Specificity of mammography and US in the evaluation of a palpable abnormality: retrospective review

PURPOSE: To determine the number of patients who received a diagnosis of breast cancer after having an area of clinical concern at presentation and combined negative mammographic and ultrasonographic (US) findings. MATERIALS AND METHODS: During a 4-year period, 829 patients with a palpable abnormality at presentation and combined negative mammographic and US findings were identified. The number of women who went on to receive a diagnosis of breast cancer was determined retrospectively. The authors searched the breast imaging database and the pathology database, sent a contact letter to the referring physicians, and linked their data to the State Cancer Registry. They also analyzed the breast parenchymal density among all patients who had more than 2 years of follow-up. RESULTS: Of the 829 women, 374 had follow-up information. Two-hundred thirty-three patients had negative imaging findings with more than 2 years of follow-up. The other 141 women were presumed to be cancer free, as they were not identified by the State Cancer Registry. Six (2.6%) of the 233 women had a diagnosis of breast cancer in the area of the palpable abnormality. The six cancers were diagnosed among the 156 women who had radiographically dense breast tissue (Breast Imaging Reporting and Data System category 3 or 4). Among the 77 women with predominantly fatty tissues, no cancers were diagnosed. CONCLUSION: A negative mammographic and US finding of a palpable abnormality does not exclude breast cancer, but the likelihood of breast cancer is low, approximately 2.6%-2.7%. It may be higher if the breast tissues are dense and lower if they are predominantly fatty.     

A multicenter,randomized, controlled trial comparing bupivacaine with ropivacaine for labor analgesia

BACKGROUND: A meta-analysis of studies comparing high doses of bupivacaine with ropivacaine for labor pain found a higher incidence of forceps deliveries, motor block, and poorer neonatal outcome with bupivacaine. The purpose of this study was to determine if there is a difference in these outcomes when a low concentration of patient-controlled epidural bupivacaine combined with fentanyl is compared with ropivacaine combined with fentanyl. METHODS: This was a multicenter, randomized, controlled trial, including term, nulliparous women undergoing induction of labor. For the initiation of analgesia, patients were randomized to receive either 15 ml bupivacaine, 0.1%, or 15 ml ropivacaine, 0.1%, each with 5 microg/ml fentanyl. Analgesia was maintained with patient-controlled analgesia with either local anesthetic, 0.08%, with 2 microg/ml fentanyl. The primary outcome was the incidence of operative delivery. We also examined other obstetric, neonatal, and analgesic outcomes. RESULTS: There was no difference in the incidence of operative delivery between the two groups (148 of 276 bupivacaine recipients vs. 135 of 279 ropivacaine recipients; P = 0.25) or any obstetric or neonatal outcome. The incidence of motor block was significantly increased in the bupivacaine group compared with the ropivacaine group at 6 h (47 of 93 vs. 29 of 93, respectively; P = 0.006) and 10 h (29 of 47 vs. 16 of 41, respectively; P = 0.03) after injection. Satisfaction with mobility was higher with ropivacaine than with bupivacaine (mean +/- SD: 76 +/- 23 vs. 72 +/- 23, respectively; P = 0.013). Satisfaction for analgesia at delivery was higher for bupivacaine than for ropivacaine (mean +/- SD: 71 +/- 25 vs. 66 +/- 26, respectively; P = 0.037). CONCLUSIONS: There was no difference in the incidence of operative delivery or neonatal outcome among nulliparous patients who received low concentrations of bupivacaine or ropivacaine for labor analgesia.     

Cost-effectiveness of hepatic metastasectomy in patients with metastatic colorectal carcinoma: a state-transition Monte Carlo decision analysis

