Influencing factors for port-site hernias after single-incision laparoscopy.

PURPOSE: Single-incision laparoscopic surgery (SILS) has been demonstrated to be a feasible alternative to multiport laparoscopy, but concerns over port-site incisional hernias have not been well addressed. A retrospective study was performed to determine the rate of port-site hernias as well as influencing risk factors for developing this complication. METHODS: A review of all consecutive patients who underwent SILS over 4 years was conducted using electronic medical records in a multi-specialty integrated healthcare system. Statistical evaluation included descriptive analysis of demographics in addition to bivariate and multivariate analyses of potential risk factors, which were age, gender, BMI, procedure, existing insertion-site hernia, wound infection, tobacco use, steroid use, and diabetes. RESULTS: 787 patients who underwent SILS without conversion to open were reviewed. There were 454 cholecystectomies, 189 appendectomies, 72 colectomies, 21 fundoplications, 15 transabdominal inguinal herniorrhaphies, and 36 other surgeries. Cases included 532 (67.6 %) women, and among all patients mean age was 44.65 (±19.05) years and mean BMI of 28.04 (±6). Of these, 50 (6.35 %) patients were documented as developing port-site incisional hernias by a health care provider or by incidental imaging. Of the risk factors analyzed, insertion-site hernia, age, and BMI were significant. Multivariate analysis indicated that both preexisting hernia and BMI were significant risk factors (p value = 0.00212; p value = 0.0307). Morbidly obese patients had the highest incidence of incisional hernias at 18.18 % (p value = 0.02). CONCLUSIONS: When selecting patients for SILS, surgeons should consider the presence of an umbilical hernia, increased age and obesity as risk factors for developing a port-site hernia.

Herpetic tracheobronchitis. Cytologic and virologic detection.

Tracheobronchitis due to herpes simplex virus is a well-recognized finding in cases of burns, debilitation, or immunosuppression. Nearly all reported cases have been diagnosed at necropsy despite the possibility for clinical detection of such infections by exfoliative cytological studies, virus isolation and identification, or both. The present report details the cytologic and virologic diagnosis of herpetic tracheobronchitis in a patient with carcinoma of the lung and alcoholic fatty liver. Respiratory cells with herpetic infection cytologically showed less tendency to multinucleation than the characteristic herpes-infected cells of squamous epithelium, which may be a source of diagnostic confusion.

Case control study of cerebrovascular damage defined by magnetic resonance imaging in patients with OSA and normal matched control subjects.

STUDY OBJECTIVES: To assess whether MRI detectable evidence of silent cerebrovascular disease is more prevalent in patients with obstructive sleep apnea (OSA) when compared to carefully matched control subjects. DESIGN AND SETTING: Case-control study of patients with OSA attending a specialist sleep clinic and matched control subjects drawn from the normal community. PARTICIPANTS: Forty-five sleep clinic patients with moderate to severe OSA and excessive daytime sleepiness, matched to 45 control subjects without excessive sleepiness or evidence of OSA on a sleep study. Matched variables included age, body mass index (BMI), alcohol and cigarette consumption, treated hypertension, and ischaemic heart disease. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: All subjects underwent 24-hour ambulatory blood pressure recordings (before treatment in OSA patients) and sagittal T1, axial T2, and coronal dual echo cerebral MRI imaging to detect clinically silent abnormalities related to hypertensive cerebrovascular disease; areas of high signal foci in deep white matter (DWM), lacunae, and periventricular hyperintensity. Lacunae/high signal foci in DWM and/or periventricular hyperintensity were present in 15 (33%) OSA subjects and 16 (35%) controls, despite significant increases in mean daytime diastolic blood pressure (4.6mmHg, p<0.05), and both nighttime diastolic (7.2mmHg, p<0.001) and systolic blood pressures (9.2mmHg, p<0.05) in OSA subjects. These data exclude more than a 17% excess prevalence of MRI detected minor cerebrovascular disease in the OSA patients, with 95% confidence. CONCLUSIONS: Sub-clinical cerebrovascular disease is prevalent in both clinic patients with OSA and their matched control subjects. Despite the increased arterial blood pressures, there is, however, no apparent excess of MRI-evident subclinical cerebrovascular disease in patients with OSA compared to appropriately matched control subjects.

Complex cryptococcal empyema.

