Fine-needle aspiration biopsy of liver masses: diagnostic value and reproducibility of cytological criteria.

There are many helpful cytological criteria for the diagnosis of liver fine-needle aspiration biopsies (FNABs), but none of them are pathognomonic of primary or metastatic tumors. We analyzed the diagnostic value and reproducibility of 28 cytological parameters in FNABs from 140 hepatic masses, including 29 benign lesions, 49 hepatocellular carcinomas (HCCs), and 62 metastatic tumors, encompassing 48 adenocarcinomas (ACAs). Five different observers evaluated each sample, and the interobserver and intraobserver agreement was studied. Multivariable analysis showed that the criteria more closely associated with malignancy were irregular nuclear contour, three-dimensional cell groups, and atypical naked nuclei. Capillaries separating tumor cells and granular cytoplasm were strongly associated with HCCs, while eccentrically placed nuclei and necrosis were most commonly seen in ACAs and in metastatic tumors. The intraobserver and interobserver agreement was excellent for the final cytological diagnosis, and there was fair to very good interobserver agreement for 22 of the 28 criteria studied. Architectural features were less reproducible than pure cytological criteria. Intraobserver variability was not influenced by the years of experience in the field. A precise and strict definition of terminology rendered a better reproducibility of the cytological criteria.

A comparative study of magnetic resonance cholangiography and direct cholangiography.

OBJECTIVE: Magnetic resonance cholangiopancreatography (MRCP) is a rapidly developing method for the noninvasive assessment of the biliary tree and pancreatic duct that obviates the need for contrast medium. We describe our experience with this new diagnostic imaging method in patients with obstruction of the biliary tree. We assessed both the location and cause of obstruction, and compared the results with direct cholangiography. METHODS: Between 1997 and 1998, 81 patients underwent MRCP at our facility. Two different image acquisition protocols (half-Fourier acquisition single-shot turbo spin-echo -HASTE- and rapid acquisition with relaxation enhancement -RARE-) for T2-weighted turbo spin echo sequences as well as cross-sectional fast multiplanar gradient-echo pulse (T1-weighted FL2D) and T2-weighted fast spin echo (T2 TSE) sequences were used. All patients underwent direct (either percutaneous or endoscopic retrograde) cholangiography or surgery for confirmation and/or treatment. The images obtained with MRCP were evaluated by two radiologists with expertise in biliary tree imaging who were unaware of the patient's clinical characteristics, and their diagnostic interpretations were compared with the findings obtained upon surgery or direct cholangiography. RESULTS: The sensitivity and specificity of MRCP in ruling out pathologies and detecting the presence of dilatation of the biliary tree were 100%. In assessing the level of the obstruction, sensitivity and specificity varied with location (intrahepatic/hilar, suprapancreatic, intrapancreatic or ampullary). Sensitivity in these locations was 100, 92, 69 and 86%, respectively, whereas specificity was 100, 94, 92 and 91%, respectively. In determining the cause of the obstruction, the results were variable depending on the cause: choledocholithiasis (sensitivity, 89%; specificity, 90%) malignant obstruction (sensitivity, 92%; specificity, 88%), benign stricture (sensitivity, 63%; specificity, 90%), and chronic pancreatitis (sensitivity, 50%; specificity, 99%). CONCLUSIONS: MRCP offered high diagnostic accuracy in the assessment of the occurrence and location of biliary obstruction. Sensitivity and specificity in establishing the cause varied, and were highest for choledocholithiasis and malignant obstruction. MRCP may be used instead of ERCP, which may then be reserved for patients who are likely to require surgery.

Accidental removal of endotracheal and nasogastric tubes and intravascular catheters.

OBJECTIVES: To characterize the rates of accidental removal of endotracheal tubes, nasogastric tubes, central venous catheters, and arterial catheters. To assess the efficacy of corrective measures aimed at reducing the accidental removal of these devices. DESIGN: Prospective, observational, and interventional study. SETTING: Eighteen-bed medical-surgical intensive care unit of a 650-bed tertiary care hospital. PATIENTS: Patients admitted to the intensive care unit who had any of the following devices in place for more than 24 hrs: endotracheal tube, nasogastric tube, central venous catheter, arterial catheter. MEASUREMENTS AND INTERVENTIONS: Data were collected on the date of placement of tubes and catheters, position of vascular catheters, date of removal, and reason for removal. The study involved three consecutive 6-month periods. At the end of the first and the second periods, information about rates of accidental removal was provided to the physicians and nurses. In addition, the personnel were instructed to be more vigilant and specific measures aimed at reducing the accidental removal were introduced. MAIN RESULTS: In the first period, 289 endotracheal tubes were placed and 13.1% (24.7 per 1000 days) were removed accidentally. In the second and third periods, 17.1% (25.5 per 1000 days) and 11.4% (15.1 per 1000 days) were removed accidentally, respectively. In the first period, 368 nasogastric tubes were placed and 41% (73.9 per 1000 days) were removed accidentally. In both the second and the third period, a significant reduction in the rate of accidental removal was observed (32.4% or 41.2 per 1000 days and 25.8% or 29.8 per 1000 days, respectively). A significant decrease was observed in the rates of accidental removal of central venous catheters from 7.5% (12.4 per 1000 days) in the first period to 3.6% (5.4 per 1000 days) in the second period. The rate of arterial catheters accidentally removed expressed according to the time at risk significantly decreased from 46.5 per 1000 days in the first period to 19.1 per 1000 days in the second period and 25.3 per 1000 days in the third period. CONCLUSIONS: The information provided by the rates of accidental removal expressed by patient-days is helpful to compare results obtained in populations with different times of follow-up. Education of medical personnel and limiting upper-extremity access to within 20 cm from any catheter or tube resulted in a significant reduction of patient-related removal of tubes and catheters.

