Confocal laser endomicroscopy for upper tract urothelial carcinoma: validation of the proposed criteria and proposal of a scoring system for real-time tumor grading.

PURPOSE: Confocal laser endomicroscopy (CLE) is a fluorescence-based fiber-optic imaging technique with the potential for intraoperative grading of upper tract urothelial carcinoma (UTUC). This study aims to (1) investigate the prevalence of the previously proposed CLE criteria for bladder cancer in papillary UTUC, (2) estimate the diagnostic value of CLE for UTUC grading and (3) propose a scoring system for a more quantifiable approach of CLE-based grading of UTUC. MATERIALS AND METHODS: Ureteroscopic CLE was performed in patients with UTUC. Following CLE imaging, co-localized biopsies were taken for histopathologic comparison. Postoperatively, two blinded raters assessed the CLE images. RESULTS: Fifty-three papillary UTUCs (34 low grade and 19 high grade) were imaged with CLE in 36 patients. All the previously described CLE criteria were identifiable in varying proportions. After excluding 10 non-diagnostic recordings (5 low grade and 5 high grade) due to insufficient image quality, the histopathologic grade was correctly identified with CLE in 26 low-grade UTUCs (90%) and in 12 high-grade UTUCs (86%). The most prevalent CLE criteria with the highest diagnostic potential were cellular organization, morphology and cohesiveness of cells. A scoring system was proposed with these criteria, which yielded similar diagnostic accuracies. CONCLUSIONS: Based on the previously proposed criteria, CLE enables accurate grading of papillary UTUC at a non-diagnostic rate of 19%. The most prevalent CLE criteria with the highest diagnostic potential for grading of papillary UTUC are cellular organization, morphology and cohesiveness of cells. The proposed scoring system may simplify the assessment of CLE images for UTUC grading but external validation is required.

Fluorescence in situ hybridization in 1 mL of selective urine for the detection of upper tract urothelial carcinoma: a feasibility study.

Kidney-sparing surgery of upper tract urothelial carcinoma (UTUC) requires a stringent follow-up with frequent ureteroscopies. Triage testing could reduce the number of follow-up ureteroscopies and hence minimize the invasiveness of follow-up. The use of urine-based markers for triage seems appealing but should be feasible with selective urine from outpatient cystoscopy to maximize the reduction of invasiveness. In this study, the feasibility of UroVysion® fluorescence in situ hybridization (FISH) for the detection of UTUC in 1 mL of selective urine is investigated. Ten consecutive patients with biopsy-proven UTUC and five patients with negative diagnostic ureteroscopy findings were included in this case-control study. During ureteroscopy, 1 mL of selective urine was collected passively with a ureteral splint for Urovysion® FISH. The FISH rater was blinded to any clinical information. The results of FISH were compared to the findings of concomitantly collected selective urine cytology and the patients' UTUC status. FISH was feasible in all samples with a sensitivity of 90% and a specificity of 80% for UTUC. In comparison, selective cytology resulted in a diagnostic yield of 87% with a sensitivity of 80% and a specificity of 67%. In conclusion, UTUC detection is feasible with FISH in 1 mL of passively collected selective urine. Thus from a technical point of view, FISH could be used as an outpatient triage test to decide if follow-up ureteroscopy is necessary after kidney-sparing surgery of UTUC. Evaluation of the diagnostic accuracy of FISH for the suggested pathway deserves further attention.

Measuring abdominal adiposity in 6 to 7-year-old children.

BACKGROUND/OBJECTIVES: Both intra-abdominal adipose tissue (IAAT) and subcutaneous abdominal adipose tissue (SAAT) are associated with cardiovascular risk factors, even in childhood. Currently, the gold standard in assessing IAAT and SAAT is computed tomography (CT), which is not widely applicable. The aim of this study was to estimate abdominal fat using anthropometry, dual-energy X-ray absorptiometry (DEXA) and ultrasound, and compare these estimates with the amounts of IAAT and SAAT determined by CT in 6 to 7-year-old children. SUBJECTS/METHODS: In 31 healthy children, weight, height, circumferences, skinfolds, DEXA, abdominal ultrasound and CT were performed. Measurements were compared by simple correlations and receiver operating characteristic analyses. RESULTS: Total abdominal fat on CT did not differ between boys and girls (86.5 versus 89.8 cm(3), P=0.84). Boys had a higher IAAT to SAAT ratio than girls (0.56 versus 0.37, P=0.03). The sum of supra-iliac and abdominal skinfolds was most strongly correlated with SAAT on CT (r=0.93, P<0.001), and the abdominal skinfold with IAAT on CT (r=0.72, P<0.001). Diagnosis of subcutaneous abdominal and intra-abdominal adiposity can also be made using skinfolds. The associations with circumferences, body mass index and DEXA were less pronounced; however, these techniques can also be used to classify children according to SAAT and IAAT. Ultrasound can be used to diagnose subcutaneous adiposity, although it was not superior to skinfold measurements. CONCLUSION: Skinfold measurements are the best non-invasive technique in predicting subcutaneous as well as intra-abdominal fat in our population of 6 to 7-year-old children.

