Systemic air embolism after transthoracic lung biopsy: A case report and review of literature

Computed tomography (CT)-guided lung biopsy is a common diagnostic procedure that is associated with various complications, including pneumothorax, hemoptysis and parenchymal hemorrhage. Systemic air embolism is a very rare (0.07%) but potentially lifethreatening complication. We report a fatal case of air embolism to the cerebral and coronary arteries confirmed by head and chest CT, followed by a review of the literature.

Multimodality imaging of ovarian cystic lesions: Review with an imaging based algorithmic approach

Ovarian cystic masses include a spectrum of benign, borderline and high grade malignant neoplasms. Imaging plays a crucial role in characterization and pretreatment planning of incidentally detected or suspected adnexal masses, as diagnosis of ovarian malignancy at an early stage is correlated with a better prognosis. Knowledge of differential diagnosis, imaging features, management trends and an algorithmic approach of such lesions is important for optimal clinical management. This article illustrates a multi-modality approach in the diagnosis of a spectrum of ovarian cystic masses and also proposes an algorithmic approach for the diagnosis of these lesions.

Computed tomography imaging of acute neck inflammatory processes

Early diagnosis and management of neck infections and inflammatory processes is a common challenge for emergency and ear,neck and throat physicians,as well as radiologists.Emergency neck infections are diverse in their presentation,ranging from a transient enlargement of a lymph node to a rapidly spreading necrotizing fasciitis.Symptoms and signs,with the clinical history,usually suggest the diagnosis.But complex neck anatomy and sometimes limited physical examination can obscure and delay diagnosis,thus the need for an appropriate imaging exam and correct interpretation.In this pictorial review,we will consider common neck acute inflammatory processes that may be encountered in the emergency room and discuss some of their salient imaging findings.

Split-dose bowel preparation improves adequacy of bowel preparation and gastroenterologists' adherence to National Colorectal Cancer Screening and Surveillance Guidelines

AIM To quantify the impact of split-dose regimen on endoscopists' compliance with guideline recommendations for timing of repeat colonoscopy in patients with normal colonoscopy or 1-2 small polyps(< 10 mm).METHODS A retrospective chart review of all endoscopy reports was undertaken in average-risk individuals > 50 years old with a normal screening colonoscopy and 1-2 small polyps. Data were abstracted from two time periods, pre and post-split-dose bowel preparation institution. Main outcome measurements were recommendation for timing of repeat colonoscopy and bowel preparation quality. Bivariate analysis by χ~2 tests and Student's t-tests were performed to assess differences between the two cohorts. Multivariable logistic regression was used with guideline consistent recommendations as the dependent variables and an indicator for 2011 cohort as the primary predictor. RESULTS Four thousand two hundred and twenty-five patients were included in the study; 47.0%(1987) prior to the institution of split dose bowel preparation, and 53.0%(2238) after the institution of split dose bowel preparation. Overall, 82.2%(n = 3472) of the colonoscopies were compliant with guideline recommendations, with a small but significantly increased compliance rate in year 2011(83.7%) compared to year 2009(80.4%, P = 0.005), corresponding to an unadjusted odds ratio of 1.25(95%CI: 1.07-1.47; P = 0.005). Colonoscopies with either "Adequate" or "Excellent" had increased from 30.6% in year 2009 to 39.6% in year 2011(P < 0.001). However, there was no significant difference in poor/inadequate category of bowel preparation as there was a mild increase from 4.6% in year 2009 to 5.1% in year 2011(P = 0.50). CONCLUSION Split-dose bowel regimen increases endoscopists' compliance to guidelines in average-risk patients with normal colonoscopy or 1-2 small polyps.

