EUS-guided tissue acquisition in the study of the adrenal glands: Results of a nationwide multicenter study.

BACKGROUND: There are limited data about the role of endoscopic ultrasound-guided tissue acquisition (EUS-TA), by fine needle aspiration (EUS-FNA) or biopsy (EUS-FNB), in the evaluation of the adrenal glands (AG). The primary aim was to assess the diagnostic yield and safety. The secondary aims were the malignancy predictors, and to create a predictive model of malignancy. METHODS: This was a retrospective nationwide study involving all Spanish hospitals experienced in EUS-TA of AGs. Inclusion period was from April-2003 to April-2016. Inclusion criteria: all consecutive cases that underwent EUS-TA of AGs. EUS and cytopathology findings were evaluated. Statistical analyses: diagnostic accuracy of echoendoscopist's suspicion using cytology by EUS-TA, as gold standard; multivariate logistic regression model to predict tumor malignancy. RESULTS: A total of 204 EUS-TA of AGs were evaluated. Primary tumor locations were lung70%, others19%, and unknown11%. AG samples were adequate for cytological diagnosis in 91%, and confirmed malignancy in 60%. Diagnostic accuracy of the endosonographer's suspicion was 68%. The most common technique was: a 22-G (65%) and cytological needle (75%) with suction-syringe (66%). No serious adverse events were described. The variables most associated with malignancy were size>30mm (OR2.27; 95%CI, 1.16-4.05), heterogeneous echo-pattern (OR2.11; 95%CI, 1.1-3.9), variegated AG shape (OR2.46; 95%CI, 1-6.24), and endosonographer suspicion (OR17.46; 95%CI, 6.2-58.5). The best variables for a predictive multivariate logistic model of malignancy were age, sex, echo-pattern, and AG-shape. CONCLUSIONS: EUS-TA of the AGs is a safe, minimally invasive procedure, allowing an excellent diagnostic yield. These results suggest the possibility of developing a pre-EUS procedure predictive malignancy model.

Influence of the Histopathological Features of the Lesion on the Diagnostic Yield of Fine-Needle Aspiration Cytology of Pancreatic Solid Lesions.

OBJECTIVE: The rate of pancreatic lesions has increased in recent decades due to the widespread use of advanced imaging techniques. Nowadays, a significant proportion of cases are incidentally discovered in asymptomatic patients and cytology is an important tool for the diagnosis and multidisciplinary management of these cases. STUDY DESIGN: In this study we retrospectively review the experience with pancreatic fine-needle aspiration cytology in the last 17 years at a single large tertiary hospital in Madrid, Spain. RESULTS: Our results indicate that more than 60% of pancreatic malignant lesions are cytologically confirmed before surgery and 30% of the patients are asymptomatic. Despite this, we have noted that the total number of malignant lesions surgically resected in our hospital has basically remained unchanged over the years, because incidental diagnosis is not always synonymous with resectability and a substantial number of patients are already metastatic at the time of diagnosis. Our series also shows an increase in the number of neuroendocrine tumors, which now represent almost 20% of all cytological diagnoses at our hospital. The sensitivity in our series is 70% and the false negative rate remains 30%, despite sample quality control by experienced cytologists and standardized technical conditions. Fibrosis and necrosis are the 2 features of the primary tumor that significantly and negatively influence the accuracy of cytologic diagnosis. CONCLUSION: We herein report our experience with cytologic diagnosis of pancreatic lesions in a single tertiary hospital. Our results confirm that cytology is a safe, reliable, and important tool for pancreatic lesion diagnosis and management.

Reliability of the MDi Psoriasis® Application to Aid Therapeutic Decision-Making in Psoriasis. / Fiabilidad de una aplicación de ayuda a la toma de decisiones terapéuticas en el paciente con psoriasis (MDi Psoriasis®).

BACKGROUND: Therapeutic decisions in psoriasis are influenced by disease factors (e.g., severity or location), comorbidity, and demographic and clinical features. OBJECTIVE: We aimed to assess the reliability of a mobile telephone application (MDi-Psoriasis) designed to help the dermatologist make decisions on how to treat patients with moderate to severe psoriasis. METHOD: We analyzed interobserver agreement between the advice given by an expert panel and the recommendations of the MDi-Psoriasis application in 10 complex cases of moderate to severe psoriasis. The experts were asked their opinion on which treatments were most appropriate, possible, or inappropriate. Data from the same 10 cases were entered into the MDi-Psoriasis application. Agreement was analyzed in 3 ways: paired interobserver concordance (Cohen's κ), multiple interobserver concordance (Fleiss's κ), and percent agreement between recommendations. RESULTS: The mean percent agreement between the total of 1210 observations was 51.3% (95% CI, 48.5-54.1%). Cohen's κ statistic was 0.29 and Fleiss's κ was 0.28. Mean agreement between pairs of human observers only, excluding the MDi-Psoriasis recommendations, was 50.5% (95% CI, 47.6-53.5%). Paired agreement between the recommendations of the MDi-Psoriasis tool and the majority opinion of the expert panel (Cohen's κ) was 0.44 (68.2% agreement). CONCLUSIONS: The MDi-Psoriasis tool can generate recommendations that are comparable to those of experts in psoriasis.