Use of a stimulating catheter for total knee replacement surgery: preliminary results.

BACKGROUND: There is continuing debate as to whether the use of electrical stimulation that aids in localizing nerves is also beneficial for optimizing placement of nerve catheters and lead to improved clinical outcomes, such as reductions in pain scores and opioid consumption. METHODS: We undertook a retrospective, non-randomized comparison of stimulating and non-stimulating nerve catheters in 419 patients undergoing total knee replacement between December 2002 and July 2004. Before surgery, patients received sciatic and femoral nerve blocks with a catheter for the femoral nerve. In 159 patients a stimulating catheter system (Stimucath; Arrow International, Reading, PA, USA) and in 260 patients a non-stimulating catheter system (Contiplex; B. Braun, Melsungen, Germany) was used. After surgery, pain scores and morphine consumption were recorded at 4-h intervals until the first postoperative morning. In a subset of 85 patients, the postoperative evaluation period was lengthened to 3 days. RESULTS: Postoperative visual analogue scores (VAS) for pain were similar in the two groups during the first 24 h (P=0.305). In patients followed for 3 days, VAS scores did not differ on any of the days (P=0.427). Total morphine consumption did not differ on the first postoperative day (mean [95% CI]: stimulating, 12.4 [10.1-14.7] mg; non-stimulating 10.4 [8.9-11.8] mg; P=0.140) or on subsequent days. CONCLUSIONS: The practical advantages of the stimulating catheter, as reported by previous investigators, were not obvious in this clinical situation. In terms of outcome measures such as pain scores and morphine consumption, we found no significant differences between stimulating and non-stimulating catheters.

Effect of intra-operative end-tidal carbon dioxide partial pressure on tissue oxygenation.

Postsurgical infection risk is correlated with subcutaneous tissue oxygenation. Mild hypercapnia augments cutaneous perfusion. We tested the hypothesis that peripheral tissue oxygenation increases as a function of arterial PCO2 in surgical patients. Twenty patients were randomly assigned to intra-operative end tidal PCO2 of 3.99 (control) or 5.99 kPa (hypercapnia). All other anaesthetic management was per protocol. Tissue oxygen partial pressure, transcutaneous oxygen tension, cerebral oxygen saturation, and cardiac output were measured. Mean (SD) subcutaneous tissue oxygen tension was 8.39 (1.86) kPa in control and 11.84 (2.53) kPa hypercapnia patients (p = 0.014). Cerebral oxygen saturation was 55 (4)% for control vs. 68 (9)% for hypercapnia (p = 0.004). Neither cardiac index nor transcutaneous tissue oxygen tension differed significantly between the groups. Mild intra-operative hypercapnia increased subcutaneous and cerebral oxygenation. Increases in subcutaneous tissue oxygen partial pressure similar to those observed in patients assigned to hypercapnia are associated with substantial reductions in wound infection risk.

Representation of clinical practice guidelines through an interactive World-Wide-Web interface.

The widespread utility of clinical practice guidelines is greatly dependent on the ease with which they can be accessed, used, and applied. Because it supports hyperlinking and is widely accessible, the World-Wide Web is a medium that is well suited for browsing through guidelines. We have developed a process for implementing algorithmic guidelines into a graphical format that allows the user to browse these guidelines in an interactive fashion. The guidelines we used were already in or could be transformed to an algorithmic format that lends itself well to analysis with decision table techniques, which in turn permits a fairly straightforward conversion into a graphical representation. The results of this process allow a user to browse a particular guideline algorithm and to visualize the traversed parts of the algorithm by flowcharts. Our first experiences with this method of representing a few sample clinical practice guidelines have been encouraging, and we hope to extend this method to other guidelines.

Coexistent idiopathic retroperitoneal and mediastinal fibrosis presenting with portal hypertension.

A rare case is described of coexistent idiopathic retroperitoneal and mediastinal fibrosis presenting with portal hypertension. Portal hypertension was caused by fibrotic entrapment of the portal venous system. The present case provides further evidence for the concept of systemic idiopathic fibrosis and underlines the variable manifestations of the disorder.

Integrating QMR with a computer-based patient record.

Most diagnostic decision support (DDS) systems are used as stand-alone applications. At present, the physician can only benefit from the suggestions of a DDS system if he is sufficiently motivated to re-enter patient data and run a diagnostic case analysis. If data from a computer-based patient record (CBPR) could be made available electronically to a DDS system, the use of that DDS system may become much more practical. Integrating a CBPR with a DDS system requires a mapping between two different data structures and dictionaries. We have explored a strategy to create a mapping between our CBPR and QMR. Our research has provided more general insight in the potential and limitations of such a mapping.