Cryptococcus neoformans continues to present diagnostic and treatment challenges in patients with underlying malignant neoplasms. Cryptococcal empyema is a relatively rare complication of cryptococcal disease. It is important to distinguish whether uncontrolled malignancy or cryptococcal infection is responsible for the effusion. We used traditional diagnostic approaches, bronchoscopy and transthoracic fine needle aspiration, to verify the presence of the organism but continued to have treatment failure until adequate drainage was established.

Fine-needle aspiration of inguinal lymph nodes in gynecologic practice.

Palpable inguinal lymph nodes are a common finding in gynecologic patients. Assessment of such nodes is especially important in the clinical staging of pelvic cancers. To determine the accuracy, safety, and usefulness of fine-needle aspiration in this setting, we retrospectively reviewed pathologic and clinical data from 62 consecutive aspirates of inguinal lymph nodes in 48 gynecologic patients, of whom 42 had cancer. Aspirates from 37 patients yielded diagnostic material. Aspirated tumor cells consistently reflected the primary tumor histology. Tumors included carcinomas of the vulva, vagina, and cervix, and carcinomas and mixed mesodermal cancers of the corpus and ovary. Node excision and clinical observations provided adequate follow-up for 19 positive and 15 negative aspirates, and identified no false positives and two false negatives. The role of fine-needle aspiration varied with the tumor type and stage. It provided the first microscopic diagnosis of cancer in six patients and the first diagnosis of metastasis in six others. Decisions concerning surgery, radiation ports, and chemotherapy frequently depended on the results of fine-needle aspiration. There were no complications from the procedure. Fine-needle aspiration is an accurate, safe, and useful method for assessing clinically suspicious inguinal nodes.

Is (re)titration of nasal continuous positive airway pressure for obstructive sleep apnoea necessary?

OBJECTIVE: To assess changes in nasal continuous positive airway pressure (nCPAP) pressure requirements across time in obstructive sleep apnoea (OSA), and whether routine retitrations are indicated. BACKGROUND: Most sleep laboratories perform one nCPAP titration, although some authors have found changes in pressures with time. A cohort of patients with OSA in a randomised controlled trial of nCPAP provided us with data on changes in titration pressures with time. METHODS: One hundred and one patients with symptomatic OSA (Epworth Sleepiness Scale > or =10, and >10 episodes/h of >4% dips in SaO(2) overnight) were recruited to a 1 month trial comparing real (autotitrated) and placebo nCPAP. At 1 month all patients were titrated and received real nCPAP thereafter. Eighty five were retitrated at about 6 months. RESULTS: Average pressures did not change between the initial value and 1 month (95th centile, 8.47 (SD 3.00), 8.94 (2.85) cm H(2)O), although there were large individual changes (mean difference, +0.47, SD 2.30, range -5 to +6 cm H(2)O). There was a small fall at 6 months (mean difference -0.68, SD 2.60, range -6 to +6 cm H(2)O, P<0.03) with no suggestion that the changes from 1-6 months were clinically important. CONCLUSIONS: This study suggests that routine nCPAP retitrations are not necessary. In conjunction with other published data, the night to night variation we found implies that a nCPAP calibration using an algorithm (based on obesity and OSA severity) might be as clinically successful as conventional one night titrations. However, further studies will be needed to specifically confirm this hypothesis.

Embryonal rhabdomyosarcoma in ascitic fluid. Immunocytochemical and DNA flow cytometric study.

We report the case of an 18-year-old woman who had a small-cell malignant neoplasm of the left paranasal sinuses and who, 18 months later, developed malignant ascites. Immunoperoxidase stains of the ascitic fluid cells and, subsequently, the original tumor, identified it as embryonal rhabdomyosarcoma. Flow cytometric DNA analysis of the ascitic fluid demonstrated an aneuploid cell population that was also present in the paraffin-embedded tissue on which the original diagnosis had been made.

Transthoracic fine needle aspiration of primary and metastatic sarcomas.