Punctate inner choroidopathy complicated with exudative neurosensory detachment: A favourable response to treatment with systemic corticosteroids and intravitreal ranibizumab. / Coroidopatía punctata interna complicada con desprendimiento neurosensorial exudativo: respuesta favorable al tratamiento con corticoides y ranibizumab intravítreo.

CASE REPORT: Punctate inner choroidopathy (PIC) is a variant of multifocal choroiditis that principally affects young and healthy women. A case of this condition is described in a woman who presented with a scotoma as the main complaint. Four months after the diagnosis of PIC, she developed an exudative neurosensory detachment associated with an active focus of juxtafoveal choroiditis. Finally, with systemic corticosteroids and intravitreal ranibizumab, she made excellent progress. DISCUSSION: Intravitreal ranibizumab, associated with systemic corticosteroids, may be an effective treatment for exudative neurosensory detachment complicating PIC.

Predictive factors for initial treatment response after circumferential radiofrequency ablation for Barrett's esophagus with early neoplasia: a prospective multicenter study.

BACKGROUND AND STUDY AIMS: Radiofrequency ablation (RFA) is safe and effective for the eradication of neoplastic Barrett's esophagus; however, occasionally there is minimal regression after initial circumferential balloon-based RFA (c-RFA). This study aimed to identify predictive factors for a poor response 3 months after c-RFA, and to relate the percentage regression at 3 months to the final treatment outcome. METHODS: We included consecutive patients from 14 centers who underwent c-RFA for high grade dysplasia at worst. Patient and treatment characteristics were registered prospectively. "Poor initial response" was defined as < 50 % regression of the Barrett's esophagus 3 months after c-RFA, graded by two expert endoscopists using endoscopic images. Predictors of initial response were identified through logistic regression analysis. RESULTS: There were 278 patients included (median Barrett's segment C4M6). In poor initial responders (n = 36; 13 %), complete response for neoplasia (CR-neoplasia) was ultimately achieved in 86 % (vs. 98 % in good responders; P < 0.01) and complete response for intestinal metaplasia (CR-IM) in 66 % (vs. 95 %; P < 0.01). Poor responders required 13 months treatment (vs. 7 months; P < 0.01) for a median of four RFA sessions (vs. three; P < 0.01). We identified four independent baseline predictors of poor response: active reflux esophagitis (odds ratio [OR] 37.4; 95 % confidence interval [CI] 3.2 - 433.2); endoscopic resection scar regeneration with Barrett's epithelium (OR 4.7; 95 %CI 1.1 - 20.0); esophageal narrowing pre-RFA (OR 3.9; 95 %CI 1.0 - 15.1); and years of neoplasia pre-RFA (OR 1.2; 95 %CI 1.0 - 1.4). CONCLUSIONS: Patients with a poor initial response to c-RFA have a lower ultimate success rate for CR-neoplasia/CR-IM, require more treatment sessions, and a longer treatment period. A poor initial response to c-RFA occurs more frequently in patients who regenerate their endoscopic resection scar with Barrett's epithelium, and those with ongoing reflux esophagitis, neoplasia in Barrett's esophagus for a longer time, or a narrow esophagus.

Perfusion CT and angio CT in the assessment of acute stroke.

In order to evaluate the clinical utility of non-enhanced CT with perfusion and angio CT in the assessment of acute ischaemic stroke, 42 patients with symptoms of acute stroke were examined within the first 6 h from onset of symptoms with non-enhanced CT (NECT), perfusion CT (PCT) and CT angiography (CTA). Maps of cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were analysed visually, and after drawing regions of interest (ROIs) in the territory of anterior, middle and posterior cerebral arteries, maximum-intensity projection and volume-rendering images of the cervical and cerebral vessels were created. All patients underwent a control CT or MR examination 24-48 h after the initial examination. Twenty-nine patients developed an area of infarction at control examinations. Significant perfusion abnormalities were found in 27 cases, whilst in two patients the perfusion studies were considered to be normal. All the cases with perfusion abnormalities showed arterial stenoses or occlusions on angio CT. Small infarctions at levels other than the ones selected for perfusion CT, and arteriosclerotic changes, were observed in the two cases with no perfusion abnormalities. In conclusion, combining non-enhanced CT with PCT and CTA is a simple and a very valuable tool in the initial assessment of acute stroke.

