Rapid On-Site Evaluation Reduces Needle Passes in Endoscopic Ultrasound-Guided Fine-Needle Aspiration for Solid Pancreatic Lesions: A Risk–Benefit Analysis

Background

The effectiveness of endoscopic ultrasound-guided fine-needle aspiration increases with the number of needle passes but needle passes are also associated with increased risk of adverse events. The trade-off between needle passes and adequacy has not been well-characterized.

Aims

The purpose of this study was to compare the risk–benefit tradeoff of different sampling protocols with and without rapid onsite evaluation (ROSE).

Patients and Methods

We used a discrete-event simulation model to compare eight different sampling protocols. Each sampling protocol was simulated 10,000 times to obtain the average performance for each scenario. The per-pass adequacy rates, ROSE, accuracy of the assessor and sampling limits were varied to determine the impact of these factors on the number of needle passes and adequacy rates.

Results

Increasing per-class adequacy can be achieved at a cost of increased needle passes. Sampling with ROSE achieved higher adequacy with fewer needle passes than policies using a fixed number of needle passes without ROSE.

Conclusions

Variable sampling policies using ROSE generally achieve greater per-case adequacy with fewer needle passes than non-ROSE sampling policies using a fixed number of passes.     

Particle formation and risk of embolization during transseptal catheterization: comparison of standard transseptal needles and a new radiofrequency transseptal needle

Objective  

Anecdotally, the Brockenbrough transseptal needle generates plastic particles through a process of skiving (shaving off particles), when advanced through the dilator and sheath. This study was performed to assess particle creation by the Brockenbrough needle during transseptal catheterization. We explore strategies that may reduce this phenomenon, including use of the Brockenbrough stylet and a radiofrequency transseptal needle.     

Comparative study of catheter drainage and needle aspiration in management of large liver abscesses

Objective  

To compare the effectiveness of percutaneous catheter drainage (PCD) and percutaneous needle aspiration (PNA) in the management of large (>10 cm diameter) liver abscesses.     

Occupational injury history and universal precautions awareness: a survey in Kabul hospital staff

Background  

Health staff in Afghanistan may be at high risk of needle stick injury and occupational infection with blood borne pathogens, but we have not found any published or unpublished data.     

Outcome of Repeat ERCP After Initial Failed Use of a Needle Knife for Biliary Access

Introduction  

A needle knife is often used to gain bile duct access when standard techniques have failed. If unsuccessful, the next step may involve either radiological- or endoscopic ultrasound-guided biliary access. However, repeat endoscopic retrograde cholangiopancreatography (ERCP) may be an option if the patient’s clinical condition permits.     

Transjugular renal biopsy in high-risk patients: an American case series

Background  

In the United States, transjugular renal biopsies using the Quickcore™ side cut needle system have previously been described primarily for transjugular renal biopsy in patients with concurrent liver and kidney disease.     

Needle and syringe programmes and opioid substitution therapy for preventing HCV transmission among people who inject drugs: findings from a Cochrane Review and meta‐analysis

Aims

To estimate the effects of needle and syringe programmes (NSP) and opioid substitution therapy (OST), alone or in combination, for preventing acquisition of hepatitis C virus (HCV) in people who inject drugs (PWID).

Methods

Systematic review and meta‐analysis. Bibliographic databases were searched for studies measuring concurrent exposure to current OST (within the last 6 months) and/or NSP and HCV incidence among PWID. High NSP coverage was defined as regular NSP attendance or ≥ 100% coverage (receiving sufficient or greater number of needles and syringes per reported injecting frequency). Studies were assessed using the Cochrane risk of bias in non‐randomized studies tool. Random‐effects models were used in meta‐analysis.

