Human papillomavirus, cervical intraepithelial cancer and immunosuppression. Two cases in renal transplant recipients]

Immunosuppression is therapeutically induced in an increasing number of patients, exceeding largely the only transplant recipients. Its carcinological complications are a major preoccupation, among which the uterine cervix intraepithelial neoplasia. The strong relationship between these genital neoplasia and the lesions caused by human Papillomavirus is now evident and has to be taken in consideration for an early and regular follow-up of these women. Cervical smear tests, colposcopic assessment and histological examinations allow to undertake the adequate treatment and to give some preventive advice.     

Percutaneous drainage of complicated abscesses and fluid collections

The original concept of percutaneous, radiological abscess drainage was confined to well circumscribed, solitary abscesses, that could be reached by a short access avoiding transgression of uninvolved organs or compartments. With increasing experience criteria for percutaneous abscess drainage have been expanded to radiological treatment of pancreatic, periappendiceal, diverticular, interloop and mediastinal abscesses and fluid collections. The authors present their experience with percutaneous treatment of such "complicated" abscesses in 140 patients.     

Intravascular gas as an incidental finding at US after blunt abdominal trauma

PURPOSE: To describe the occurrence and importance of intravascular gas at ultrasonography (US) during the initial examination of patients after blunt abdominal trauma. MATERIALS AND METHODS: Reports of all abdominal US examinations performed at one institution for blunt trauma from October 1995 through June 1996 were reviewed. The charts of patients with intravascular gas were examined to determine the mechanism of injury, associated findings, and clinical outcome. RESULTS: A total of 730 patients underwent abdominal US examinations during the 9 months of study; five had intravascular gas demonstrated. Two patients had portal venous gas, one had hepatic venous gas, and two had inferior vena caval gas. Four of the five patients were involved in motor vehicle accidents, and one had been assaulted. In patients in whom follow-up studies were obtained, there was no evidence of intravascular gas at US or computed tomography. No cause was found at imaging or clinical examination. CONCLUSION: Intravascular gas may occur as a transient incidental finding after blunt abdominal trauma.     

Critical Race Theory as a Lens for Examining Primary Care Provider Responses to Persistently-Elevated HbA1c

IntroductionClinical inertia remains a persistent problem in the treatment of diabetes in clinical care. Primary care provider behavior is thought to be a significant contributor to diabetes clinical inertia. This study used the lens of Critical Race Theory to examine whether provider's diabetes management activities differ by patient race and frame implications for future research.MethodsChart abstractors retrospectively reviewed a random sample of charts from primary care patients with persistently-elevated HbA1c to assess providers' diabetes management activities in the subsequent year. Provider activities aligned with the American Diabetes Association's standards of medical care and included HbA1c test ordering, documentation of patient medication adherence, counseling on lifestyle modification, lifestyle modification referral, endocrinologist participation in care, and medication titration. Differences in provider actions by patient race (Black, white, or other) were examined using chi-square tests.ResultsA total of 188 patient charts were reviewed. For all provider actions, there were statistically-significant differences by patient race. Black patients were least likely to be counseled on dietary changes (72.0%) or physical activity (57.7%) by their primary care provider, but most likely to be referred to an outside specialist for this counseling (46.2%). Black patients were also least likely to have medication adjustments made (72%).DiscussionStudy findings showed an association between provider diabetes management behaviors and patient race, Future studies showed explore providers' racial beliefs, attitudes and clinical decision-making, and patients’ experiences with historical exclusion from medical care and racism in healthcare encounters In addition, more research is needed to explore the role of structural racism in clinical inertia.     

Hypotensive patients with blunt abdominal trauma: performance of screening US

PURPOSE: To determine retrospectively the accuracy of screening ultrasonography (US) in patients with hypotension (systolic blood pressure or =2) (consensus by three readers) and were assigned to a low- or high-risk group according to the presence of hematuria and/or axial fracture on radiographs. Screening US results were compared with findings with the best available reference standard (computed tomography [CT]), repeat US, other diagnostic test, laparotomy, autopsy, clinical course). Data were compared by using chi(2) or Fisher exact test, depending on expected frequencies, with Bonferroni correction for multiple comparisons. Continuous variables were compared by using unpaired Student t test or Mann-Whitney U test, depending on data distribution. RESULTS: The study included 77 male and 51 female patients (mean age, 42 years). Sensitivity was 85% (44 of 52) for detection of any injuries, 97% (30 of 31) for surgical injuries (ie, injuries requiring surgery), and 100% (10 of 10) for fatal injuries. Specificity was 96% (73 of 76), 82% (80 of 97), and 69% (81 of 118), and accuracy was 91% (117 of 128), 86% (110 of 128), and 71% (91 of 128), for respective injury categories. One nonfatal surgical injury was missed in a high-risk patient. For each injury category, frequency of injury in patients with a fluid score of 2 or more was nine times that in patients with a score of 0 (P < .001 for all comparisons). Frequency of false-negative US findings in high-risk patients was eight times that in low-risk patients (P < .01). CONCLUSION: In patients who are hypotensive after blunt abdominal trauma and not hemodynamically stable enough to undergo diagnostic CT, negative US findings virtually exclude surgical injury, while positive US findings indicate surgical injury in 64% of cases.     

Percutaneous drainage access: a simplified coaxial technique

We describe an access technique that we have used in 150 nephrostomy and biliary drainage procedures and for access to some abscesses and viscera. The system provides safe coaxial access with a 22-gauge removable hub needle, which then acts as a guide wire and is replaced by an 18-gauge cannula. A major advantage is that only one guide wire is used (0.038-inch) for the entire drainage procedure. No significant complications have occurred to date with this method.     

Thin-layer chromatography to monitor cholesterol gallstone dissolution by methyl tert-butyl ether

We describe a simple and inexpensive method of monitoring methyl tert-butyl ether (MTBE) dissolution of cholesterol gallstones with thin-layer chromatography (TLC) in 10 patients. TLC is a routine semiquantitative laboratory method that can be used to measure the cholesterol concentration present in the MTBE and bile mixture aspirated through the cholecystostomy catheter during gallstone dissolution. TLC is practical in the clinical setting because it can be used to determine if gallstone dissolution is occurring and when MTBE lavage is no longer effective. TLC is performed in the laboratory with routine material and is completed in 15 min. Each TLC measurement costs about $1. The procedure provides objective and specific chemical information on effectiveness and progression of gallstone dissolution, apart from the radiologic and sonographic studies. In our study, TLC signaled effective dissolution in the initial phase of gallstone dissolution by detecting large amounts of cholesterol in the MTBE and bile mixture even before a visible change in size or shape of the stone became apparent by transcatheter cholecystography or by sonography (six of 10 patients). Conversely, lack of cholesterol on TLC after 1 hr or more of MTBE infusion indicates that the stones are pigmented or contain substantial calcium. This means that dissolution with MTBE will be ineffective and that solvent infusion should be terminated. In those cases in which dissolution is progressing well, when TLC shows decreasing amounts of cholesterol in the effluent, only residual fragments insoluble to MTBE remain or the stone is sequestered from MTBE; at this point, solvent infusion should be discontinued or the catheter must be repositioned. Monitoring the rate of cholesterol dissolution by TLC provides important complementary information to cholecystography and sonography during gallstone treatment with MTBE.