Large plaque-like glomuvenous malformation (glomangioma) simulating venous malformation

Glomuvenous malformations and venous malformations are vascular lesions that can be distinguished on the basis of clinical and pathological features. A vascular lesion of the skin and superficial and deep soft tissues of a lower limb in a 5-year-old child is described. The clinical and radiological features, including skeletal muscle involvement, were typical of venous malformation, whereas the histopathological features were those of a glomuvenous malformation. The clinical and histopathological features are briefly discussed.     

Systemic and Hepatic Hemodynamics in Hepatosplenic Manson's Schistosomiasis with and Without Propranolol

Systemic and hepatic hemodynamics wereprospectively studied in 11 patients with Manson'sschistosomiasis and portal hypertension, as well asalterations resulting from the use of propranolol. Itwas decided that patients whose portal pressure was reducedby 30% with the use of the drug would not undergosurgery and that treatment would consist of the chronicuse of propranolol, associated with sclerosis of esophageal varices. This objective was not metby any of the patients whose portal pressure wasmeasured and the study was interrupted. Results showthat patients with Manson's schistosomiasis and portal hypertension have hyperdynamic circulation,mild pulmonary hypertension, greatly increased splenicblood flow, and preservation of total hepatic bloodflow. Administration of propranolol correctshyperdynamic circulation, aggravates pulmonary hypertension,does not alter portal pressure and reduces the sectorialportal blood flows, especially of the azygos vein, withmaintenance of total hepatic blood flow. These data favor the hypothesis of portaloverflow in the physiopathology of portal hypertensionof schistosomiasis.     

A generalizability study of the medical judgment vignettes interview to assess students' noncognitive attributes for medical school

Background  

Although the reliability of admission interviews has been improved through the use of objective and structured approaches, there still remains the issue of identifying and measuring relevant attributes or noncognitive domains of interest. In this present study, we use generalizability theory to determine the estimated variance associated with participants, judges and stations from a semi-structured, Medical Judgment Vignettes interview used as part of an initiative to improve the reliability and content validity of the interview process used in the selection of students for medical school.     

Value of thrombomodulin immunostaining in the diagnosis of transitional cell carcinoma: a comparative study with carcinoembryonic antigen

Aims: Thrombomodulin (TM) is a surface glycoprotein involved in the regulation of intravascular coagulation that has been reported to be expressed in a variety of tumours. We investigated TM expression in transitional cell carcinoma (TCC) and compared the value of TM immunostaining with that of carcinoembryonic antigen (CEA) for differentiating TCC from other tumours with which it may be confused.  

Methods and results:

Immunostaining was performed on formalin-fixed, paraffin-embedded tissue sections using the avidin–biotin–peroxidase complex method. TM immunoreactivity was observed in 80 of 91 primary (51/58 urinary bladder, 10/12 renal pelvis, 3/3 ureter, 15/15 prostate, 1/3 ovary), and 18 of 20 metastatic TCCs expressed this marker. Only 37 of the 91 primary (23/58 urinary bladder, 4/12 renal pelvis, 1/3 ureter, 9/15 prostate, 0/3 ovary) and six of the 20 metastatic TCCs reacted for CEA. In order to evaluate the practical utility of TM immunostaining in surgical pathology, 30 adenocarcinomas of the prostate, 18 of the bladder, 12 of the colon, and 22 renal cell carcinomas were also stained for these markers. CEA reactivity was obtained in 12 of 30 adenocarcinomas of the prostate, 12 of 18 of the bladder, and 12 of 12 of the colon, but in none of the 22 renal cell carcinomas. Only three of the 18 adenocarcinomas of the bladder showed focal TM reactivity, but no staining for this marker was observed in any of the other types of tumours.  

Conclusions:

TM is a more sensitive marker than CEA for TCC and, because it has a more restricted reactivity with other tumours, TM has more practical value in separating TCCs from adenocarcinomas of the prostate, colon and bladder, and renal cell carcinomas than CEA.     

Influence of projected complication rates on estimated appropriate use rates for carotid endarterectomy. Appropriateness Project Investigators. Academic Medical Center Consortium.

OBJECTIVE: To examine specifically the influence of estimated perioperative mortality and stroke rate on the assessment of appropriateness of carotid endarterectomy. DATA SOURCES/STUDY SETTING: An expert panel convened to rate the appropriateness of a variety of potential indications for carotid endarterectomy based on various rates of perioperative complications. We then applied these ratings to the charts of 1,160 randomly selected patients who had carotid endarterectomy in one of the 12 participating academic medical centers. STUDY DESIGN: An expert panel evaluated indications for carotid endarterectomy using the modified Delphi approach. Charts of patients who received surgery were abstracted, and clinical indications for the procedure as well as perioperative complications were recorded. To examine the impact of surgical risk assessment on the rates of appropriateness, three different definitions of risk strata for combined perioperative death or stroke were used: Definition A, low risk < 3 percent; Definition B, low risk < 5 percent; and Definition C, low risk < 7 percent. PRINCIPAL FINDINGS: Overall hospital-specific mortality ranged from 0 percent to 4.0 percent and major complications, defined as death, stroke, intracranial hemorrhage, or myocardial infarction, varied from 2.0 percent to 11.1 percent. Most patients (72 percent) had surgery for transient ischemic attack or stroke; 24 percent of patients were asymptomatic. Most patients (82 percent) had surgery on the side of a high-grade stenosis (70-99 percent). When the thresholds for operative risk were placed at the values defined by the expert panel (Definition A), only 33.5 percent of 1,160 procedures were classified as "appropriate." When the definition of low risk was shifted upward, the proportion of cases categorized as appropriate increased to 58 percent and 81.5 percent for Definitions B and C, respectively. CONCLUSIONS: Despite the high proportion of procedures performed for symptomatic patients with a high degree of ipsilateral extracranial carotid artery stenosis and generally low rates of surgical complications at the participating institutions, the overall rate of "appropriateness" using a perioperative complication rate of < 3 percent was low. However, the rate of "appropriateness" was extremely sensitive to judgments about a single clinical feature, surgical risk. These data show that before applying such "appropriateness" ratings, it is crucial to perform sensitivity analyses in order to assess the stability of the results. Results that are robust to moderate in variation in surgical risk provide a much sounder basis for policy making than those that are not.