Cockcroft-gault revisited: New de-liver-ance on recommendations for use in cirrhosis

The Cockcroft-Gault(CG) equation has become perhaps the most popular practical approach for estimating renal function among health care professionals. Despite its widespread use, clinicians often overlook not only the limitations of the original serum creatinine(SCr) based equation, but also may not appreciate the validity of the many variations used to compensate for these limitations. For cirrhotic patients in particular, the underlying pathophysiology of the disease contributes to a falsely low SCr, thereby overestimating renal function with use of the CG equation in this population. We reviewed the original CG trial from 1976 along with data surrounding clinician specific alterations to the CG equation that followed through time. These alterations included different formulas for body weight in obese patients and the "rounding up" approach in patients with low SCr. Additionally, we described the pathophysiology and hemodynamic changes that occur in cirrhosis; and reviewed several studies that attempted to estimate renal function in this population. The evidence we reviewed regarding the most accurate manipulation of the original CG equation to estimate creatinine clearance(Cr Cl) was inconclusive. Unfortunately, the homogeneity of the patient population in the original CG trial limited its external validity. Elimination of body weight in the CG equation actually produced the estimate closest to the measure Cr Cl. Furthermore, "rounding up" of SCr values often underestimated Cr Cl. This approach could lead to suboptimal dosing of drug therapies in patients with low SCr. In cirrhotic patients, utilization of SCr based methods overestimated true renal function by about 50% in the literature we reviewed.

Bugbee flexible electrocautery facilitates choledochoscopic biopsy,fulguration,and debulking of a high grade intraductal papillary neoplasm of the bile duct

To the Editor:Intraductal papillary neoplasm of the bile duct(IPNB)may occur in the setting of primary sclerosing cholangitis,choledochal cysts or hepatolithiasis[1].The entity may be a precursor of cancer or intrahepatic cholangiocarcinoma.Invasive carcinoma,tubular or mucinous adenocarcinoma is present in approximately 40%-80%of IPNBs[1–3].IPNB is frequently found in the resection margins of patients undergoing hepatectomy for cholangiocarcinoma[4].

Splenic Arteriogastric Fistula Resulting from Adrenocortical Carcinoma: A Rare Cause of Massive Upper Gastrointestinal Hemorrhage

Splenic arteriogastric fistula is a rare cause of upper gastrointestinal (GI) hemorrhage, only reported a handful of times in the literature. Herein, we present a case of a 49-year-old woman with metastatic adrenocortical carcincoma who developed a fistula between the splenic artery and gastric lumen as a result of local invasion of her primary tumor. This fistula led to several episodes of massive upper GI bleeding. Selective splenic artery embolization was successful in ceasing the GI bleed;however, the intervention was not timely enough for the patient to survive the hemorrhage. We outline several clinical and imaging findings to assist physicians with earlier detection of splenic arteriogastric fistulas, and advocate prophylactic selective splenic artery embolization when this rare but highly fatal entity is discovered.

成人肝移植术后早期再次手术

目的回顾性观察肝移植术后早期再次剖腹探查及对预后的影响,分析其原因及特征,并籍此找出可能避免再次手术的措施。方法总结密歇根大学医院自2006年8月1日至2007年2月28日间所行成人肝移植手术患者资料,将再手术患者组与未再手术患者组资料进行对照和统计学分析。结果52例患者行肝移植手术共54次。随访3至9个月,其中共14次(12例患者)术后再次剖腹探查,所有再手术均在移植术后20 d内。6例系手术技术相关的术后腹腔出血,2例为非手术技术相关腹腔出血,2例术后肝动脉栓塞,1例术后移植物无功能再次肝移植,1例肝动脉取栓后再栓塞行再次肝移植,1例术后肠粘连保守治疗无效,1例阴性探查。行剖腹探查者1例患者死亡。结论移植术后手术技术相关的腹腔出血是再次手术探查的主要指征,MELD评分较高的患者建议移植术后常规置放引流;原发性移植物无功能和肝动脉栓塞是早期再次肝移植的主要指征;肝动脉栓塞的诊断和处理需要快速果断,再次手术取栓、融栓与吻合口的校正可能是解决问题的根本办法;移植术后的真菌感染后果是致死性的,提高警惕性和早期预防是关键。

全氟戊烷微滴乳剂增强HIFU疗效的研究

用小型HIFU系统,详细研究了在体内激发全氟戊烷微滴乳剂变成微泡及其在胶体内的热吸收规律。试验证明,该小型HIFU系统能在体激发全氟戊烷微滴乳剂,转化为体积增大数十倍的微泡;适宜浓度的全氟戊烷微滴乳剂能有效加强HIFU辐照形成的损伤。

