Comparative hospital economics and patient presentation: vertebroplasty and kyphoplasty for the treatment of vertebral compression fracture.

BACKGROUND AND PURPOSE: Previous studies evaluating vertebral augmentation procedure costs have not made detailed comparisons between vertebroplasty and kyphoplasty. Our study contrasts hospital costs for vertebroplasty versus kyphoplasty for the treatment of vertebral compression fractures in routine clinical practice in the United States. MATERIALS AND METHODS: This retrospective cohort study analyzed 2007-2008 hospital discharge and billing records from the Premier Perspective data base. The primary outcome variable, differences in total hospital cost between vertebroplasty and kyphoplasty, was assessed by using analysis of covariance. RESULTS: Three thousand six hundred seventeen patients received vertebroplasty (64% inpatient, 36% outpatient), and 8118 received kyphoplasty (54% inpatient, 46% outpatient). Approximately 75% were women, and most were white. Mean total unadjusted inpatient costs were $9837 for vertebroplasty versus $13 187 for kyphoplasty (P < .0001). Outpatient vertebroplasty costs were $3319 versus $8100 for kyphoplasty (P < .0001). Lower vertebroplasty costs were largely due to differences in hospital supply and OR. Mean vertebroplasty OR costs were $73.60 (anesthesia), $112.06 (recovery room), and $990.12 (surgery) versus $172.16 (anesthesia), $257.47 (recovery room), and $1,471.49 (surgery) with kyphoplasty. Adjustments for age, sex, admission status, and disease severity accentuated the differences. Mean adjusted inpatient costs were $11 386 for vertebroplasty versus $16 182 for kyphoplasty (P < .0001), and outpatient costs were $2997 for vertebroplasty versus $7010 for kyphoplasty (P < .0001). After adjustments for the same covariates, length-of-stay differences were no longer evident (P = .4945). CONCLUSIONS: Performing vertebroplasty versus kyphoplasty reduces hospital costs by nearly $5000 for inpatient procedures and by more than $4000 for outpatient procedures.

The genetics of hydatidiform moles: new lights on an ancient disease.

Hydatidiform mole (HM) is a human pregnancy with no embryo but cystic degeneration of chorionic villi. The common form of this condition occurs in 1 in every 1500 pregnancies in western societies and at a higher incidence in some geographic regions and populations. Recurrent moles account for 2% of all molar cases and a few of them occur in more than one family member. By studying a familial form of recurrent moles, a recessive maternal locus responsible for this condition was mapped to 19q13.4 and causative mutations identified. The defective protein, NALP7, is part of the CATERPILLAR protein family with roles in pathogen-induced inflammation and apoptosis. The exact role of NALP7 in the pathophysiology of molar pregnancies is unknown yet. NALP7 could have a role either in oogenesis or in the endometrium during trophoblast invasion and decidualization. In this review, we outlined recent advances in the field of HMs and reviewed the literature in the light of the new data.

Erythropoietin receptor expression in biopsy specimens from patients with uterine cervix squamous cell carcinoma.

Hypoxia, an important mechanism of radioresistance, is a strong stimulus for erythropoietin (EPO) production. The stimulatory effects of EPO are mediated through the activation of its receptors, EPO receptors (EPORs). The objective of this study is to determine whether EPORs are expressed in biopsy specimens of patients with squamous cell carcinoma of the cervix. Eighteen biopsy specimens were studied after obtaining Institutional Review Board-approved consent. Standard immunohistochemistry techniques were utilized. Expression of EPORs was present in 16 out of 18 (88.9%) specimens. The intensity (qualitative) and the frequency (semiquantitative) of EPORs expression showed a statistically significant correlation (P= 0.00379). Statistical analysis was performed to determine whether EPORs expression is related to other parameters such as age, FIGO stage, histologic grade, and hemoglobin levels. Only age showed a statistically significant correlation with EPORs frequency of expression (P= 0.00878). Currently, work is in progress in our laboratory to study the radiobiologic effects of EPO on the radiation response of cultured cancer cell lines in vitro.

Systemic amyloidosis involving the diaphragm and acute massive hydrothorax during peritoneal dialysis.

