Usefulness of standard plasma coagulation tests in the management of perioperative coagulopathic bleeding: is there any evidence?

Standard laboratory coagulation tests (SLTs) such as prothrombin time/international normalized ratio or partial thromboplastin time are frequently used to assess coagulopathy and to guide haemostatic interventions. However, this has been challenged by numerous reports, including the current European guidelines for perioperative bleeding management, which question the utility and reliability of SLTs in this setting. Furthermore, the arbitrary definition of coagulopathy (i.e. SLTs are prolonged by more than 1.5-fold) has been questioned. The present study aims to review the evidence for the usefulness of SLTs to assess coagulopathy and to guide bleeding management in the perioperative and massive bleeding setting. Medline was searched for investigations using results of SLTs as a means to determine coagulopathy or to guide bleeding management, and the outcomes (i.e. blood loss, transfusion requirements, mortality) were reported. A total of 11 guidelines for management of massive bleeding or perioperative bleeding and 64 studies investigating the usefulness of SLTs in this setting were identified and were included for final data synthesis. Referenced evidence for the usefulness of SLTs was found in only three prospective trials, investigating a total of 108 patients (whereby microvascular bleeding was a rare finding). Furthermore, no data from randomized controlled trials support the use of SLTs. In contrast, numerous investigations have challenged the reliability of SLTs to assess coagulopathy or guide bleeding management. There is actually no sound evidence from well-designed studies that confirm the usefulness of SLTs for diagnosis of coagulopathy or to guide haemostatic therapy.

Achievement of immune tolerance in a patient with haemophilia B and inhibitory antibodies, complicated by an anaphylactoid reaction.

We describe a young boy with severe haemophilia B who developed inhibitory antibodies and an anaphylactoid reaction to factor IX. Immune tolerance was achieved by desensitisation with escalating doses of factor IX followed by the Malmö regimen.

Cystic renal masses: accurate Bosniak classification requires adequate renal CT.

OBJECTIVE: The objective of this study was to assess the practical usefulness of the Bosniak classification system for separating surgical from nonsurgical cystic renal masses in a large number of patients examined with properly performed renal CT. The study included only patients whose scans were technically adequate to allow proper assignment of the lesion to a category. MATERIALS AND METHODS: The scans of 109 patients were gathered from two large teaching institutions both prospectively and retrospectively, yielding a total of 116 analyzable renal cystic lesions. Eighty-two masses were resected from 77 of these patients, retrospectively categorized by two experienced uroradiologists using the Bosniak classification system, and correlated with pathology reports. A second group of 34 lesions in 32 patients with atypical cysts was followed up prospectively for periods ranging from 3 months to 10 years. RESULTS: The results were similar for the two institutions: 15 resected categories I and II lesions were correctly identified as benign, and all 18 category IV lesions were malignant. Twenty-nine (59%) of 49 pooled category III masses were malignant. No malignancies have been identified in the prospectively monitored group of patients. CONCLUSION: Our results are compared with earlier, smaller series and support those that show that the Bosniak classification system is useful in separating lesions requiring surgery from those that can be safely followed up, provided proper CT techniques are used.

Diagnosis of chronic ectopic gestation by hysterosalpingography.

Pelvic ultrasound and human chorionic gonadotropin assays are currently the standard methodology to detect tubal pregnancy. We report a case of infertility investigated by hysterosalpingography in which a clinically unsuspected chronic tubal pregnancy was identified with the predisposing factor of bilateral salpingitis isthmica nodosa. The radiographic findings of this very rare cause of tubal filling defect are shown.

Radiologic evaluation of small and indeterminant renal masses.

A common problem in radiologic and urologic practice today is what to do with the small or indeterminant renal mass. Whether found incidentally or sought after because of patient symptomatology, these lesions present a challenge in diagnosis and management. This article outlines the scope of the problem, illustrates representative lesions, suggests imaging and management strategies culled from personal experience, and provides a review of available literature.

Ectopic adrenal myelolipoma presenting as a splenic mass.