Results

We identified 28 studies (n = 6279) in North America (13), United Kingdom (five), Europe (four), Australia (five) and China (one). Studies were at moderate (two), serious (17) critical (seven) and non‐assessable risk of bias (two). Current OST is associated with 50% [risk ratio (RR) =0.50, 95% confidence interval (CI) = 0.40–0.63] reduction in HCV acquisition risk, consistent across region and with low heterogeneity (I² = 0, P = 0.889). Weaker evidence was found for high NSP coverage (RR = 0.79, 95% CI = 0.39–1.61) with high heterogeneity (I² = 77%, P = 0.002). After stratifying by region, high NSP coverage in Europe was associated with a 56% reduction in HCV acquisition risk (RR = 0.44, 95% CI = 0.24–0.80) with low heterogeneity (I² = 12.3%, P = 0.337), but not in North America (RR = 1.58, I² = 89.5%, P = < 0.001). Combined OST/NSP is associated with a 74% reduction in HCV acquisition risk (RR = 0.26, 95% CI = 0.07–0.89, I² = 80% P = 0.007). According to Grades of Recommendation Assessment, Development and Evaluation (GRADE) criteria, the evidence on OST and combined OST/NSP is low quality, while NSP is very low.

Conclusions

Opioid substitution therapy reduces risk of hepatitis C acquisition and is strengthened in combination with needle and syringe programmes (NSP). There is weaker evidence for the impact of needle syringe programmes alone, although stronger evidence that high coverage is associated with reduced risk in Europe.     

Does onsite cytotechnology evaluation improve the accuracy of endoscopic ultrasound-guided fine-needle aspiration biopsy?

BACKGROUND:

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the preferred modality for the cytological diagnosis of various cancers. Onsite cytopathology interpretation is not available in most centres.

OBJECTIVE:

To assess whether the the adequacy of tissue sampling assessed by an onsite cytotechnologist improves the diagnostic accuracy of EUS-FNA.

METHODS:

The present study is a retrospective review of all patients undergoing solid mass EUS-FNA between September 2005 and August 2007. Patients in group I (September 2005 to August 2006) had cytology slides prepared by an endoscopy nurse. Patients in group II (September 2006 to August 2007) had cytology slides prepared, stained and assessed for adequacy of tissue sampling by a cytotechnologist in the endoscopy suite. The final cytopathological diagnosis (definitely positive, definitely negative or inconclusive) was compared between the two groups.

RESULTS:

A total of 49 EUS-FNA procedures were performed in 47 patients in group I and 60 EUS-FNA procedures in 55 patients in group II. Pancreatic masses were the most common target site in both groups. The total number of needle passes was 105 in group I (mean 2.14 passes per patient; range one to five needle passes) and 158 in group II (mean 2.63 passes per patient; range one to four needle passes). The difference in the number of needle passes was not statistically significant between groups. The final diagnosis was definite in 53% in group I compared with 77% in group II (P=0.01). The percentage of inconclusive diagnoses was 47% in group I and 23% in group II (P=0.001).

CONCLUSION:

Onsite cytotechnologist interpretation of adequacy of tissue sampling significantly improves the diagnostic yield of EUS-FNA. This appears to be independent of the total number of needle passes undertaken for tissue sampling.     

Needle Size Has Only a Limited Effect on Outcomes in EUS-Guided Fine Needle Aspiration: A Systematic Review and Meta-Analysis

Background

Several recent studies have investigated the utility of 19-, 22-, and 25-gauge needles in endoscopic ultrasound-guided fine needle aspiration (EUS–FNA) of pancreatic and peri-pancreatic tumors.

Aim

The objective of this study was to summarize data from these studies and estimate the effect of needle size on reported outcomes such as accuracy, adequacy, and complications.

Methods

Systematic review and meta-analysis comparing the effect of needle size (19, 22, and 25G) on diagnostic accuracy, adequacy, number of needle passes, and complications.

