Accuracy and Adequacy of Computed Tomography-Guided Lung Biopsies: Experience From a Community Hospital.

CONTEXT: Small tissue biopsies obtained through minimally invasive methods have become the primary diagnostic tools for the pathologic characterization and testing of lung masses. In view of recent advances in targeted therapy for non-small cell lung carcinoma, and lung adenocarcinoma in particular, pathologists are now expected to thoroughly characterize lung lesions microscopically while making certain that enough tissue remains for potential molecular analysis if indicated. OBJECTIVE: To report our experience with computed tomography (CT)-guided lung needle biopsies with particular concentration on diagnostic yield, diagnostic accuracy, and adequacy of tissue for molecular testing if indicated. METHODS: A retrospective observational study analyzed 224 biopsies in 222 patients undergoing CT-guided lung needle biopsies. Accuracy of diagnosis and adequacy of tissue for molecular testing, if applicable, was evaluated. A standardized protocol for specimen evaluation, triage, and processing was used. This protocol included intraprocedural real-time microscopic specimen evaluation and triage by a pathologist and use of a histologic protocol specifically designed to conserve tissue for ancillary testing. The initial biopsy was considered successful if the specimen was malignant, had specific benign features, or had nonspecific benign features with follow-up supporting benign lesion. Initial biopsy failure cases were those with inadequate tissue or a nonspecific result with highly suspicious imaging or clinical findings. RESULTS: Of the 224 biopsies, 8 cases with benign but nonspecific findings lacked follow-up and were excluded from the study. The biopsy was diagnostically successful in 189 of 216 (88%) cases. Of these 189 cases, 154 (81%) were malignant, and 35 (19%) were benign. There were 28 diagnostic failures. Subsequent tissue sampling of 13 of 28 diagnostic failures found 9 (69%) to be malignant. Molecular studies were requested on 25 cases: 24 had sufficient material for some of the requested tests, and 20 had enough tissue for all requested testing. CONCLUSION: A standardized protocol and team approach for CT-guided lung needle biopsy optimizes the ability to achieve a high accurate diagnostic yield with adequate tissue for molecular testing.

Spica casting compared to Bryant's traction after complete primary repair of exstrophy: safe and effective in a longitudinal cohort study.

PURPOSE: Bryant's traction is the most commonly used method for immobilization after bladder exstrophy repair. We hypothesized that spica casting is a safe and effective alternative to Bryant's traction after complete primary repair of exstrophy. MATERIALS AND METHODS: Complete primary repair of exstrophy was performed for initial repair in 39 consecutive children by all surgeons at Seattle Children's Hospital since 1998. Three sequential cohorts were evaluated-Bryant's traction without osteotomy (13 patients), spica casting without osteotomy (14) and spica casting with osteotomy. These 3 sequential cohorts represent eras of care and an evolution of practice. Primary outcomes included major complications related to immobilization, dehiscence, urinary incontinence and length of stay. We defined complications of immobilization as nonunion of pelvic osteotomy, femoral nerve palsy, revision of spica cast requiring return to the operating room, infection at the osteotomy site and activity limiting pain at the osteotomy site. Fisher's exact test or t test was used to determine statistical significance. RESULTS: There was no difference in urinary continence (p = 0.09). Use of Bryant's traction was associated with double the length of stay (p >0.001). There was no correlation of major complications to the type of immobilization used. CONCLUSIONS: Spica casting compared to Bryant's traction is associated with shorter hospitalization following complete primary repair of exstrophy and does not have a significant difference in the rate of complications. In our longitudinal cohort study with long-term followup spica cast was safe and effective for patients with bladder exstrophy, and should be considered an acceptable method of immobilization.

Augmentation cystoplasty rates at children's hospitals in the United States: a pediatric health information system database study.

PURPOSE: We identified augmentation cystoplasty rates in children with spina bifida at children's hospitals enrolled in the Pediatric Health Information System database. MATERIALS AND METHODS: The Pediatric Health Information System database tabulates demographic and diagnostic patient data from 35 children's hospital centers in the United States. Between October 1999 and September 2004 we extracted data on 0 to 19-year-old patients with International Classification of Diseases-9 diagnosis codes for spina bifida. The International Classification of Diseases-9 procedure code for augmentation cystoplasty was cross-referenced with these patients to determine the total number of patients with augmentation, total population augmentation rates and individual institution rates of bladder augmentation. RESULTS: Staff at enrolled pediatric medical centers submitted inpatient data accounting for 9,059 beds servicing an aggregate metropolitan population of 82 million individuals. In the 5-year period 12,925 unique spina bifida patient encounters were identified, including 665 patients who underwent augmentation cystoplasty. The mean 5-year institutional number of augmentations performed in children with spina bifida was 20 (range 1 to 121) and the mean annual number of augmentations performed per institution was 4. The overall augmentation rate at 33 hospitals contributing data for the full years 2000 to 2003 was 5.4% (range 0.5% to 16.3%, p <0.0001). The male-to-female ratio of those who underwent augmentation was 1:1.2. Median length of stay in children with augmentation was 7 days (mean 9). The median age of children with augmentation was 10.4 years, that is 11.3 years in boys and 9.8 years in girls. The difference in mean age was statistically significant (p <0.003). At institutions where 10 or more augmentations were performed in 5 years (mean 27) mean patient age at operation was 10.1 years. This was significantly younger than the mean patient age of 12.3 years at hospitals where fewer than 10 augmentations (mean 5) were done in 5 years (p <0.05). CONCLUSIONS: Clinical management for neurogenic bladder conditions has evolved to emphasize nonoperative management. Several studies suggest that aggressive early intervention improves bladder compliance and may protect renal function. However, results from the Pediatric Health Information System database demonstrate no change in augmentation rates during this time and they demonstrate significant interinstitutional variability. To our knowledge this represents the largest series of augmentation cystoplasty in children with spina bifida to date.

The evolution of vesicoureteral reflux management in the era of dextranomer/hyaluronic acid copolymer: a pediatric health information system database study.

PURPOSE: Since Food and Drug Administration approval of Deflux, injection therapy for vesicoureteral reflux has increased. Little data exist on the effect that injection therapy has had on the incidence of ureteral reimplantation and total vesicoureteral reflux procedures. We used the Pediatric Health Information System database to define practice trends for vesicoureteral reflux therapy. MATERIALS AND METHODS: From 2002 to 2004 we extracted data on 0 to 19-year-old patients with International Classification of Diseases-9 diagnosis codes for vesicoureteral reflux, and procedure codes for ureteral reimplantation and subureteral injection therapy. Of 37 hospitals enrolled in Pediatric Health Information System 18 submitted ambulatory surgery and inpatient data. Data on the total number of patients who underwent reimplantation and injection were analyzed using linear regression analysis for trend. RESULTS: We identified a total of 4,570 procedures performed in 1,948 patients treated with injection therapy and in 2,483 treated with reimplantation. The mean number of injections per institution yearly increased from 17 to 66 from 2002 to 2004 or 288%, while the mean number of reimplantations yearly was not statistically different from 2002 to 2004 (p = 0.02 and 0.09, respectively). In addition, the annual mean number of vesicoureteral reflux procedures per institution increased from 75 to 116 or 55% (p <0.05), primarily due to the increased number of injections. CONCLUSIONS: With the introduction of a new, minimally invasive procedure for reflux therapy the number of procedures for reflux has increased, while open surgery rates have remained stable. This may be explained by public and clinician acceptance of a newer injection material that is safe and increasingly successful. To our knowledge this represents the largest series of patients treated for vesicoureteral reflux in the United States.