Myelolipoma is a benign tumor composed of mature adipose tissue and hematopoietic elements. Although they are most commonly found in the adrenal glands, extra-adrenal myelolipomas are well documented. We describe a case of myelolipoma arising within or adjacent to the spleen of a patient with sickle cell disease. This encapsulated tumor contained myeloid and adipose components, as well as clear cells resembling adrenal cortical tissue. Although ectopic adrenal tissue has not been reported in the spleen, we feel that this is the most likely site of origin of this mass. To our knowledge, this is the first instance of this neoplasm presenting as a splenic mass. The possible pathogenesis and etiology of this unusual lesion is discussed.

Imaging cystic renal masses.

Determining whether a renal mass is benign or malignant usually is possible with proper use of imaging. A few lesions will defy classification without surgery.

Small renal masses (lesions smaller than 3 cm): imaging evaluation and management.

The current use of CT and sonography for a wide variety of indications has led to the frequent incidental discovery of small (1.5-3.0 cm) and very small (< 1.5 cm) lesions in the renal parenchyma. These lesions are usually small benign cysts, complicated cysts, or small neoplasms. Although the increased sophistication of imaging technology has certainly improved the detection of these lesions, a specific diagnosis can be elusive, and management is controversial. The question remains as to whether lesions that prove to be neoplasms warrant treatment or whether they are clinically insignificant and should be ignored. The radiologist plays a major role in making this decision. The purpose of this article is to review the literature regarding the etiology and imaging evaluation of small renal lesions and to make recommendations for their appropriate management.

Unilateral renal cystic disease in an adult.

Unilateral renal cystic disease (URCD) is a rare, nonfamilial, nonprogressive, unilateral cystic disorder of the kidney. Very few adults with this condition have been documented [1-4]. We describe a case with a 30 year radiologic follow-up. Absence of a family history of cystic renal disease, benign clinical course through adulthood, and limitation of the process to one kidney distinguish this condition from asymmetric autosomal dominant polycystic kidney disease (ADPKD).

Cystic pheochromocytoma: radiologic diagnosis.

Cystic pheochromocytomas are unusual variants of adrenal pheochromocytomas. Computed tomography and pathologic findings in the two cases reported here illustrate three cardinal principles in the diagnosis of cystic pheochromocytomas: (1) A suprarenal cystic tumor discovered on CT may be the result of hemorrhage and necrosis of an adrenal pheochromocytoma. (2) The cystic pheochromocytoma typically exhibits areas of low attenuation, with Hounsfield units in the range of 5 to 15 and rim enhancement on contrast administration. (3) Incidental adrenal lesions with these features discovered on CT scanning are an indication for catecholamine assays to screen for pheochromocytoma.

Isolated lymphoma of genitourinary tract and adrenals.

With the routine use of computed tomographic imaging, intrinsic involvement of the genitourinary tract in newly diagnosed non-Hodgkin's lymphoma is seen in as many as 10 percent of patients. Incidental discovery of an extranodal, extra-lymphatic lesion in the genitourinary tract without clinical or radiographic evidence of disease elsewhere, however, is an uncommon occurrence. The clinical presentation and imaging findings in 4 patients with initial manifestation of lymphoma isolated to the kidney, ureter, bladder, and adrenals, respectively, are presented. These patients had no evidence of lymphoma elsewhere, and imaging studies mimicked the more common neoplasms affecting these organs.

Renal cystic disease associated with orofaciodigital syndrome.

Three families affected by the rare genetic disorder orofaciodigital syndrome, type I (OFD-1) were screened by computed tomography (CT) to determine the presence of cysts in the kidneys and liver, an association known to occur but not previously described in the radiologic literature. Renal cystic changes in four females with oral, facial, and digital malformations were variable and not distinguishable from other inherited cystic kidney diseases. One patient had biliary ectasia and hepatic cysts. "Polycystic" kidneys occurring only in female members of a family should suggest OFD-1, an X-linked dominant disorder that is lethal in utero in males. Patients known to have the syndrome should be screened for cystic renal disease.