Anaesthetic considerations for elective cesarean section in a patient with a giant Tarlov cyst.

Tarlov cysts are a pathological dilatation of the meninges. Their incidence is more frequent in women between 30 and 50 years of age. The imaging test of choice for diagnosis is MRI. Of unknown etiology, most cases are asymptomatic, but symptoms of radicular irritation, among others, may occur. The therapeutic possibilities are multiple, reserving surgical excision as the last option. We report a case of successful spinal anaesthesia for elective cesarean section in a patient with a giant Tarlov cyst but with potential airway compromise, in whom the risks of general anaesthesia would be increased. Anaesthetic management presents a challenge for the anesthesiologist, especially in situations where the patient presents an increased anaesthetic risk for general anaesthesia, as is the case in the obstetric patient.

Monitoring intraoperative neuromuscular blockade and blood pressure with one device (TOF-Cuff): A comparative study with mechanomyography and invasive blood pressure. / Monitorización intraoperatoria del bloqueo neuromuscular y la presión arterial con un solo dispositivo (TOF-Cuff): estudio comparativo con la mecanomiografía y la presión arterial invasiva.

OBJECTIVE: The overall objective of the study is to determine the ability of TOF-Cuff device (blood-pressure modified cuff, including stimulation electrodes) to monitor with the same device the non-invasive blood pressure (NIBP) and the depth of a neuromuscular blockade (NMB) induced pharmacologically, by stimulation of the brachial plexus at the humeral level and recording evoked changes in arterial pressure. MATERIAL AND METHOD: Clinical, single-centre, open-controlled study with 32 adult patients ASA I-III for scheduled elective surgery under general anaesthesia in supine position, for the validation of neuromuscular monitoring, comparing the values obtained from neuromuscular relaxation TOF-Cuff with those obtained by mechanomyography (MMG) (control method) during the recovery phase of NMB, when a TOF ratio>0.7 and>0.9 (primary endpoint) were reached respectively. And an additional consecutive study of 17 patients for validation of NIBP monitoring with TOF-Cuff device vs invasive blood pressure measured by an intra-arterial catheter. All data were analyzed using the Bland-Altman method. RESULTS: Recovery from NMB measured with the TOF-Cuff was earlier compared to MMG. Comparing TOF-ratio>0.9 measured with TOF-Cuff vs TOF-ratio>0.7 with MMG, a specificity of 91% and a positive predictive value of 84% were obtained. In NIBP measurement, the mean error and standard deviation of both systolic blood pressure (1.6±7mmHg) and diastolic blood pressure (-3.4±6.3) were within the European accuracy requirements for medical devices. CONCLUSIONS: The TOF-Cuff device has been shown to be valid and safe in the monitoring of NMB and in the measurement of NIBP, with no patient presenting any adverse events, skin-level lesions or residual pain. It is not interchangeable with MMG, having a TOF-ratio>0.9 quantified by the TOF-Cuff device, a good correlation with a TOF-ratio>0.7 on MMG.

A case series of the use of the ProSeal laryngeal mask airway in emergency lower abdominal surgery.

The ProSeal laryngeal mask airway (PLMA) has been used routinely for anaesthesia and for difficult airway management including airway rescue in non-fasted patients. Compared with the classic laryngeal mask airway the PLMA increases protection against gastric inflation and pulmonary aspiration, by separating the respiratory and gastro-intestinal tracts. The PLMA has potential advantages over use of the tracheal tube including smoother recovery, reduced pharyngolaryngeal morbidity and even reduced postoperative pain. We report a series of patients scheduled for emergency appendicectomy, without other risk factors for regurgitation, managed with the PLMA. Anaesthesia was induced and maintained with remifentanil, target controlled propofol and rocuronium. A series of 102 cases were managed without complications and high rates of first time placement of the PLMA (inserted over a suction tube placed in the oesophagus). With careful patient selection the PLMA may offer an alternative airway for use by experienced anaesthetists in patients undergoing minor lower abdominal surgery.

On the utility of fine-needle aspiration in the diagnosis of primary scalp lesions.

A study of the clinico-cytologic findings of 62 primary palpable lesions located in the scalp is reported. Trichilemmal cyst (16 cases) followed by lipoma (8 cases) and benign melanocytic proliferation (4 cases) were the most frequent benign conditions (n = 45); basal-cell carcinoma (6 cases) and squamous-cell carcinoma (5 cases) were the most frequently aspirated malignant tumors (n = 17). In the cytologic category of benign lesions (n = 45), cytohistologic correlation was carried out in 19 cases and the cytohistologic agreement was 100%, except for the three actinic keratosis cases that were diagnosed as atypical epidermal lesions. Cytohistologic agreement was 100% in the 16 malignant lesions in which excisional biopsy was performed. Based on the findings reported here, fine-needle aspiration is indicated as the first-choice technique for the clinical evaluation of primary scalp lesions. Experience with cutaneous cytopathology is essential in order to be able to carry out this task.

On the utility and limitations of fine-needle aspiration of palpable lesions located in the hand.

Various types of superficial and deep-seated lesions may occur in the hand, causing concern to the patient and posing diagnostic dilemmas to the clinician. A study was undertaken to evaluate the utility of fine-needle aspiration (FNA) or scraping for the diagnosis of palpable lesions located in the hand. From a clinico-cytologic point of view, lesions were classified as superficial (n = 41) or deep-seated (n = 66), and aspirates were categorized into five groups: benign without specific cytohistologic diagnosis, benign with specific cytohistologic diagnosis, atypical, malignant without specific cytohistologic diagnosis, and malignant with specific cytohistologic diagnosis. Out of 107 cases with aspirates adequate for cytologic evaluation, 85 had histologic correlation; in 22 cases, histologic confirmation was deemed unnecessary because of unequivocal cytologic findings and/or clinical workup. Sensitivity was 90.9%, specificity 100%, and efficacy 98%. Based on these findings, we believe that FNA or scraping may help in the clinical workup of patients with either superficial or deep-seated lesions located in this anatomic region.