Improved detection of liver metastases with contrast-enhanced wideband harmonic imaging: comparison with CT findings.

OBJECTIVE: To evaluate the capability of contrast-enhanced wideband harmonic imaging (WHI) to detect liver metastases in comparison with fundamental B-mode US and postcontrast CT. METHODS: We studied 27 patients with hepatic metastases from different malignancies with conventional B-mode sonography, WHI 3 min after injection of contrast agent (Levovist(R) 2.5 g, 300 mg/ml) and postcontrast helical CT (HCT). The number and location of the lesions and the smallest lesion for each patient were noted by two different observers and compared. RESULTS: Both readers recorded an increase in the number of lesions in harmonic mode compared with conventional B-mode in all 27 patients with hepatic metastases with a mean increase in both observers from 9.3 lesions with B-mode to 18.8 lesions with WHI. The smallest lesions were detected with WHI when compared with conventional US and HCT (2 mm with WHI, 5 mm with B-mode and 5 mm with CT). WHI detected more lesions than conventional US or HCT. CONCLUSIONS: Contrast-enhanced WHI seems superior to conventional US and HCT for the detection of hepatic metastases, specially for those nodules under 1 cm of diameter.

[Value of power Doppler ultrasonography with intravenous contrast medium (Levograf) in the diagnosis of acute cholecystitis]. / Valor de la ecografía power Doppler con contraste intravenoso (Levograf) en el diagnóstico de colecistitis aguda.

The aim of this study was to evaluate the potential capacity of color and power Doppler sonography with intravenous contrast medium in the diagnosis of acute cholecystitis. We examined 18 patients with acute cholecystitis, 5 patients with chronic cholecystitis and a control group of 11 patients without gallbladder disease. In these patients, vascularization of the gallbladder wall was evaluated by color and power Doppler sonography before and after intravenous administration of contrast medium (Levograf). Vascularization was evaluated with a 3-point scale (grades 0, 1 and 3) according to the intensity and localization of signs of color. In the diagnosis of acute cholecystitis, basal examination with power Doppler had a sensitivity of 38.8%. After administration of intravenous contrast medium, sensitivity was 100%. In conclusion, the use of sonographic contrast media in the diagnosis of acute cholecystitis showed a sensitivity and specificity of 100%. This technique represents a viable diagnostic alternative to other complementary or imaging studies.

[Present and future of neurology in Spain]. / Presente y futuro de la neurología española.

This is a document prepared by the Spanish Society of Neurology (SEN), which was given to the President of Spain (Mr. José María Aznar) last September with the main aim of examining the current situation of Neurology in our country. It analyses the present and future of Neurology in clinical assistance, teaching and research. To prepare this document the criteria of patients' associations has been considered, including the Declaration of Madrid which has been subscribed by thirty of these associations. In spite of its relevant development in the previous decades, the current situation of Neurology in Spain is far from the ideal. To reach the recommendable menber of 3 or 4 neurologists per 100,000 inhabitants it is necessary to duplicate the present number of neurologists which has been estimated around 2/100,000; this situation is especially urgent in some Autonomous Communities. The most important problems in neurological assistance are: inadequate follow-up of the chronic outpatients, low numbers of neurological beds and of duties of Neurology, as well as of neurological case of patients with urgent neurological disorders. It is also necessary to increase the number of professors of Neurology to adequately cover pregraduate teaching; again there are important differences in teaching positions among Autonomous Communities. Neurology residence should be prolonged from 4 to 5 years. Finally, it is necessary to support the appearance of superespecialised units and to promote a coordinated research with other close specialities including basic neuroscience.

Activity of Crohn's disease assessed by colour Doppler ultrasound analysis of the affected loops.

The aim of this study was to evaluate with colour Doppler ultrasound the vascular changes in the wall of the loops affected by Crohn's disease, and to establish whether these changes reflects clinical or biochemical activity of Crohn's disease. Seventy-nine patients with Crohn's disease (44 with active disease and 35 inactive patients) were studied with frequency- and amplitude-encoded duplex Doppler sonography. A group of 35 healthy volunteers were also included. The exam consisted of the search for colour signals in the walls of the loops affected by Crohn's disease, classifying the degree of vascularity with a simple scoring system into three groups: absence of colour signal (score of 0); weak or scattered colour signals (score of 1); and multiple colour signals or clear identification of vessels in the loops walls (score of 2). Doppler curves were obtained of the detected vessels with measurement of the resistive index (RI). There was a visible increase in the gut walls' vascularity in the active patients compared with those with inactive disease. The mean RI was statistically significantly lower in the gut wall vessels of the patients with active illness than that obtained in the inactive patients. Colour Doppler ultrasound is a useful tool in the assessment of activity in Crohn's disease.