Hydrothorax secondary to trans-diaphragmatic fluid leakage through a peritoneo-pleural communication is an occasional, potentially serious complication of peritoneal dialysis. The etiology of this condition is not clear, being thought to be due either to congenital or acquired diaphragmatic fenestrations or acquired scarcity of muscle fibers in the tendinous part of the diaphragm which are compounded by increased intra-abdominal pressure during the dwell period of peritoneal dialysis. We report a 54-year-old woman who developed irreversible acute renal failure from adjuvant chemotherapy for ovarian cancer previously resected surgically. Three days after the onset of continuous ambulatory peritoneal dialysis, she developed acute respiratory distress associated with a massive right hydrothorax secondary to a peritoneo-pleural communication demonstrated by scintigraphy. At autopsy 2 weeks later, systemic amyloidosis was surprisingly found and histologic examination of the right hemidiaphragm showed the presence of amyloid, among sparse muscle fibers. This is the first case report of a distinct pathological process, i.e. amyloidosis, involving the diaphragm associated with a peritoneo-pleural communication causing massive hydrothorax at the onset of peritoneal dialysis.

Adenomyosis: US features with histologic correlation in an in-vitro study.

PURPOSE: To evaluate the accuracy of ultrasonographic (US) features of adenomyosis by correlating them with histologic findings and to assess inter- and intraobserver agreement. MATERIALS AND METHODS: US was performed and videotaped in 102 consecutive hysterectomy specimens in a water bath. Videotapes were reviewed initially by two independent radiologists blinded to the clinical and histologic findings and after 1 month by one of the two; US and histologic findings were correlated. Features evaluated included diffuse abnormal echotexture of myometrium, subendometrial myometrial cysts, subendometrial echogenic nodules, subendometrial echogenic linear striations, nodular endometrial-myometrial junction, poor definition of the endometrial-myometrial junction, asymmetric thickness of the anteroposterior wall of the myometrium, and globular configuration. RESULTS: The prevalence of adenomyosis in this cohort was 29.4% (30 of 102 specimens). The mean sensitivity, specificity, negative predictive value, positive predictive value (PPV), and accuracy for the diagnosis of adenomyosis for the three reviews were 81%, 71%, 90%, 54%, and 74%, respectively. All findings evaluated, except for nodular endometrial-myometrial junction, were significantly more common in uteri with adenomyosis (P <.05). Heterogeneous myometrium reached borderline significance (P =.05). The specificities and PPVs of subendometrial striations, subendometrial echogenic nodules, and asymmetric myometrial thickness were significantly higher than those of other features (P <.05). The interobserver agreement was moderate (kappa = 0.48), and the intraobserver agreement was good (kappa = 0. 67) for the three reviews. CONCLUSION: The presence of subendometrial linear striations, subendometrial echogenic nodules, or asymmetric myometrial thickness improves the specificity and PPV of US in diagnosing adenomyosis.

Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation.

Uterine adenomyosis is a common gynecologic condition that is characterized by the presence of heterotopic endometrial glands and stroma in the myometrium with adjacent smooth muscle hyperplasia. The histopathologic features of adenomyosis are varied and contribute to its imaging appearance. The accompanying smooth muscle hyperplasia produces the typical gross appearance of adenomyosis and corresponds to areas of decreased echogenicity at endovaginal ultrasonography (US) and areas of decreased signal intensity at magnetic resonance (MR) imaging. Endovaginal US also shows heterogeneity of the myometrial echotexture, which corresponds to small echogenic islands of heterotopic endometrial tissue surrounded by the hypoechoic smooth muscle. On T2-weighted MR images, bright foci are seen in areas of abnormal low signal intensity within the myometrium in approximately 50% of patients. These foci correspond to islands of heterotopic endometrial tissue, cystic dilatation of heterotopic glands, or hemorrhagic foci. With the advent of high-resolution imaging techniques, signs associated with the presence of heterotopic endometrial tissue are being detected with increasing frequency. These signs include myometrial cysts, myometrial nodules, linear striations, pseudowidening of the endometrium, and poor definition of the endomyometrial junction. Pitfalls in diagnosis of uterine adenomyosis include leiomyoma, endometrial carcinoma, myometrial contractions, and muscular hypertrophy.

Diffuse adenomyosis: comparison of endovaginal US and MR imaging with histopathologic correlation.