OBJECTIVE: To evaluate the cost-effectiveness of hepatic resection ("metastasectomy") in patients with metachronous liver metastases from colorectal carcinoma (CRC), and to investigate the impact of operative and follow-up strategies on outcomes, cost, and cost-effectiveness. SUMMARY BACKGROUND DATA: There is substantial evidence that resection of CRC liver metastases can result in long-term survival in some patients. However, several unresolved issues are difficult to address using currently available clinical data. These include the appropriate threshold for resection, whether to perform repeat resection, and the relative cost-effectiveness of the procedure(s). METHODS: The authors developed a state-transition Monte Carlo decision model to evaluate the (societal) cost-effectiveness of hepatic metastasectomy in patients with metachronous CRC liver metastases. The model tracks the presence, number, size, location, growth, detection, and removal of up to 15 individual metastases in each patient. Survival, quality of life, and cost are predicted on the basis of disease extent. Imaging and surgery affect outcomes via detection and removal of individual metastases. Several patient management strategies were developed and compared with respect to cost, effectiveness, and incremental cost-effectiveness ($/quality-adjusted life year [QALY]). A reference strategy in which metastasectomy is not offered and imaging is not performed for the purpose of assessing resectability or operative planning ("no-surgery" strategy) was included for comparison. Extensive sensitivity analysis was performed to evaluate the impact of alternative model assumptions on results. RESULTS: A strategy permitting resection of up to six metastases and one repeat resection, with CT follow-up every 6 months, resulted in a gain of 2.63 QALYs relative to the no-test/no-treat strategy, at an incremental cost of 18,100 US dollars/QALY. When additional surgical strategies were considered, the incremental cost-effectiveness ratio (ICER; relative to the next least effective strategy) of the six metastases, one repeat, 6-month strategy was 31,700 US dollars/QALY. Across a range of model assumptions, more aggressive treatment strategies (i.e., resection of more metastases, resection of recurrent metastases) were superior to less aggressive strategies and had ICERs below 35,000 US dollars/QALY. Findings were insensitive to changes in most model parameters but somewhat sensitive to changes in surgery and treatment costs. CONCLUSIONS: Hepatic metastasectomy is a cost-effective option for selected patients with metachronous CRC metastases limited to the liver. When considering metastasectomy, more aggressive approaches are generally preferred to less aggressive approaches. Overall, surgeons should be encouraged to consider resection for all patients whose metastases can technically be removed.     

Caveat arthroplasty

Caveat arthroplasty is arthroplasty undertaken to treat a presumed nonneoplastic disorder, which is later determined to be secondary to an extraarticular tumor. We identified 6 patients who had caveat arthroplasty before referral to our orthopedic oncology center. Three patients had completed arthroplasties at an average of 29 weeks before discovery of a neoplasm. Three arthroplasties were aborted after a neoplasm was discovered intraoperatively. Prearthroplasty radiographs of 4 patients were reviewed, all demonstrating evidence of malignancy. Caveat arthroplasty may be avoided if malignancy is considered preoperatively, particularly in patients with atypical symptoms, histories of cancer, and rapid periarticular bone loss. If a neoplasm is discovered intraoperatively, the arthroplasty should be aborted. Patients in whom malignancy is suspected should be referred to a musculoskeletal oncologist.     

Peripartum anesthetic management of patients with aortic valve stenosis: a retrospective study and literature review

BackgroundAnesthetic management of parturients with aortic stenosis is controversial. Early studies suggest maternal mortality was related to cardiac condition and anesthetic care. In this report, management of parturients with moderate or severe aortic stenosis in two institutions is compared, and published cases are reviewed.MethodsPeripartum anesthetic management of all parturients with moderate or severe aortic stenosis who gave birth between 1990 and 2005 at our institutions, is described. Patients with mild or non-valvular aortic stenosis were excluded.ResultsThere were 12 parturients, six with moderate and six with severe aortic stenosis. Two patients with moderate aortic stenosis were New York Heart Association (NYHA) classification II, the others were asymptomatic. Five patients with severe aortic stenosis were symptomatic (NYHA classification II or III). Two patients with moderate and three with severe aortic stenosis underwent cesarean delivery; epidural anesthesia was used for two. Two patients with moderate and all with serious aortic stenosis were observed postpartum for 24 to 48 h in a high-dependency unit. There were no severe maternal or neonatal complications.ConclusionsCarefully titrated regional analgesia is usually well tolerated in patients undergoing vaginal or cesarean delivery even in the presence of severe aortic stenosis. Standard monitoring is usually adequate for vaginal delivery, but invasive monitoring may facilitate management in some patients. An arterial line allows close monitoring of systemic blood pressure. Facilities for close 24-48-h post-partum observation should be available. A multidisciplinary approach is needed.     

