Single versus sequential fine-needle aspiration biopsy in the management of thyroid nodular disease.

Fine-needle aspiration biopsy (FNAB) is considered a safe, reliable and cost-effective means of selecting thyroid nodules with risk for malignancy. However, there are limitations of this method including false positive/negative and "nondiagnostic" results that may be reduced by repeating FNAB. OBJECTIVE: To evaluate accuracy, sensitivity, specificity and costs of sequential FNAB in the management of thyroid nodular disease. METHODS: Charts of all patients who underwent thyroidectomy at a university teaching hospital in Toronto from 1998 to 2000 were reviewed. FNAB reports of "suspicious for malignancy," "follicular lesion" and "cellular atypia" were considered to be positive. Data were analyzed with chi2 and z tests. RESULTS: There were 268 patients (225 women and 43 men; age range 18-89 yr; mean age 47 yr) who underwent a total of 449 FNABs (mean 1.7 FNABs/patient) within a year before thyroidectomy. Accuracy (63.8%), sensitivity (73.8%) and specificity (69%) were determined for single FNABs. Sequential FNAB increased the accuracy of method by 22.6%, sensitivity by 13.8% and specificity by 6.2%, with reduction of false positive/negative results by 14.2% and "nondiagnostic" results by 100%. However, the costs of sequential cytology per patient were 70% higher than single FNAB. CONCLUSIONS: Multiple FNABs are unpleasant for patients, but useful in the selection for treatment of patients with thyroid nodular diseases. Although sequential FNAB increases the costs of method, the improvement of precision of FNAB may imply a reduction in overall health-care costs.     

Adult supratentorial oligodendrogliomas. Surgical treatment: indications and techniques

Surgical resection is the first step in the treatment of adult supratentorial oligodendrogliomas (OLG). However, the role of resection on prognosis, the most appropriate time for surgery along the natural history of those tumors, and the best operative strategy remain debated. Survival curves after resection vary greatly among reported series, in particular as a result of a persisting confusion in identification and classification of cerebral OLG. Surgical or stereotactic biopsy is the first surgical procedure which enables confirmation of the diagnosis suggested on imaging, assessment of extension of tumor cell infiltration beyond abnormalities limit described an imaging, and currently available molecular biology studies. Biopsies may be the only surgical procedure in patients having a deep-seated tumor with minimal mass effect, or prior to a surgical resection or a "wait and watch" strategy. Surgical resection is indicated for the other patients. However, it has not been demonstrated that time for resection has an influence on survival, excepted in patients with rapidly growing tumors, with mass effect causing increased intracranial pressure. A wait and watch strategy is therefore warranted in patients with a tumor aspect suggestive of a grade A OLG; surgical resection may be indicated later. There is a current trend for maximal safe resection, preserving functional cerebral areas, since truly complete resection of the tumor including infiltration is exceptional. However, from the contradictory results reported to date, one cannot ascertain whether large or complete resection based on imaging is associated with significantly longer survival. Neuronavigation guidance, intraoperative imaging, and cortical stimulation techniques are helpful neurosurgical techniques enabling maximal safe resection with preservation of functional areas.     

Spatial delimitation of low grade oligodendrogliomas

Image-guided surgery is the central element of therapeutic management of low grade gliomas and consequently, a precise preoperative definition of their spatial extension is necessary. The question of the present work is: do the imaging abnormalities delineate the real spatial development of low grade oligodendrogliomas? A review of the literature showed that MRI on T2-weighted and FLAIR sequences are used to delineate the spatial developement of these tumours and that spectroscopic magnetic resonance imaging is more sensible to appreciate it. Moreover, mathematical models and histological studies suggest that MRI does not indicate the actual spatial extension of low grade oligodendrogliomas. This study focused on histological analysis of biopsy samples performed outside MRI imaging abnormalities in patients who harboured a low grade oligodendroglioma. It showed that isolated tumour cells were identified beyond imaging abnormalities in all of the 17 patients studied. In 15 of those 17 patients, isolated tumour cells were identified in the most distant biopsy samples taken outside imaging abnormalities. Thus, conventional imaging findings, including MRI on T2-weighted and FLAIR sequences, are not able to provide the real spatial development and boundaries of low grade oligodendrogliomas.     

