Current practical applications of diagnostic immunohistochemistry in breast pathology

In recent years, immunohistochemistry has assumed an increasingly prominent role in diagnostic breast pathology. Immunohistochemistry is now frequently used in the evaluation of many epithelial proliferations of the breast. Common applications include the use of myoepithelial markers to evaluate for stromal invasion, E-cadherin to distinguish between ductal and lobular neoplasia, high molecular weight cytokeratins to differentiate usual ductal hyperplasia from ductal carcinoma in situ, immunohistochemical profiles to characterize site of origin of metastatic carcinomas, and cytokeratin stains to detect metastases in sentinel lymph nodes. Recent advances, practical considerations, and potential pitfalls in the use of immunohistochemistry in these five diagnostic categories are discussed herein.     

Bladder rupture after blunt trauma: guidelines for diagnostic imaging

PURPOSE: The purpose of this study was to establish guidelines for diagnostic imaging for bladder rupture in the blunt trauma victim with multiple injuries, in whom the delay caused by unnecessary testing can hamper the trauma surgeon and threaten outcome. METHODS: We undertook chart review (1995-1999) of patients with blunt trauma and bladder rupture at our four institutions and performed focused literature review of retrospective series. RESULTS: Of our 53 patients identified, all had gross hematuria and 85% had pelvic fracture. Literature review revealed similar rates. CONCLUSION: The classic combination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims. Existing data do not support lower urinary tract imaging in all patients with either pelvic fracture or hematuria alone. Clinical indicators of bladder rupture may be used to identify atypical patients at higher risk. Patients with isolated hematuria and no physical signs of lower urinary tract injury may be spared the morbidity, time, and expense of immediate cystographic evaluation.     

Quality control of sedation for diagnostic radiological procedures in paediatric patients (waiting for guidelines)

BACKGROUND: The number of children requiring sedation for radiological procedures is increasing. Anaesthesiologists are increasingly involved in giving sedation or general anaesthesia in the rooms of the Radiology Department. This activity is not easy, and can be dangerous. The procedure is often performed on an ambulatory basis, so the child must be alert and discharged rapidly after the procedure. METHODS: We reviewed the medical charts of 488 patients in order to evaluate the incidence of complications during deep sedation for diagnostic radiological procedures. The patients were sedated with intravenous thiopental or propofol, or with oral chloral hydrate. All the patients were breathing spontaneously and received only supplemental O(2). RESULTS: We found only a few cases of complications, immediately treated without any recourse to tracheal intubation: respiratory failure with arterial desaturation to 94%, regurgitation, vomiting and persistent cough. CONCLUSIONS: On the basis of our experience, we believe that deep sedation with endovenous drugs guarantees safety and rapid discharge after the procedure.     

A critical appraisal of clinical practice guidelines for diagnostic imaging in the spinal cord injury

BACKGROUND CONTEXTSpinal cord injury (SCI) is a serious health problem which carries a heavy economic burden. Imaging technologies play an important role in the diagnosis of SCI. Although several organizations have developed guidelines for diagnostic imaging of SCI, their quality has not yet been systematically assessed.PURPOSEWe aim to conduct a systematic review to appraise SCI guidelines and summarize their recommendations for diagnostic imaging of SCI.STUDY DESIGNSystematic review.METHODSWe searched Embase, Medline, Web of Science, Cochrane, some guideline-specific databases (eg, Scottish Intercollegiate Guidelines Network) and Google Scholar from January 2000 to January 2022. We included guidelines developed by nationally recognized organizations. If multiple versions could be obtained, we included the latest one. We appraised included guidelines using the Appraisal of Guidelines for Research and Evaluation, 2nd edition instrument which contains six domains (eg, scope and purpose). We also extracted recommendations and assessed their supporting evidence using levels of evidence (LOE). The evidence was categorized as A (the best quality), B, C, and D (the worst quality).RESULTSSeven guidelines (2008–2020) were included. They all received the lowest scores in the domain of applicability. All guidelines (7/7, 100%) recommended magnetic resonance imaging (MRI) in patients with SCI or SCI without radiographic abnormality (SCIWORA). A total of 12 recommendations involving patient age (eg, adult and child patients), timing of MRI (eg, as soon as possible and in the acute period), symptoms indicated for MRI (eg, a stiff spine and midline tenderness, suspected disc and posterior ligamentous complex injury, and neurological deficit), and types of MRI (eg, T2-weighted imaging and diffusion tensor imaging) were extracted. Among them, the LOE was C in nine (75%) recommendations and D in three (25%) recommendations.CONCLUSIONSSeven guidelines were included in the present systematic review, and all of them showed the worst applicability scores in the Appraisal of Guidelines for Research and Evaluation, 2nd edition instrument. They all weakly recommended MRI for patients with suspected SCI or SCIWORA based on a low LOE.     

