An apparatus for MR-guided breast lesion localization and core biopsy: design and preliminary results

System design and initial results are presented from a new unilateral MR-guided breast lesion localization and core biopsy system. Over 150 imaging studies, an accuracy study on phantoms with 50 localization wire deployments and 33 core biopsy trials, and 19 clinical procedures are reported. The mean spatial accuracy from the lesion center for a 20-gauge (G) needle (N = 13) was within 1.2 +/- 1.4 mm (SD) and for a 14G biopsy (N = 4) 0.8 +/- 1.1 mm. For sampling using a 16G core through a 14G needle, the mean accuracy was 5.6 mm (N = 2). The needle guide geometry imposed a small, calculable targeting error. For phantom measurements using the 20G device, the mean geometry-induced error was 0.73 +/- 0.43 mm. However, this contribution was, on average, 42% of the mean measured 2.35 +/- 1.65 mm offset. The new device design provided an accurate and simple guidance method for localization or core biopsy of MR-visible breast lesions.     

Drug-induced methemoglobinemia during thoracoscopic lung biopsy

Acquired methemoglobinemia occurs rarely in clinical practice. We present a case of a 57-year-old man who developed severe drug-induced methemoglobinemia after exposure to benzocaine spray and lidocaine jelly during intubation for an elective thoracoscopic lung biopsy. Information regarding the classifications, pathophysiology, diagnosis, and treatment of this entity is reviewed.     

Human epidermal growth factor receptor 2 as a prognostic indicator in osteogenic sarcoma

Prognostic biologic factors that can be assessed at the time of diagnosis for patients with osteogenic sarcoma have not been identified. The current study was designed to evaluate the prognostic significance of the human epidermal growth factor receptor 2 as it relates to histologic response to preoperative chemotherapy and event-free survival. A retrospective immunohistochemical study was performed on material from patients who were newly diagnosed with osteogenic sarcoma who were treated according to the T12 protocol from the authors' institution between 1986 to 1993. Staining for HER2/erbB-2 was accomplished using standard monoclonal antibodies and methods. At the time of initial biopsy, 42.6% of the samples showed HER2/erbB-2 overexpression. Higher levels of expression were observed in samples from patients with clinically detectable metastases at initial presentation and at relapse. Expression of HER2/erbB-2 correlated with inferior event-free survival in patients with nonmetastatic disease (47% versus 79% at 5 years). In addition, HER2/erbB-2 expression was associated with significantly less tumor necrosis after preoperative chemotherapy as determined by the Huvos grading system. These data suggest that HER2/erbB-2 should be evaluated prospectively as a prognostic indicator and clinical trials using antibodies that target this receptor should be considered for the treatment of patients with osteogenic sarcoma.     

Assessment of tissue viability in complex extremity injuries: utility of the pyrophosphate nuclear scan

BACKGROUND: Extensive extremity injuries often require difficult decisions regarding the necessity for amputation or radical debridement. During the past decade, we have used technetium-99 pyrophosphate (PyP) scanning as an adjunct in this setting. This study was performed to assess the accuracy of PyP scan in predicting the need for amputation in relation to clinical, operative, and pathologic findings. METHODS: Review of our computerized registry identified 11 patients (10 men, age 36.1 +/- 14.9 years) admitted from 1990 to 1999 who underwent PyP scan. Using operative and pathologic findings, accuracy of the PyP scan was graded as supporting or refuting the clinical assessment of the need for amputation. RESULTS: Eight patients suffered high-voltage electrical injuries, one had severe frostbite, and two suffered soft-tissue infections. In most cases, PyP scan showed clear demarcation of viable and nonviable tissue, verifying the need for amputation (positive); those that demonstrated viable distal tissues confirmed at operation were considered negative. PyP scan had a sensitivity of 94%, a specificity of 100%, and an accuracy of 96% in this setting. CONCLUSION: Technetium-99 PyP scanning is a useful adjunct in predicting the need for amputation in extremities damaged by electrical injury, frostbite, or invasive infection. In addition, by providing an objective "picture" of extremity perfusion, PyP scans can be helpful in convincing patients of the need for amputation.     

Factors influencing pediatric injury in side impact collisions

BACKGROUND: Side impact collisions pose a great risk to children in crashes, but information about the injury mechanisms is limited. METHODS: This study involves a case series of children in side impact collisions who were identified through Partners for Child Passenger Safety, a large, child-focused crash surveillance system. The aim of the current study was to use in-depth crash investigations to identify injury mechanisms to children in side impact collisions. RESULTS: Ninety-three children in 55 side impact crashes were studied. Twenty-three percent (n = 22) of the children received an Abbreviated Injury Scale (AIS) score > or = 2 (clinically significant) injury. In these 22 children, head (40%), extremity (23%), and abdominal injuries (21%) were the most common significant injuries. Cases that illustrate body region-specific injury mechanisms are discussed. CONCLUSION: The cases revealed that serious injuries, particularly head injuries, occur even in minor crashes, and efforts should be made to make the interiors of vehicles more child occupant friendly. Lower extremity and abdominal injuries occurred because of contact with the intruding door. Design of vehicles to minimize crush should mitigate the occurrence and severity of these injuries.     

Computerized decision support for mechanical ventilation of trauma induced ARDS: results of a randomized clinical trial

BACKGROUND: Variability and logistic complexity of mechanical ventilatory support of acute respiratory distress syndrome, and need to standardize care among all clinicians and patients, led University of Utah/LDS Hospital physicians, nurses, and engineers to develop a comprehensive computerized protocol. This bedside decision support system was the basis of a multicenter clinical trial (1993-1998) that showed ability to export a computerized protocol to other sites and improved efficacy with computer- versus physician-directed ventilatory support. The Memorial Hermann Hospital Shock Trauma intensive care unit (ICU) (Houston, TX; a Level I trauma center and teaching affiliate of The University of Texas Houston Medical School) served as one of the 10 trial sites and recruited two thirds of the trauma patients. Results from the trauma patient subgroup at this site are reported to answer three questions: Can a computerized protocol be successfully exported to a trauma ICU? Was ventilator management different between study groups? Was patient outcome affected? METHODS: Sixty-seven trauma patients were randomized at the Memorial Hermann Shock Trauma ICU site. "Protocol" assigned patients had ventilatory support directed by the bedside respiratory therapist using the computerized protocol. "Nonprotocol" patients were managed by physician orders. RESULTS: Of the 67 trauma patients randomized, 33 were protocol (age 40 +/- 3; Injury Severity Score [ISS] 26 +/- 3; 73% blunt) and 34 were nonprotocol (age 38 +/- 2; ISS 25 +/- 2; 76% blunt). For the protocol group, the computerized protocol was used 96% of the time of ventilatory support and 95% of computer-generated instructions were followed by the bedside respiratory therapist. Outcome measures (i.e., survival, ICU length of stay, morbidity, and barotrauma) were not significantly different between groups. Fio2 > or = 0.6 and Pplateau > or = 35 cm H2O exposures were less for the protocol group. CONCLUSION: A computerized protocol for bedside decision support was successfully exported to a trauma center, and effectively standardized mechanical ventilatory support of trauma-induced acute respiratory distress syndrome without adverse effect on patient outcome.