PURPOSE: To compare the accuracy of endovaginal ultrasound (US) and magnetic resonance (MR) imaging in the diagnosis of adenomyosis. MATERIALS AND METHODS: The authors prospectively studied 119 consecutive patients undergoing hysterectomy. The endovaginal US scans and MR images were interpreted independently in a double-blind fashion. Imaging findings were compared with those at histopathologic examination. RESULTS: At histopathologic examination, adenomyosis was found in 28 of the 119 patients (24%). Sensitivity and specificity was 89% for endovaginal US and 89% for MR imaging. The positive predictive value was 71% for US and 65% for MR imaging. The negative predictive value was 96% for US and 95% for MR imaging. There was no statistically significant difference between the sensitivities (P = .65) and specificities (P = .75) of endovaginal US and MR imaging. The mean junctional zone (JZ) thickness on MR images in patients with and without proved adenomyosis was 15.0 mm +/- 4.9 and 7.7 mm +/- 3.3, respectively (P < .0001). When receiver operating characteristic curves were applied retrospectively, the optimal JZ value for the diagnosis of adenomyosis with MR imaging was > or = 12 mm. CONCLUSION: Endovaginal US was as accurate as MR imaging in the diagnosis of uterine adenomyosis. Use of a JZ thickness of > or= 12 mm should further optimize the diagnostic accuracy of MR imaging.

Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography.

PURPOSE: To determine the accuracy of endovaginal ultrasound (US) in the diagnosis of uterine adenomyosis and to evaluate the frequency of observed sonographic criteria. MATERIALS AND METHODS: Endovaginal US was performed in 100 consecutive women undergoing hysterectomy for a variety of benign and malignant conditions. Adenomyosis was diagnosed when a poorly defined area of abnormal echotexture (decreased or increased echogenicity, heterogeneous echotexture, myometrial cysts) was present in the myometrium. All endovaginal US findings were correlated with those from histologic examination. RESULTS: Endovaginal US depicted 25 of 29 pathologically proved cases of adenomyosis. Adenomyosis was correctly ruled out in 61 of 71 patients. Endovaginal US had a sensitivity of 86%, a specificity of 86%, and a positive and negative predictive value of 71% and 94%, respectively. Of the 25 patients with true-positive findings at US, the myometrium demonstrated heterogeneous and hypoechoic areas with or without the presence of cysts in 21 (84%) patients, hypoechoic areas with cysts in three (12%) patients, and heterogeneous areas within the myometrium in one (4%) patient. CONCLUSION: Adenomyosis of the uterus can be accurately diagnosed with endovaginal US with use of specific sonographic criteria.

Hypoechogenic embryologic ventral aspect of the head and uncinate process of the pancreas: in vitro correlation of US with histopathologic findings.

PURPOSE: To evaluate the hypothesis that hypoechogenicity of the embryologic ventral aspect of the head of the pancreas is due to diminished fat content. MATERIALS AND METHODS: Ultrasound and histopathologic findings in 13 pancreatic autopsy specimens were compared, and the prevalence of areas of hyperattenuation of the embryologic ventral aspect of the head of the pancreas at computed tomography (CT) was studied. RESULTS: In vitro examination of pancreatic autopsy specimens showed this variant in seven (54%) of the 13 specimens, and histopathologic correlation confirmed that there is diminished fat content corresponding to the hypoechoic portion of the head of the pancreas. This difference in attenuation was visible on 21 (22%) of 96 CT scans. There was a statistically significant (P < .05, r = .212) increase in the prevalence of this finding with increasing age. CONCLUSION: Hypoechogenicity of the embryologic ventral aspect of the head of the pancreas is due to diminished fat content. This difference in attenuation is also commonly seen on CT scans.

Metastatic patterns of bladder carcinoma.

The authors reviewed 227 new bladder cancers from two main hospitals in Beirut Lebanon. They analyzed the morphologic features of these tumours, insisting particularly on the number, the size, the site, the grade, the stage, the mode of spread and the vascular permeation. The latter four factors appear to be directly related to the metastatic spread of these tumours. The metastatic patterns are summarized, regional lymph node metastases being the main problem because of therapeutic implications (radical surgery, radiotherapy and chemotherapy). The problems of generalized carcinoma, unusual lymph node metastases and solitary distant metastases are also considered.

Extraskeletal myxoid chondrosarcoma with "chordoid" features (chordoid sarcoma).

The light and electron microscopic features of a so-called chordoid sarcoma arising in the area of the gastrocolic ligament are described and illustrated. Despite the tumor's histologic resemblance to chordoma, the ultrastructural markers are those of chondroid rather than chordoid neoplasms. These are well-developed, vesciular granular endoplasmic reticulum, intracytoplasmic glycogen, lipid bodies, and a collagen-poor extracellular matrix with electron-dense granules, presumably representing chondroitin sulfate. Similar submicroscopic alterations have been observed in extraskeletal myxoid chondrosarcomas. Because of the distinctive morphologic appearance of this peculiar lesion, the term "myxoid chondrosarcoma with chordoid features" is suggested to reconcile histologic and ultrastructural features and histogenesis.