Sarcomas, excluding lymphomas, are relatively uncommon targets of transthoracic fine needle aspiration. This paper presents a series of 11 adult patients with a variety of histologically documented sarcomas that were positive on transthoracic fine needle aspiration. Most tumors were metastatic from extrathoracic primary sites. We summarize the cytologic appearances of the aspirates and the clinical roles of fine needle aspiration in this setting. The aspirates resembled the corresponding histologic sections in cellular morphology. Nine different histologic types of sarcomas therefore produced a wide variety of cytologic appearances. Two findings, though not specific for sarcomas, were common and are suggested as clues to the recognition of sarcomas: (1) poor cohesion of cells and (2) numerous spindle cells. Transthoracic fine needle aspiration confirmed a strongly suspected clinical diagnosis in 7 cases, and it clarified a more obscure clinical diagnosis in 4 cases. Suggestions are presented for differential diagnosis.

Fine-needle aspiration of subcutaneous phaeohyphomycosis caused by Wangiella dermatitidis.

Two cases of subcutaneous phaeohyphomycosis, first recognized by fine-needle aspiration (FNA), were confirmed with culture, excision, and histologic study. Both patients had debilitating medical problems and a solitary mass on the left leg. Pigmented hyphae and other fungal elements, numerous in both aspirates, assumed a variety of forms that did not permit specific identification. Culture grew Wangiella dermatitidis in both cases. FNA also yielded purulent exudate, multinucleated giant cells, and, in one case, epithelioid histiocytes. Both excised lesions were abscesses, with associated granulomatous inflammation, fibrosis, and plant splinters. Fungi in sections resembled those seen in the aspirates.

Cytologic detection of urothelial cancer and other abnormalities in a cohort of workers exposed to aromatic amines.

A total of 541 members of a cohort at increased risk for occupational bladder cancer underwent a 33-month program of screening with urine cytology. Selected workers received further urologic study with cystoscopy and bladder biopsies. Eight workers had positive or suspicious cytologic findings. Only one of the eight had a prior history of bladder cancer. Biopsies showed invasive carcinoma and/or nonpapillary carcinoma in situ in five workers in this group, severe atypia in one, and no significant abnormality in two. Of 56 workers who had atypical cytologic findings, 16 had bladder biopsies, which showed atypia of flat urothelium in 11, nonpapillary carcinoma in situ in one, noninfiltrating papillary carcinoma in one, and no significant abnormality in three. The cytologic detection of urothelial abnormalities often required more than a single specimen. Since the cohort in this study may develop more bladder cancers with the passage of time, continued follow-up is indicated.

Relation between systemic hypertension and sleep hypoxaemia or snoring: analysis in 748 men drawn from general practice.

OBJECTIVE: To establish whether a history of snoring or the degree of overnight hypoxaemia is an important independent predictor of systemic blood pressure. DESIGN: Prospective community based study of blood pressure in relation to overnight oxygen saturation, height, weight, and a questionnaire assessment of snoring, smoking, and alcohol consumption. Analysis was by multiple linear regression techniques and analysis of variance. SETTING: Small town outside Oxford, served by one group general practice of four partners. All measurements were made at home. SUBJECTS: The names of 836 men aged 35-65 were drawn at random from the general practitioners' age and sex register and the men then asked to participate; 752 (90%) agreed. MAIN OUTCOME MEASURES: Systolic, mean, and diastolic blood pressures and their association with age, obesity, alcohol consumption, cigarette consumption, snoring, and overnight hypoxaemia. RESULTS: Though systemic blood pressure correlated significantly with overnight hypoxaemia, this was due to the cross correlation with age, obesity, and alcohol consumption. No independent predictive effect of overnight hypoxaemia was found. Snoring was correlated with systemic blood pressure but not significantly so and also was not an independent predictor once age, obesity, and alcohol consumption had been allowed for. CONCLUSIONS: It is unlikely that snoring and sleep hypoxaemia from occult sleep apnoea are important causes of diurnal systemic hypertension when compared with age, obesity, and alcohol consumption. The increased prevalence of cardiovascular complications reported in snorers may be due to the confounding variable of obesity or to nocturnal rises in blood pressure that are not reflected in the daytime figures.

Vaginal intraepithelial neoplasia III detected after hysterectomy for benign conditions.

Because primary vaginal cancer is rare, many experts discourage routine cytologic sampling of the vaginal vault following hysterectomy for benign circumstances. The following report describes a case of vaginal intraepithelial neoplasia III (VAIN III) detected by a vaginal vault Papanicolaou smear obtained from an asymptomatic 57-year-old woman 23 years after she had a total abdominal hysterectomy for a benign condition. As VAIN III is a true vaginal cancer precursor, the innocent disregard of recommended screening practices averted significant morbidity and possibility mortality for this otherwise healthy woman.