头颈部鳞癌:CT灌注有助于无创性预测瘤内微血管密度

目的在头颈部鳞癌评估中．确定CT灌注成像参数与瘤内微血管密度的相关性。方法此项符合HIPPA的前瞻性研究得到了当地伦理委员会批准，所有参加本研究的病人均签署知情同意书。13例进展期头颈部鳞癌病人（Ⅲ和Ⅳ期）进行了颈部CT增强、CT灌注成像和原发肿瘤的内镜活检。病人的平均年龄为57．4岁（范围为41～78岁）。经小鼠抗人类CD31抗体免疫染色后，检测瘤内微血管密度。记录每一标本在10个高倍视野（×400）下的平均染色微血管数目。

Esophagogastric junction distensibility assessed using the functional lumen imaging probe

AIM To assess reference values in the literature for esophageal distensibility and cross-sectional area in healthy and diseased subjects measured by the functional lumen imaging probe(FLIP). METHODS Systematic search and review of articles in Medline and Embase pertaining to the use of FLIP in the esophagus was conducted in accordance with the PRISMA guidelines. Cross-sectional area and distensibility at the esophagogastric junction(EGJ) were abstracted for normal subjects, achalasia, and gastroesophageal reflux disease(GERD) patients, stratified by balloon length and volume of inflation.RESULTS Six achalasia studies(n = 154), 3 GERD(n = 52), and 5 studies including healthy controls(n = 98) were included in the systematic review. Normative data varied widely amongst studies of healthy volunteers. In contrast, studies in achalasia patients uniformly demonstrated low point estimates in distensibility ≤ 1.6 mm2/mmH g prior to treatment that increased to ≥ 3.4 mm2/mmH g following treatment at 40 mL bag volume. In GERD patients, distensibility fell to the range of untreated achalasia(≤ 2.85 mm2/mm Hg) following fundoplication.CONCLUSION FLIP may be a useful tool in assessment of treatment efficacy in achalasia. The drastic drop in EGJ distensibility after fundoplication suggests that FLIP measurements need to be interpreted in the context of esophageal body motility and highlights the importance of pre-operative screening for dysmotility. Future studies using standardized FLIP protocol and balloon size are needed.

1999～2006年急性冠脉综合征患者死亡及心力衰竭发生率降低

背景：有关药物和介入治疗对ST段抬高型和非ST段抬高型急性冠脉综合征（non—ST-segment elevation acute coronary syndrome，NSTE ACS）患者的作用，随机试验已经提供了足够的证据，但是是否已经转化为相应的临床变化还不清楚。 目的：确定ST段抬高型心肌梗死（ST-segment elevation myocardial infarction，STEMI）和NSTE ACS患者的院内治疗改变是否伴随临床结果的改善。 设计、地点及患者：全球急性冠脉事件注册研究（Global Registry of Acute Coronary Events，GRACE）是一项多国家队列研究。自1999年7月1日至2006年12月31日，该研究共入选并随访了来自14个国家、113家医院的44372例ACS患者。 主要观测指标：当前循证药物和介入治疗应用的趋势及患者预后（死亡、充血性心力衰竭、肺水肿、心源性休克、卒中和心肌梗死）。 结果：随着研究时间的进展，相关药物的应用增加（β-受体阻滞剂、他汀类药物、血管紧张素转换酶抑制剂、行或未行经皮冠状动脉介入治疗[percutaneous coronary intervention，PCI]患者应用噻氯毗啶、糖蛋白Ⅱb／Ⅲa抑制剂和低分子肝素；P〈0．001）。STEMI患者药物再灌注治疗下降了22个百分点（95％可信区间[confidence interval，CI]，-27～-17），而直接PCI增加了37个百分点（95％CI，33—41）。在NSTEMI患者中，PCI的比例显著升高了18个百分点（95％CI，15～20）。充血性心力衰竭和肺水肿在STEMI患者中降低了9个百分点（95％CI，-12～-6），在NSTEACS患者中降低了6．9个百分点（95％CI，-8．4～-4．7）。STEMI患者的院内死亡率降低了18个百分点（95％CI，-5．3～-1．9），心源性休克降低了24个百分点（95％CI，-4．3～-0．5）。校正了危险评分后，NSTEACS患者的院内死亡率降低了0．7个百分点（95％CI，-1．7～0．3）；STEMI患者6个月随访时卒中发生率降低了0．8个百分点（95％CI，-1．7～0．1），心肌梗死发生率降低了2．8个百分点（95％CI，-6．4～0．9）。NSTEACS患者6个月死亡率降低了1．6个百分点（95％CI，-3．0～-0．1），卒中发生率降低了0．7个百分点（95％CI，-1．4～0．1）。 结论：在本项多国家观察性研究中，ACS患者治疗的改善与6个月新发心力衰竭、死亡率、卒中和心肌梗死发生率显著降低相关。