Results

25G appear to confer an advantage in adequacy rates relative to 22G needles (risk difference = 0.12 %, 95 % CI 0.01, 0.25). There was no significant difference in accuracy with an overall sensitivity and specificity for 22G being 0.78 (95 % CI 0.74–0.81) and 1.00 (95 % CI 0.98–1.00) and an overall sensitivity and specificity for 25G being 0.91 (95 % CI 0.87–0.94) and 1.00 (95 % CI 0.97–1.00). There was no difference in number of passes or complications between 25 and 22G. The limited data available regarding 19G needles do not show evidence of improved outcomes with these devices.

Conclusions

In the evaluation of pancreatic and peri-pancreatic lesions by EUS–FNA, 25G needles may confer an advantage in adequacy relative to 22G needles but confer no advantages with respect to accuracy, number of passes, or complications.     

The Contribution of Endobronchial Ultrasound-guided Forceps Biopsy in the Diagnostic Workup of Unexplained Mediastinal and Hilar Lymphadenopathy

Background  

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS–TBNA) provides material for the cytological diagnostic workup. To improve the evaluation of unexplained intrathoracic lymphadenopathy, the availability of material for histological evaluation would be desirable. For this purpose, the technique of endobronchial ultrasound-guided mediastinal forceps biopsy (EBUS-guided forceps biopsy) is a potentially good candidate. The aim of the present study was, using simple methodology, to establish the additional diagnostic yield provided by supplemental EBUS-guided forceps biopsy in comparison with EBUS–TBNA alone.     

Assessment of Factors Affecting the Usefulness and Diagnostic Yield of Core Biopsy Needles with a Side Hole in Endoscopic Ultrasound-Guided Fine-Needle Aspiration

Background/Aims

A barbed puncture needle with a side hole was recently developed to improve sample quality and quantity in endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). In this study, we retrospectively assessed the usefulness of this puncture needle.

Methods

Factors affecting diagnostic yield, safety, and diagnostic accuracy were investigated in 76 patients who consecutively underwent EUS-FNA for neoplastic lesions at our hospital between January and December 2013.

Results

The procedure was successful in all cases; the rates of sample collection and determination of the correct diagnosis were 92.1% and 89.5%, respectively. The mean number of needle passes required for diagnosis was 1.1. Complications included mild intraluminal bleeding in two patients (2.6%). Multivariate analysis revealed that lesion size (≤20 mm) was significantly associated with a decreased chance of determining the correct diagnosis.

Conclusions

Core biopsy needles with a side hole are safe and provide a satisfactory diagnostic yield. However, the side hole may potentially reduce the rate of making the correct diagnosis in small lesions.     

Comparison of tissue pressure and ablation time between the LeVeen and cool-tip needle methods

Background  

Radio frequency ablation (RFA) has been accepted clinically as a useful local treatment for hepatocellular carcinoma (HCC). However, intrahepatic recurrence after RFA has been reported which might be attributable to increase in intra-tumor pressure during RFA. To reduce the pressure and ablation time, we developed a novel method of RFA, a multi-step method in which a LeVeen needle, an expansion-type electrode, is incrementally and stepwise expanded. We compared the maximal pressure during ablation and the total ablation time among the multi-step method, single-step method (a standard single-step full expansion with a LeVeen needle), and the method with a cool-tip electrode. Finally, we performed a preliminary comparison of the ablation times for these methods in HCC cases.     

Influence of the pre-operative time in upright sitting position and the needle type on the incidence of post-dural puncture headache (PDPH) in patients receiving a spinal saddle block for anorectal surgery

Background  

A spinal saddle block can be a safe method for anorectal surgery with a low rate of complications when performed with the right technique. A dreaded complication is the post-dural puncture headache (PDPH), which can be decreased by the use of non-cutting spinal needles. Regrettably, cutting Quincke (Q)-type needles are still widely used for economic reasons. Besides size and design of a spinal needle, the pre-operative time in upright sitting position may also influence the incidence of PDPH after spinal saddle block.     

Small bile duct involvement in IgG4-related sclerosing cholangitis: liver biopsy and cholangiography correlation

Background

IgG4-related sclerosing cholangitis (IgG4-SC) needs to be differentiated from primary sclerosing cholangitis (PSC). In this study, we performed a retrospective study to reveal cases in which liver needle biopsy was useful for differential diagnosis.

