquired muscle disease in those older than 50 years of age. It is likely that genetic muscular dystrophies and inclusion body myositis account for some cases of apparently "treatment-resistant" myositis. SUMMARY: A thorough clinical assessment, including a detailed family history, complemented by electromyography and creatine kinase measurements, should be undertaken in any patient with presumed idiopathic inflammatory myopathy. In addition, a muscle biopsy remains essential in all cases. A precise tissue diagnosis confirming features of an active inflammatory process should be achieved before immunosuppressive treatment is commenced. An increasing array of immunocytochemical and histioenzymatic stains now allows a full analysis and will help to confirm or exclude virtually all the differential diagnostic possibilities considered in this review. Electron microscopy may also be valuable in selected cases. Close collaboration between clinicians and muscle pathologists is essential in allowing the most accurate interpretation of myopathologic findings in the clinical context.     

Is analysis of the reticulocyte haemoglobin equivalent a useful test for the diagnosis of iron deficiency anaemia in geriatric patients?

BackgroundIron deficiency anaemia (IDA) and anaemia of chronic disease (ACD) are common in elderly patients but there are no standard diagnostic criteria. The reticulocyte haemoglobin equivalent (Ret-He) is routinely measured by modern automated blood analysers and is an early indicator of iron deficiency. The aim of this study was to investigate whether the Ret-He level as calculated by the Sysmex XE-5000 automated blood analyser is a useful parameter for the diagnosis of IDA in a geriatric hospitalized population.MethodsIn a prospective study, blood samples were collected in 26 geriatric patients with IDA and 111 patients with ACD diagnosed according to generally accepted laboratory and clinical criteria. A blood count including Ret-He, mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC) and standard iron parameters was performed in each patient.ResultsHaemoglobin, Ret-He, MCV, MCH and MCHC levels were all significantly lower in IDA as compared to ACD patients. However, the area under the curve (AUC) was greater for MCH (0.87, 95% CI 0.78–0.95) and MCHC (0.86, 95% CI 0.76–0.96) then for Ret-He (0.828, 95% CI 0.73–0.93) and MCV (0.80, 95% CI 0.68–0.91). A Ret-He cut-off value of 26 pg had a sensitivity and specificity based on its optimal combination of 85% and 69% respectively.ConclusionAnalysis of Ret-He does not perform better than the classical red cell indices such as MCH and MCHC in differentiating IDA and ACD in geriatric patients.     

Is transesophageal echocardiography overused in the diagnosis of infective endocarditis?

Because of its greater sensitivity, transesophageal echocardiography (TEE) is often misused as a screening tool for the exclusion of infective endocarditis (IE) in patients with small clinical probability of the disease. This study examined the role of using TEE exclusively at a Canadian tertiary care center for the diagnosis of IE and determined which clinical variables are most often associated with positive or negative echocardiographic results supporting or refuting the diagnosis.     

Are fibrin-related markers useful for the diagnosis of thrombosis?

Fibrin-related markers (FRMs), such as fibrin and fibrinogen degradation products (FDPs), D-dimer, and soluble fibrin (SF), are considered to be useful for the diagnosis of thrombosis. However, the evidence for the making of a diagnosis of thrombosis based on FRMs is, as yet, not fully established. Levels of FRMs are significantly elevated in patients with thrombosis, such as deep vein thrombosis, disseminated intravascular coagulation, and so on. In Japan, the D-dimer assay test result might be 2-fold higher than results for those assays commonly used in Europe and North America. The levels of SF are significantly elevated in patients before the onset of thrombosis, thus suggesting that the SF assay is useful not only for the diagnosis of thrombosis but also for diagnosing a prethrombotic state. Overall, elevated levels of FRMs indicate a high risk for thrombosis, and they are thus considered to be useful for the diagnosis of thrombosis.     

Is there evidence in support of the use of intra-articular hyaluronate in treating rheumatoid arthritis of the knee? A meta-analysis of the published literature

Abstract

Intra-articular hyaluronate (HA) injections for treating rheumatoid knee are still debatable, and this meta-analysis aims to elucidate the effectiveness of HA injection for rheumatoid knee. The meta-analysis comprised randomized clinical trials (RCTs) that compared the efficacy of HA injections with that of a placebo. The articles were retrieved after systematic searches of databases, including MEDLINE, EMBASE, and Japana Centra Revuo Medicina. The outcomes were classified into four categories: evaluation of reduction in the intensity of pain, evaluation of reduction in the intensity of inflammation, overall evaluation of therapeutic efficacy, and evaluation of adverse effects. Effect sizes were calculated from the risk ratio (RR) of each of the above-mentioned outcome categories. Five RCTs (720 participants) were pooled for the meta-analysis. The pooled effect sizes were 1.64 (p = 0.01) for pain reduction, 1.61 (p = 0.001) for reduction in inflammation, and 1.50 (p = 0.004) for the overall evaluation of treatment effectiveness. No serious side-effects were reported, while minor adverse effects were reported in patients after HA treatment (RR 0.98, p = 0.32). The results indicated that intra-articular HA is an effective and safe alternative therapy for the rheumatoid knee.     

Is there evidence in support of the use of intra-articular hyaluronate in treating rheumatoid arthritis of the knee? A meta-analysis of the published literature

Intra-articular hyaluronate (HA) injections for treating rheumatoid knee are still debatable, and this meta-analysis aims to elucidate the effectiveness of HA injection for rheumatoid knee. The meta-analysis comprised randomized clinical trials (RCTs) that compared the efficacy of HA injections with that of a placebo. The articles were retrieved after systematic searches of databases, including MEDLINE, EMBASE, and Japana Centra Revuo Medicina. The outcomes were classified into four categories: evaluation of reduction in the intensity of pain, evaluation of reduction in the intensity of inflammation, overall evaluation of therapeutic efficacy, and evaluation of adverse effects. Effect sizes were calculated from the risk ratio (RR) of each of the above-mentioned outcome categories. Five RCTs (720 participants) were pooled for the meta-analysis. The pooled effect sizes were 1.64 (p = 0.01) for pain reduction, 1.61 (p = 0.001) for reduction in inflammation, and 1.50 (p = 0.004) for the overall evaluation of treatment effectiveness. No serious side-effects were reported, while minor adverse effects were reported in patients after HA treatment (RR 0.98, p = 0.32). The results indicated that intra-articular HA is an effective and safe alternative therapy for the rheumatoid knee.