持续性医疗质量改善计划与同期经皮冠状动脉介入医疗实践和预后变量的关系

Background -The objective of this study was to evaluate the association of a continuous quality improvement program with practice and outcome variations of percutaneous coronary intervention(PCI). Methods and Results -Data on consecutive PCI were collected in a consortium of 5 hospitals; 3731 PCIs reflected care provided at baseline(January 1, 1998, to December 31, 1998), and 5901 PCIs reflected care provided after implementation of a continuous quality improvement intervention(January 1, 2002, to December 31, 2002). The intervention included feedback on outcomes, working group meetings, site visits, selection of quality indicators, and use of bedside tools for quality improvement and risk assessment. Postintervention data were compared with baseline and with 10 287 PCIs from 7 hospitals added to the consortium in 2002. Quality indicators included use of preprocedural aspirin or clopidogrel, use of glycoprotein IIb/IIIa receptor blockers and postprocedural heparin, and amount of contrast media per case. Outcomes selected included emergency CABG, contrast nephropathy, myocardial infarction, stroke, transfusion, and in-hospital death. Compared with baseline and the control group, the intervention group at follow-up had higher use of preprocedural aspirin and glycoprotein IIb/IIIa blockers, lower use of postprocedural heparin, and a lower amount of contrast media per case(P< 0.05). These changes were associated with lower rates of transfusions, vascular complications, contrast nephropathy, stroke, transient ischemic attack, and combined end points(all P< 0.05). Conclusions -Our nonrandomized, observational data suggest that implementation of a regional continuous quality improvement program appears to be associated with enhanced adherence to quality indicators and improved outcomes of PCI. A randomized clinical trial is needed to determine whether this is a “causal”or a “casual”relationship.

急性冠状动脉综合征患者同时应用氯吡格雷和CYP3A4抑制剂无相互影响

Objective: To assess a clinically significant interaction between cytochrome P450 3A4(CYP3A4)metabolised statin and clopidogrel. Design: Prospective single centre cohort study. Setting: Academic teaching hospital in the USA. Patients: 1651 patients presenting with acute coronary syndromes between January 1999 and February 2003 were studied. Data on baseline demographics, co-morbidities, and in-hospital management were collected. Main outcome measure: Association of CYP3A4 metabolised statin and clopidogrel use with in-hospital and six month mortality. The impact of the combined use of a CYP3A4 statin and clopidogrel on six month mortality and major adverse cardiac events was analysed by a risk adjusted logistic regression model. Results: The odds ratios for six month mortality were: for CYP3A4 statin, 0.43(95%confidence interval(Cl)0.27 to 0.71, p=0.0009); for CYP3A4 statin plus clopidogrel, 0.36(95%Cl 0.23 to 0.60, p < 0.001); for non-CYP3A4 statin, 0.22(95%Cl 0.08 to 0.59, p=0.002); and for non-CYP3A4 statin plus clopidogrel, 0.22(95%Cl 0.06 to 0.75, p=0.016). Conclusions: Use of a combination of a CYP3A4 statin plus clopidogrel was associated with lower six month mortality and morbidity in patients with acute coronary syndromes. There was no significant difference in clinical benefit between a CYP3A4 statin and a non-CYP3A4 statin when used in conjunction with clopidogrel. This suggests that the proposed interaction is probably an ex vivo phenomenon and may not be clinically relevant.