Angioscintigraphy in venous pathology. Comparison of isotope angioscintigraphy and radiologic examination

Results of vascular radiology and isotope examinations were compared in 48 patients with suspected ileocaval lesions (37 cases) or affections of the veins of the upper limb or superior vena cava (11 cases). Isotopic examination, which can be performed in ambulatory patients, respects normal hemodynamic conditions, is painless, and can be repeated, was found to give valid results, positive correlations with radiological investigation findings being present in 43 cases. Lack of correlation in the remaining 5 patients could have resulted from the period of time elapsed between the two examinations or the techniques employed during each investigation.     

Effect of perindopril on the onset and progression of left ventricular dysfunction in Duchenne muscular dystrophy

OBJECTIVES: The aim of this research was to examine the effects of perindopril on cardiac function in patients with Duchenne muscular dystrophy (DMD). BACKGROUND: Duchenne muscular dystrophy, an inherited X-linked disease, is characterized by progressive muscle weakness and myocardial involvement. METHODS: In phase I, 57 children with DMD and a left ventricular ejection fraction (LVEF) >55% (mean 65.0 +/- 5.4%), 9.5 to 13 years of age (mean 10.7 +/- 1.2 years), were enrolled in a three-year multicenter, randomized, double-blind trial of perindopril, 2 to 4 mg/day (group 1), versus placebo (group 2). In phase II, all patients received open-label perindopril for 24 more months; LVEF was measured at 0, 36, and 60 months. RESULTS: Phase I was completed by 56 (27 in group 1 and 29 in group 2) and phase II by 51 patients (24 in group 1 and 27 in group 2). There was no difference in baseline characteristics between the treatment groups. At the end of phase I, mean LVEF was 60.7 +/- 7.6% in group 1 versus 64.4 +/- 9.8% in group 2, and was <45% in a single patient in each group (p = NS). At 60 months, LVEF was 58.6 +/- 8.1% in group 1 versus 56.0 +/- 15.5% in group 2 (p = NS). A single patient had an LVEF <45% in group 1 versus eight patients in group 2 (p = 0.02). CONCLUSIONS: Early treatment with perindopril delayed the onset and progression of prominent left ventricle dysfunction in children with DMD.     

Magnetic resonance imaging findings and novel mutations in GM1 gangliosidosis

Two unrelated children and their siblings of Arab origin were diagnosed as having GM1 gangliosidosis on the basis of clinical features and markedly low levels of beta-galactosidase. The T2-weighted magnetic resonance images of the brain revealed certain characteristic features, including delayed myelination and abnormal appearance of the subcortical white matter, internal capsule, and basal ganglia. Their mutation analysis showed two novel mutations, which have not been described in an Arabic population.     

(1)H magnetic resonance spectroscopy of autosomal ataxias

Multiple forms of autosomal ataxia exist which can be identified by genetic testing. Due to their wide variety, the identification of the appropriate genetic test is difficult but could be aided by magnetic resonance data. In this study, magnetic resonance spectroscopy (MRS) and imaging (MRI) data were recorded for 20 ataxia patients of six different types and compared to 20 normal subjects. Spectra were acquired in the pons, left frontal lobe, left basal ganglia, left cerebellar hemisphere and vermis. Both metabolite spectra and absolute metabolite concentrations were determined. Differences in metabolite levels were observed between ataxia patients and control subjects and between ataxia patients of different types. A number of correlations were found between metabolite ratios, atrophy levels, number of repeats on the small and large allele, age at examination, symptoms duration and age at symptoms onset for ataxia patients. These MR characteristics are expected to be useful for the identification of the ataxia type.     

Women of 40 and older in i.v.f. and i.c.s.i.: the FIVNAT data

The proportion of women over 40 in i.v.f. and in i.c.s.i. has been dramatically increasing to reach 12% in 2002. Tubal and unexplained infertility increases with age. Short protocols or protocols with GnRH antagonists are more and more often used for older women. Best results are nevertheless still obtained with long protocols! Up to 35 years, pregnancy rates are similar with two or three transferred embryos. Over 35, better results are observed with three embryos. However, the rate of twins only falls below 20% when the woman is over 38, in i.v.f. as well as in i.c.s.i. The decreasing pregnancy rate should be better known by patients and clinicians so that women are treated sooner for i.v.f.