The efficacy of liquid-based cervical cytology using direct-to-vial sample collection.

BACKGROUND: Previous studies of liquid-based cervical cytology (LBCC) have used a split sample collection technique that creates a potential negative bias for its evaluation. Thus, the full diagnostic potential of LBCC has not been established. The purpose of our study was to determine rates of specimen adequacy and cervical cytologic and histologically confirmed diagnoses obtained with a liquid-based Papanicolaou (Pap) test using a direct-to-vial sample collection technique and compare these results with those obtained using the conventional Pap test (CPT). METHODS: A total of 1004 nonpregnant women aged 18 years or older with an intact cervix had Pap tests collected with an Ayre spatula and cytobrush, and the sample was placed in a preservative solution. The specimens were processed as thin layer Pap tests according to the manufacturer's specifications. Another group of 2110 women with a similar patient profile had a CPT collected immediately preceding the initiation of the trial. The subjects in each group consisted of an equal percentage of women presenting for a routine Pap test or a colposcopy examination. We compared the distributions of diagnostic categories between the groups using a chi-square test. RESULTS: A significantly greater percentage of satisfactory Pap tests were obtained using LBCC (84.0%) compared with the CPT (60.5%, P < .001). Fewer satisfactory but limited by (SBLB, 14.8%) and unsatisfactory (1.2%) Pap tests were reported using LBCC compared with the CPT (35.7% and 3.8%, respectively, chi2 = 170.7, P < .001). A significantly greater percentage of low-grade squamous intraepithelial lesion (LSIL) and high-grade squamous intraepithelial lesion (HSIL) Pap test results were reported using LBCC (7.4% and 3.7%, respectively) compared with the CPT (1.7% and 1.7%, respectively, chi2 = 74.4, P < .001). The predictive value of a positive LBCC test (93.9%) was similar to that for a positive CPT (87.8%) when compared with histology results. CONCLUSIONS: Compared with the CPT, LBCC detected a significantly greater percentage of satisfactory Pap tests and significantly reduced the number of unsatisfactory and SBLB tests. Four times the percentage of LSIL and twice the percentage of HSIL Pap test results were obtained using LBCC compared with the CPT. These findings demonstrate that LBCC significantly improves the adequacy of Pap tests and may increase the rate of detection of cervical neoplasia compared with the CPT.

Atypical glandular cells of undetermined significance and adenocarcinoma in situ: summoning colposcopic expertise?

In comparison with cervical squamous neoplasia, glandular cell neoplasia is uncommon. The evaluation of a patient with atypical glandular cells of undetermined significance is challenging because subtle colposcopic signs are frequently inaccessible to view and cytologic interpretations are extremely challenging for many cytopathologists.

The role of fine-needle aspiration biopsy in the diagnosis and management of palpable masses.

Fine-needle aspiration (FNA) is a safe and economical biopsy technique that is widely applicable to palpable masses as a first-line procedure. However, successful FNA demands high specimen quality and experience on the part of both the aspirator and the pathologist. The best diagnostic yield is achieved by examining the aspirate on site with a microscope and making repeat passes if needed. Studies from several organ sites show generally high specificity for FNA in the diagnosis of cancer but slightly lower sensitivity. The accuracy and proper role of FNA vary among organ sites and different disease categories. FNA often makes a clear cut diagnosis but sometimes assumes more of a screening role. In cases of breast cancer, FNA can usually make a definitive diagnosis in the outpatient setting and greatly facilitate further management. Breast FNA reduces the need for open biopsies in women with benign aspirates, provided clinical and mammographic findings are also benign. Salivary gland FNA separates neoplasm from inflammatory lesions and reduces the need for surgery by as much as a third. Thyroid FNA greatly improves selection of patients for surgery and increases the percentage of cancers in nodules that are excised. However, follicular adenomas resemble carcinomas on FNA and must usually be excised. The accuracy and role of lymph node FNA is greatest with metastatic cancers. Its accuracy is somewhat lower in the primary diagnosis of lymphomas, which usually requires excision and histologic study for full characterization.

Predictors and prevalence of obstructive sleep apnoea and snoring in 1001 middle aged men.