Summary of the British Thoracic Society guidelines for advanced diagnostic and therapeutic flexible bronchoscopy in adults

This new guideline covers the rapidly advancing field of interventional bronchoscopy using flexible bronchoscopy. It includes the use of more complex diagnostic procedures such as endobronchial ultrasound, interventions for the relief of central airway obstruction due to malignancy and the recent development of endobronchial therapies for chronic obstructive pulmonary disease and asthma. The guideline aims to help all those who undertake flexible bronchoscopy to understand more about this important area. It also aims to inform respiratory physicians and other specialists dealing with lung cancer of the procedures possible in the management and palliation of central airway obstruction. The guideline covers transbronchial needle aspiration and endobronchial ultrasound-guided transbronchial needle aspiration, electrocautery/diathermy, argon plasma coagulation and thermal laser, cryotherapy, cryoextraction, photodynamic therapy, brachytherapy, tracheobronchial stenting, electromagnetic navigation bronchoscopy, endobronchial valves for emphysema and bronchial thermoplasty for asthma.     

Heparin-induced thrombocytopenia in the cardiovascular patient: diagnostic and treatment guidelines.

Heparin-induced thrombocytopenia/thrombosis is an immunologic reaction to unfractionated heparin characterized by thrombocytopenia, platelet activation and thrombosis. A high index of suspicion is required for timely diagnosis and treatment. Treatment is complex and outcome maybe less then satisfactory.     

The management of endophthalmitis: diagnostic and therapeutic guidelines including the use of vitrectomy

The use of vitrectomy in the management of endophthalmitis is controversial. All cases of suspected clinical endophthalmitis should have immediate anterior chamber and vitreous aspiration combined with an intravitreal antibiotic/steroid injection. Vigorous systemic, topical and periocular therapy should accompany frequent examinations of the patient. Vitrectomy is recommended in selected clinical situations. An intraocular lens usually can be left in place and should be removed only in certain rare instances.     

Clinical guidelines for nocturia

Nocturia is a bothersome condition, defined as a complaint whereby the individual has to wake one or more times per night in order to void. Nocturia that occurs twice or more per night can have a substantial adverse effect on the patient's quality of life (QOL), and in many cases treatment may be required. These guidelines provide a treatment algorithm for use by primary care physicians. The initial assessment is conducted through a history taking interview. With a clear understanding of symptoms, patients can be classified into three broad categories: (1) nocturia only, (2) nocturia and diurnal pollakisuria without other lower urinary tract symptoms, and (3) nocturia and diurnal pollakisuria accompanying other lower urinary tract symptoms. For treatment, the literature supporting each form of drug therapy was ranked and a recommendation grade was determined for each form of therapy. A grade of ‘F (pending)’ was applied to any drug not currently approved for use in Japan or for which the efficacy and safety in Japanese patients was unconfirmed at the time of evaluation. We recommend instruction and guidance on water intake that will generally result in 24‐h urine volume of 20 to 25 mL/kg. This corresponds to a daily water intake of 2.0% to 2.5% of body weight. In Japan, desmopressin is indicated for central diabetes insipidus and nocturnal enuresis, but not indicated for nocturia. The therapeutic mechanism of the anticholinergic drugs for nocturia may depend on the action of the sensory nerve mediated by the muscarinic receptors.     

Ethics guidelines for destination therapy

The introduction of the left ventricular assist device as a destination therapy for patients with heart failure introduces several ethical issues. These issues are discussed to help destination therapy teams design ethically sound policies and procedures. This article addresses ethical issues pertaining to informed decision making, device failure, and change out, as well as guidelines for deactivation, fair employment of medical and psychosocial criteria, the nature of destination therapy as an elective end-of-life therapy, and advance care planning strategies.