Methods

Nineteen patients with IgG4-SC and 22 patients with PSC were studied. All patients underwent endoscopic retrograde cholangiography and liver needle biopsy. We defined small bile duct involvement of IgG4-SC histologically as damage to the small bile duct associated with infiltration of ??10 IgG4+ plasma cells per high power field (HPF). Clinicopathological characteristics were compared between IgG4-SC patients with and without small bile duct involvement.

Results

Small bile duct involvement was observed in 5 (26%) of the patients with IgG4-SC. Patients with small bile duct involvement showed a higher incidence of intrahepatic biliary strictures on cholangiography (80 vs. 21%, p?=?0.038). Conversely, 4 of 7 (57%) patients with intrahepatic biliary strictures on cholangiography had histologically evident small duct involvement. The number of IgG4+ plasma cells was significantly correlated with the site of the most proximal stricture on cholangiograms (p?=?0.021). The number of IgG4+ plasma cells per HPF was significantly higher in IgG4-SC patients with intrahepatic biliary strictures than in those with PSC (13.4 vs. 0.4?cells/HPF, p?<?0.001).

Conclusions

Involvement of small bile ducts is more frequent in patients with intrahepatic biliary strictures on cholangiography, and liver needle biopsy is especially useful for these patients.     

Endoscopic ultrasound guided 22 gauge core needle biopsy for the diagnosis of Autoimmune pancreatitis

Background

It is difficult to obtain adequate tissue sample for diagnosing autoimmune pancreatitis (AIP) with the help of traditional EUS-guided FNA. As per ICDC guidelines, EUS-guided FNA is not recommended for diagnosing AIP(1). We herein present a report of 2 cases of using a new flexible 22 gauge (G) core biopsy needle (SharkCore, Medtronic, Sunnydale, Calif) for diagnosing AIP.

Childhood traumatic experiences and the association with marijuana and cocaine use in adolescence through adulthood

Background and aims

Examination of longitudinal relationships between childhood traumatic experiences and drug use across the life‐course at the national level, with control of confounding by other forms of trauma, is needed. We aimed to estimate the prevalence of nine typologies of childhood traumas and the cumulative number experienced, correlation between traumas and associations between individual and cumulative number of traumas with drug use during adolescence, emerging adulthood and adulthood.

Design

Secondary data analysis using the National Longitudinal Study of Adolescent to Adult Health.

Setting

United States.

Participants

A nationally representative sample of individuals in grades 7–12 (aged 11–21 years) during 1994–95, who were re‐interviewed during emerging adulthood (2001–02; aged 18–28) and adulthood (2007–08; aged 24–34). The analytical sample comprised 12 288 participants with data at all three waves.

Measurements

Nine typologies of childhood traumas: neglect; emotional, physical and sexual abuse; parental incarceration and binge drinking; and witnessing, being threatened with and experiencing violence. Indicators of each were summed to measure cumulative dose. Outcomes were marijuana and cocaine use during adolescence, emerging adulthood and adulthood.

Findings

Approximately half experienced at least one childhood trauma; traumas were not highly correlated. We observed a dose–response relationship between the number of traumas and drug use in adolescence [marijuana, adjusted odds ratio (aOR) one trauma versus none = 1.65, 95% confidence interval (CI) = 1.42, 1.92; two traumas = 2.58, 95% CI = 2.17, 3.06; ≥ four traumas = 6.92, 95% CI = 5.17, 9.26; cocaine, aOR one trauma = 1.87, 95% CI = 1.23, 2.84; two traumas = 2.80, 95% CI = 1.74, 4.51; ≥ four traumas = 9.54, 95% CI = 5.93, 15.38]. Similar dose–response relationships with drug use were observed in emerging adulthood and adulthood. Each individual trauma was associated independently with either marijuana or cocaine use in adolescence, emerging adulthood and/or adulthood.