Advanced oropharyngeal squamous cell carcinoma: Pathogenesis, treatment, and novel therapeutic approaches

Oropharyngeal cancer accounts for approximately 2.8% of newly cancer cases. Although classically a tobacco related disease, most cases today are related to infection with human papilloma virus(HPV) and present with locally advanced tumors. HPV related tumors have been recognized as a molecularly distinct entity with higher response rates to therapy, lower rates of relapse, and improved overall survival. Treatment of oropharyngeal cancer entails a multi-disciplinary approach with concomitant chemoradiation. The role of induction chemotherapy in locally advanced tumors continues to be controversial however large studies have demonstrated no difference in survival or time to treatment failure. Surgical approaches may be employed with low volume oropharyngeal cancers and with development new endoscopic tools, more tumors are able to be resected via an endoscopic approach. Given advances in the understanding of HPV related oropharyngeal cancer, ongoing research is looking at ways to minimize toxicities via de-intensification of therapy. Unfortunately, some patients develop recurrent or metastatic disease. Novel therapeutics are currently being investigated for this patient population including immunotherapeutics. This review discusses the current understanding of the pathogenesis of oropharyngeal cancer and treatment. We also discuss emerging areas of research as it pertains to de-intensification as well novel therapeutics for the management of metastatic disease.

Malpractice claims for endoscopy

AIM: To summarize the magnitude and time trends of endoscopy-related claims and to compare total malpractice indemnity according to specialty and procedure. METHODS: We obtained data from a comprehensive database of closed claims from a trade association of professional liability insurance carriers, representing over 60% of practicing United States physicians. Total payments by procedure and year were calculated, and were adjusted for inflation (using the Consumer Price Index) to 2008 dollars. Time series analysis was performed to assess changes in the total value of claims for each type of procedure over time. RESULTS: There were 1901 endoscopy-related closed claims against all providers from 1985 to 2008. The specialties include: internal medicine (n = 766), gastroenterology (n = 562), general surgery (n = 231), general and family practice (n = 101), colorectal surgery (n = 87), other specialties (n = 132), and unknown (n = 22). Colonoscopy represented the highest frequen-cies of closed claims (n = 788) and the highest total indemnities ($54 093 000). In terms of mean claims payment, endoscopic retrograde cholangiopancreatography (ERCP) ranked the highest ($374 794) per claim. Internists had the highest number of total claims (n = 766) and total claim payment ($70 730 101). Only total claim payments for colonoscopy and ERCP seem to have increased over time. Indeed, there was an average increase of 15.5% per year for colonoscopy and 21.9% per year for ERCP after adjusting for inflation. CONCLUSION: There appear to be differences in malpractice coverage costs among specialties and the type of endoscopic procedure. There is also evidence for secular trend in total claim payments, with colonoscopy and ERCP costs rising yearly even after adjusting for inflation.

可疑胆道疾病:高空间分辨率各向同性三维T2加权MRCP的诊断性能

目的 采用高空间分辨率各向同性三维（3D）快速恢复快速自旋回波（FSE）序列及并行采集磁共振胆胰管成像（MRCP）回顾性评价可疑胆道疾病的诊断性能。材料和方法 本研究遵从HIPAA并经研究机构审查委员会同意．免除知情同意。95例病人[58例女性，37例男性，平均年龄51岁（15～91岁）]于2003年3月—2007年6月接受了呼吸门控各向同性三维快速恢复FSE序列的MRCP检查并进行了经内镜或经皮穿刺的直接胆管造影。

Transient Hypertensive Response to CO₂Aortography in a Patient with Pheochromocytoma

We report on a 15-year-old male with 4-year history of hypertension and retroperitoneal masses referred to Interventional Radiology to evaluate the nature of the persistent masses and renal artery stenosis. Angiographic evaluation began with CO2aortogram during which the patient had a hypertensive response with bradycardia and arrhythmia to the intra-aortic injection of CO2. His hypertension, bradycardia, and arrhythmia responded to an intravenous nitroglycerin drip without administration of alpha or beta blockers. Due to this response and neovascularity of the mass, selective venous sampling of catecholamines and renin was performed which confirmed functioning paragangliomas and hemodynamically significant stenosis of left accessory renal artery, respectively. This is the first known case of hypertensive response to CO2 aortography in a patient with unsuspected functioning paragangliomas. We propose that patients with known or suspected diagnosis of catecholamine-secreting tumors undergoing CO2 angiography should be considered for pre-procedural treatment with alpha and beta blockage or have the appropriate medication on hand with close monitoring in the event of hypertensive response.

术前腋窝超声检查能否排除N_2和N_3期转移性乳腺癌?

目的确定初诊乳腺癌病人N2和N3期转移的腋窝超声检查假阴性率。材料与方法本研究经机构审查委员会批准并符合HIPAA法案,同时获得病人知情同意。