One thousand and one men, aged 35-65 years, were identified from the age-sex register of one group general practice. Over four years 900 men were visited at home and asked questions about symptoms potentially related to sleep apnoea and snoring. Height, weight, neck circumference, resting arterial oxygen saturation (SaO2), and spirometric values were also determined. All night oximetry was then performed at home and the tracing analysed for the number of dips in SaO2 of more than 4%. Subjects with more than five dips of 4% SaO2 or more per hour were invited for sleep laboratory polysomnography. Seventeen per cent of the men admitted to snoring "often." Multiple linear regression techniques identified and ranked neck circumference (r2 = 7.2%), cigarette consumption (r2 = 3.4%), and nasal stuffiness (r2 = 2%) as the only significant independent predictors of snoring. Together these account for at least a sixfold variation in the likelihood of being an "often" snorer. Forty six subjects (5%) had greater than 4% SaO2 dip rates of over five an hour and 31 of these had full sleep studies. Three subjects had clinically obvious and severe symptomatic obstructive sleep apnoea, giving a prevalence of three per 1001 men (0.3%; 95% confidence interval 0.07-0.9%). Eighteen men had obstructive sleep apnoea only when supine and in 10 the cause of the SaO2 dipping on the original home tracing was not elucidated. The greater than 4% SaO2 dip rates correlated with the history of snoring. Multiple linear regression techniques identified and ranked neck circumference (r2 = 7.9%), alcohol consumption (r2 = 3.7%), age (r2 = 1%) and obesity (r2 = 1%) as the only significant independent predictors of the rate of overnight hypoxic dipping. This study shows that snoring in this randomly selected population correlates best with neck size, smoking, and nasal stuffiness. Obstructive sleep apnoea, defined by nocturnal hypoxaemia, correlates best with neck size and alcohol, and less so with age and general obesity.

Self reported snoring and daytime sleepiness in men aged 35-65 years.

BACKGROUND: It has been suggested that snoring alone, without conventional sleep apnoea or hypopnoea, may disrupt sleep and produce substantial daytime hypersomnolence. This study addresses this potential relationship. METHOD: Eight hundred and fifty men, aged 35-65 years, drawn from one general practice were visited at home and asked a range of questions potentially related to sleepiness, snoring, and sleep apnoea; these included inquiries about alcohol and cigarette consumption, nasal stuffiness, shift work, hypnotic or other drug use, and medical diagnoses. In addition, measurements of height, weight, and overnight arterial oxygen saturation were made. The relation between snoring and sleepiness, with allowance made for potentially confounding variables, including sleep apnoea, was assessed by multiple logistic regression. RESULTS: Positive answers to all questions about sleepiness were correlated significantly with self reported snoring. After potentially confounding variables and any sleep apnoea had been controlled for, positive answers to four questions about inappropriate drowsiness or sleepiness were independently related to snoring. For example, the odds ratio of admitting to "having almost had two or more car accidents while driving due to sleepiness" was 5.8 (95% confidence intervals: 2.7-12.5) in an "often" snorer. CONCLUSIONS: Although epidemiological associations such as this do not prove a causal relation, the study suggests that snoring (without classical sleep apnoea) may sometimes reduce sleep quality sufficiently to produce substantial daytime drowsiness.

Diagnosis of thoracic splenosis by tru-cut needle biopsy.

We present a case of thoracic splenosis diagnosed by tru-cut needle biopsy, which yielded histologically normal splenic tissue. This is the first report of a diagnosis of thoracic splenosis by needle biopsy. The patient had a history characteristic of thoracic splenosis. Autotransplanted splenic tissue functions and may provide some defense against serious infections. A conservative approach to diagnosis offers the advantages of preserving splenic tissue and avoiding thoracotomy.

Bronchoalveolar lavage fluid granulomas in a case of severe sarcoidosis.

A case of pulmonary sarcoidosis is presented in which cytologic analysis of bronchoalveolar (BAL) fluid showed intact granulomas. The patient had severe alveolar inflammation and probable endobronchial sarcoidosis. Thus the granulomas in the BAL fluid probably reflect a high burden of alveolar wall granulomas and/or the removal of granulomas from proximal inflamed airways. This is the first reported case of granulomas in BAL fluid in sarcoidosis. Although an unusual finding, the recovery of BAL granulomas is not diagnostic for sarcoidosis and cannot substitute for the demonstration of granulomatous inflammation in lung tissue.