Use of Population‐based Data to Demonstrate How Waitlist‐based Metrics Overestimate Geographic Disparities in Access to Liver Transplant Care

Liver allocation policies are evaluated by how they impact waitlisted patients, without considering broader outcomes for all patients with end‐stage liver disease (ESLD) not on the waitlist. We conducted a retrospective cohort study using two nationally representative databases: HealthCore (2006–2014) and five‐state Medicaid (California, Florida, New York, Ohio and Pennsylvania; 2002–2009). United Network for Organ Sharing (UNOS) linkages enabled ascertainment of waitlist‐ and transplant‐related outcomes. We included patients aged 18–75 with ESLD (decompensated cirrhosis or hepatocellular carcinoma) using validated International Classification of Diseases, Ninth Revision (ICD‐9)–based algorithms. Among 16 824 ESLD HealthCore patients, 3‐year incidences of waitlisting and transplantation were 15.8% (95% confidence interval [CI] : 15.0–16.6%) and 8.1% (7.5–8.8%), respectively. Among 67 706 ESLD Medicaid patients, 3‐year incidences of waitlisting and transplantation were 10.0% (9.7–10.4%) and 6.7% (6.5–7.0%), respectively. In HealthCore, the absolute ranges in states' waitlist mortality and transplant rates were larger than corresponding ranges among all ESLD patients (waitlist mortality: 13.6–38.5%, ESLD 3‐year mortality: 48.9–62.0%; waitlist transplant rates: 36.3–72.7%, ESLD transplant rates: 4.8–13.4%). States' waitlist mortality and ESLD population mortality were not positively correlated: ρ = ?0.06, p‐value = 0.83 (HealthCore); ρ = ?0.87, p‐value = 0.05 (Medicaid). Waitlist and ESLD transplant rates were weakly positively correlated in Medicaid (ρ = 0.36, p‐value = 0.55) but were positively correlated in HealthCore (ρ = 0.73, p‐value = 0.001). Compared to population‐based metrics, waitlist‐based metrics overestimate geographic disparities in access to liver transplantation.     

Percutaneous embolization of varicocele: technique,indications, relative contraindications,and complications

There are several options for the treatment of varicocele, including surgical repair either by open or microsurgical approach, laparoscopy, or through percutaneous embolization of the internal spermatic vein. The ultimate goal of varicocele treatment relies on the occlusion of the dilated veins that drain the testis. Percutaneous embolization offers a rapid recovery and can be successfully accomplished in approximately 90% of attempts. However, the technique demands interventional radiologic expertise and has potential serious complications, including vascular perforation, coil migration, and thrombosis of pampiniform plexus. This review discusses the common indications, relative contraindications, technical details, and risks associated with percutaneous embolization of varicocele.     

Epidural anaesthesia for Caesarean section in patients with active recurrent genital herpes simplex infections: a retrospective review

The safety of epidural anaesthesia in patients with active, recurrent genital herpes simplex (HSV) infections is controversial. We reviewed the six-year experience of the use of epidural anaesthesia in this patient population in two institutions. Eighty-nine parturients with active genital HSV were administered epidural anaesthesia for Caesarean section. No patient suffered an adverse outcome related to either the anaesthetic or the virus. The theoretical risks of regional anaesthesia in the parturient with active herpes genitalis are reviewed. We conclude from available data that the risk of an adverse outcome is small and does not contraindicate the use of epidural anaesthesia in patients with recurrent infection.     

Current and emerging technologies in melanoma diagnosis: the state of the art

Relative to other specialties, dermatologists have been slow to adopt advanced technologic diagnostic aids. Most skin disease can be diagnosed by simple visual inspection, and the skin is readily accessible for a diagnostic biopsy. Diagnostic aids, such as total body photography and dermoscopy, improve the clinician's ability to diagnose melanoma beyond unaided visual inspection, however, and are now considered mainstream methods for early detection. Emerging technologies such as in vivo reflectance confocal microscopy are currently being investigated to determine their utility for noninvasive diagnosis of melanoma. This review summarizes the currently available cutaneous imaging devices and new frontiers in noninvasive diagnosis of skin disease. We anticipate that multimodal systems that combine different imaging technologies will further improve our ability to detect, at the bedside, melanoma at an earlier stage.