Conclusions

Childhood trauma is prevalent in the United States, and individual types as well as the total number experienced are associated significantly with marijuana and cocaine use throughout the life‐course.     

Comparison of Patient's Preference,Pain Perception,and Usability between Micro Fine Plus? 31-Gauge Needle and Microtapered NanoPass? 33-Gauge Needle for Insulin Therapy

Background

How smoothly insulin is injected is one of the major concerns when patients commence insulin injection therapy. Improving its usability may be important in initiation therapy and adherence, resulting in clinical benefits to the patient.

Methods

In a single-center, open-label and randomized two-period crossover trial, the effect of the tapered needle of NanoPass® (33 gauge, 5 mm) on usability in comparison with the standard needle of Micro Fine Plus® (31 gauge, 5 mm) was examined using a questionnaire. Patients with insulin-dependent diabetes (n = 40, self-injecting insulin four times daily for more than 3 months) were randomized to use NanoPass or Micro Fine Plus needles for 1 week and then use the alternative for 1 week. Patients completed the questionnaire before and after each test week. Each evaluation was scored from −100 (worst) to +100 (best) by a visual analogue scale. A higher score indicated a more favorable outcome compared with the other needle.

Results

The NanoPass needle was significantly less painful to insert and caused less bruising than the Micro Fine Plus needle. However, there was no significant difference in the overall patient satisfaction score between the two needles. Meanwhile, the NanoPass needle, which had less resistance in insertion with a new lubricant coating method, had a significantly superior (P < 0.001) overall patient''s satisfaction score, including less frightening use, less bleeding, and less dribbling of injected insulin in comparison with the former evaluation.

Conclusions

For overall patient satisfaction in using an insulin needle, developing a thinner needle and improving other factors, such as lubricity coating the needle, are important.     

Histopathology of Post-Transplant Liver Biopsies,the First Report From Iran

Background

Evaluation of a transplanted liver by Imaging techniques and enzyme changes is sensitive to hepatocellular or biliary problems, but in most instances liver allograft biopsies are performed in order to find out the final reason for these changes.

Objectives

It’s been about 17 years (with more than 1326 cases) since the first liver transplantation in the Namazi Hospital of Shiraz University of Medical Sciences while during the last five years the number of post liver transplant biopsies have increased. Until now there has been no report of the pathological results of post liver transplant needle biopsies from Iran.

Materials and Methods

During the last 5 years, there have been 382 post liver transplant biopsies. We studied the clinical charts and pathological results of all needle biopsies.

Results

A total of 382 needle biopsies were performed on 287 patients aged between 1 and 64 years old. The earliest specimen was obtained within the first few hours following transplantation, and the last was gathered 3209 days (261 ± 523) post-transplantation. Acute rejection was the most common diagnosis, which occurred in 180 (47%) of specimens. Among other complications were vascular problems (8.6%), preservation/reperfusion (I/R) injury (7%), chronic rejection (5.2%), biliary injury/obstruction (3.4%), recurrence of primary disease (2.6%), drug-induced hepatic injury (1.8%), cirrhosis (1.6%), sepsis (1.4%), cytomegalovirus hepatitis (1.4%), post-transplantation lymphoproliferative disease (1%) and Venous outflow obstruction (0.5%).

Conclusions

The most common pathological diagnosis of post-transplant liver needle biopsies has been acute rejection, followed by ischemia due to hepatic artery thrombosis, preservation/reperfusion injury, and chronic rejection.     

Chapter 4: Effective Search Strategies for Systematic Reviews of Medical Tests

BACKGROUND  

The number of hospitalists in the US is growing rapidly, yet little is known about their worklife to inform whether hospital medicine is a viable long-term career for physicians.     

Internal Medicine Residents’ Comfort with and Frequency of Providing Dietary Counseling to Diabetic Patients

BACKGROUND  

Resident physicians’ preparedness to provide dietary counseling for the rising number of diabetic patients is unclear.