[Reliability of routine cytological diagnosis in bladder cancer]. / Fiabilidad del diagnóstico citológico de rutina en el cáncer vesical.

OBJECTIVES: To establish the reliability of three cystopathologists for cytological diagnosis of primary bladder tumors. METHODS: Pre-operative voided urine specimens of 71 patients with bladder cancer and 55 healthy controls were retrospectively and blindly reviewed by 3 independent cytologists, and their results--positive for bladder cancer, negative or inconclusive--were compared with each other. The estimation of the interobserver agreement was calculated using the weighted kappa-coefficient (k). A multivariative analysis was carried out to identify the factors associated with the disagreement among the three observers. The sensitivity and specificity for each of the participants were calculated in order to clearly identify the origin of the disagreement, in terms of the performance of the diagnostic test in the hands of each observer. A comparison of the overall diagnostic performance was made by plotting sensitivity versus 1-specificity. RESULTS: The weighted k coefficient among observers was 0.46. The multivariative analysis did not identify any variable that could have caused such disagreement. Large differences in sensitivity and specificity were detected between observer number 1 (sens., 0.90, spec., 0.45) and observers number 2 (sens., 0.67, spec., 0.72) and number 3 (sens., 0.71, spec., 0.80), but the overall diagnostic performance (sensitivity vs 1-specificity) was superimposable in the three cases (p = ns). CONCLUSIONS: Simple, reproducible and agreed-on diagnostic criteria should be established to yield reliable results in a group of cytologists. The consideration of individual diagnostic performances can give a false idea of homogeneity between observers. In this field, concordance analysis makes quality control reliable and should be a routine procedure of any pathology department.

Reliability of the routine cytological diagnosis in bladder cancer.

OBJECTIVES: To establish the reliability of three cytopathologists for cytological diagnosis of primary bladder tumors. METHODS: Preoperative voided urine specimens of 71 patients with bladder cancer and 55 noncancer controls were retrospectively and blindly reviewed by 3 independent cytologists, and their results compared. The estimation of the interobserver agreement was calculated using the weighted kappa coefficient. A multivariate analysis was carried out to identify the factors associated with the disagreement between the three observers. The sensitivity and specificity for each of the participants was calculated in order to clearly identify the origin of the disagreement, in terms of the performance of the diagnostic test in the hands of each observer. A comparison of the overall diagnostic performance was made by plotting sensitivity versus 1-specificity. RESULTS: The weighted kappa coefficient among the 3 observers was 0.46. The multivariate analysis did not identify any variable that could have caused such disagreement. Vast differences in sensitivity and specificity were detected between observer 1 (sens. 0.90, spec. 0.45) and observers 2 (sens. 0.67, spec. 0.72) and 3 (sens. 0.71, spec. 0.80), but the overall diagnostic performance (sensitivity vs. 1-specificity) was superimposable in the 3 cases (p = NS). CONCLUSIONS: Simple, reproducible and agreed-on-diagnostic criteria should be established to yield reliable results in a group of cytologists. The consideration of individual diagnostic performances can give a false idea of homogeneity between observers. In this field, concordance analysis makes quality control reliable and should be a routine procedure of any pathology department.

Dose-related hemodynamic and renal effects of dopamine in septic shock.

offstudied hemodynamic and renal effects of increasing the dosage of dopamine (DP) by 5 micrograms/kg X min, in 7 patients with peritonitis and clinical findings of septic shock, all of whom were already receiving variable dosages of DP. Stroke index (SI) (p less than .01), except in 3 cases, and mean arterial pressure (p less than .01) were significantly elevated without significant increases in HR and systemic vascular resistance index (SVRI). Changes in mean pulmonary artery pressure (MPAP) and pulmonary wedge pressure (WP) were insignificant (less than 3 mm Hg). Renal response showed augmentation of diuresis (p less than .01), inulin clearance (Cin) (p less than .05), and fractional excretion of sodium (FENa) (p = .02) without significant changes in either paraminohypurate clearance (Cpha) or filtration fraction. There was no correlation between hemodynamic or renal changes and initial dosage of DP. We conclude that increasing the DP dosage in septic shock patients may be useful even when the patient is already receiving large doses. Increased natriuresis was not due to changes in plasma renal flow.