On the limited value of fine-needle aspiration for the diagnosis of benign melanocytic proliferations of the skin.

This a retrospective study of 39 patients with pigmented cutaneous lesions with a subsequent histologic diagnosis of melanocytic neoplasia. The most important cytologic features seen in the fine-needle aspirates were assessed in the 26 cases deemed satisfactory for evaluation. Though cytology, along with essential clinical data, could enable a general diagnosis of melanocytic lesion and could differentiate it from other nonmelanocytic pigmented lesions, cytology could not provide a precise diagnosis of the different histologic types of benign melanocytic nevi, nor could it enable their differentiation from dysplastic melanocytic nevi or incipient malignant melanoma.

Basal-cell carcinoma: cytologic and immunocytochemical findings in fine-needle aspirates.

The smears of fine-needle aspirates corresponding to 137 histologically proven basal-cell carcinomas (BCCs) were reviewed. Satisfactory for evaluation were 127 smears; the remaining 10 were unsatisfactory. In 124 cases (97.6%), the cytologic diagnoses coincided with the histologic ones. The remaining 3 were false negatives, and the subsequent histologic correlation demonstrated superficial BCC missed by the needle. The cytologic criteria that permitted a diagnosis of BCC were: variable-sized and irregular-shaped cohesive epithelial clusters, round to oval monomorphic nuclei, bland chromatin pattern, and sparse cytoplasm. In 35 cases, a panel of antibodies was used in the smears and in the respective histologic sections. Epithelial clusters of BCC showed an intense and diffuse positivity for AE-3 and BerEP4, while UEAI and AE-1 were negative. Although HMB45 and S100-A tested negative in the epithelial clusters, a faint and sparse focal positivity for HMB45 and S-100A was seen in some clusters. This positivity is believed to correspond to just a few normal melanocytes and Langerhans cells trapped in the neoplastic epithelial clusters. In the histologic correlates, the same results were obtained, although HMB45 positivity was more conspicuous at the periphery of the neoplastic nests.

Utility of fine-needle aspiration in the diagnosis of panniculitis.

This is a retrospective reassessment of the most important cytopathologic features of 23 FNA smears with a cytologic diagnosis of panniculitis (PN). Patients were sent by clinicians. Clinical diagnoses were as follows: 16 suspicious of PN; three cutaneous metastases of an extracutaneous primary neoplasm; four with no clinical diagnosis. Thirteen cases were subsequently submitted to histopathologic study. The following cytoarchitectural patterns were found to be very useful for the cytologic diagnosis of PN: adipocytes intermingled with foamy histiocytes, donut-like granulomas, aggregates of adipocytes intermingled with plump histiocytes, a granular basophilic background forming a lattice-like pattern, and well-formed granulomas with or without multinucleated giant cells. Inflammatory cells could be seen combined with any of these cytoarchitectural patterns. FNA does not pretend to replace excisional biopsy as the diagnostic procedure for these entities but it is a very useful diagnostic tool in certain cases: for confirming the recurrence of PN previously diagnosed by histology, for evaluating the onset of subcutaneous nodules in patients with a non-cutaneous malignant primary neoplasm, for evaluating cutaneous nodules with no clinical suspicion, and for confirming a clinical diagnosis of PN and differentiating it from other entities that mimic PN clinically.

Ocular melanoma: an experimental model in New Zealand white rabbits.

An experimental model is suggested for reproducing ocular melanoma in New Zealand white rabbits using B16 melanoma cells and protocols differing with respect to either tumour origin (subcutaneous fragments of melanoma B16 or B16-F10 tumour cell cultures) or implant site (the anterior chamber or subchoroidal). In 20 animals, 20 mg of methylprednisolone acetate was injected subconjunctivally as a local immunosuppressant. The only protocol resulting in tumour was inoculation of 4 x 10(6) B16-F10 melanocytes into the anterior chamber of the eye. Trans-scleral injections of cell suspensions produced tumour growth in 43% (13/30) of animals so treated. Thirteen animals developed non-neoplastic pigmented lesions formed of numerous melanophages. Another 19 animals showed non-pigmented lesions caused by reaction to the surgical procedures. Subconjunctivally injected methylprednisolone acetate did not increase the incidence of tumour growth.

Infantile cutaneous rhabdomyosarcoma (Li-Fraumeni syndrome): cytological presentation of fine-needle aspirate biopsy, report of a case.

We describe the cytopathological picture of a cutaneous rhabdomyosarcoma located in the left nasal furrow of a 4-mo-old girl, some of whose close relatives have died or suffered from different types of neoplasias (Li-Fraumeni syndrome). We believe that the cytological picture is highly characteristic and rules out other round cell tumours of childhood. We underline the usefulness of FNAC in dermatology and strongly advocate the introduction of this technique into the diagnostic armoury of every dermatologist.

Fine needle aspiration cytology of cutaneous vascular tumours.

We have studied 12 cutaneous vascular tumours by means of fine-needle aspiration cytology (FNAC): six capillary haemangiomas, one cavernous haemangioma, one Masson's pseudo-angiosarcoma, two angiosarcomas, one benign haemangioendothelioma and one glomus tumour. We describe the main cytopathological findings and we discuss the differential diagnosis in each case. We consider that the cytopathological findings of the above lesions, evaluated in the context of the clinical findings, are sufficiently characteristic for us to be able to make a definitive diagnosis. We believe that FNAC can play an important part in the diagnosis and therapeutic planning of these tumours.