Hyperechoic focal bacterial nephritis: findings on contrast-enhanced Colour Doppler ultrasound.

We report a case of atypical focal bacterial nephritis (lobar nephronia) simulating a renal mass on gray-scale ultrasound, describing the findings on Colour Doppler ultrasound before and after administration of a galactose-based ultrasound contrast agent.

Hepatitis B virus-specific T-cell proliferation and cytokine secretion in chronic hepatitis B e antibody-positive patients treated with ribavirin and interferon alpha.

Immune elimination of hepatitis B virus (HBV) during antiviral therapy depends on the activation of T-cell responses, which are generally impaired in chronic hepatitis B. HBV-specific T helper (Th)-cell reactivity has been assessed post-treatment in liver and peripheral blood of 18 anti-HBe-positive patients with chronic hepatitis B administered combined ribavirin/interferon alfa (IFN-alpha) therapy. The results showed that patients with undetectable HBV DNA by quantitative polymerase chain reaction under combination therapy were able to mount an HBV-specific CD4(+) Th-cell proliferative response and such T-cell reactivity is detectable 1 year after HBV DNA clearance. Hepatitis B virus core (HBcAg) and e (HBeAg) antigen-specific Th-cell proliferation was found more frequently in the liver and peripheral blood in those patients who sustained the alanine aminotransferase (ALT) normalization together with HBV DNA loss. However, HBV-specific IFN-gamma production in vitro in peripheral blood mononuclear cells augmented in 4 of 5 sustained responders and all 13 nonresponders, interleukin 10 (IL-10) production decreased in all 5 sustained responders but increased in 7 of 13 nonresponders. Furthermore, intrahepatic HBcAg plus HBeAg-specific Th-cell proliferation only occurred in sustained responders (2 of 3, 67%, vs. 0 of 9; P =.045) whose cells showed in vitro significantly increased productions in HBcAg/HBeAg-specific IFN-gamma and IL-12 compared with nonresponders in whom IFN-gamma and IL-12 productions decreased together with increased IL-10 secretion. In conclusion this study indicates that combined therapy with ribavirin and IFN-alpha for chronic hepatitis B not only significantly reduces viremia levels but also induces lasting CD4(+) T-cell proliferation and Th1 cytokine release at the site of infection, which may lead to sustained eradication of the HBV.

Wireless endoscopy.

Wireless endoscopy consists of a small-sized device which allows gastrointestinal tract images to be taken as it physiologically advances along its lumen after being orally ingested. Its primary contribution is the study of small bowel conditions, a gastrointestinal tract segment in which diagnosis difficulties still arise when using current tests, including enteroscopy. Preliminary studies in animals and healthy subjects have revealed data on image quality, sensitivity, specificity, and safety that demonstrate the benefits of this new technique. This review discusses technical aspects, indications and contraindications, as well as studies reported so far on this endoscopic diagnostic procedure.

Sustained response to combination therapy in a patient with chronic hepatitis C and thrombocytopenia secondary to alpha-interferon.

Recent data suggest that hepatitis C viral (HCV) infection may induce a significant autoimmune reaction to platelets, but the mechanism is unknown. Many patients with chronic hepatitis C, in fact, have high levels of platelet-associated immunoglobulin G (PAIgG) and HCV-RNA is present in the platelets of 100% of those patients with thrombocytopenia and high PAIgG levels. Hepatitis C virus infection has been associated with the development of thrombocytopenic purpura, sometimes triggered during interferon (IFN) therapy. In such cases, the treatment of the underlying disease is a difficult problem to solve. We report the case of a patient with chronic hepatitis C, who developed life-threatening thrombocytopenic purpura after a prolonged course of IFN-alpha2b over a 4-year period. Treatment with anti-immunoglobulin gammaglobulin (Polyglobin; Química Farmaceutica Bayer, Barcelona, Spain) had a transient effect on the platelet count, but prolonged therapy with prednisone was necessary for definitive relief of the haematological complication. Two years later, the patient was treated with combined therapy, including ribavirin (1200 mg/day) and IFN-alpha2b (5 mU, t.i.w.) for 12 months. This therapy induced a sustained response, both biochemical and virological, without haematological complications. This observation suggests that ribavirin may be of benefit in the treatment of immune-mediated thrombocytopenia in patients with chronic hepatitis C, preventing the harmful effect of IFN-alpha but also allowing both drugs to be combined so as to increase the probability of sustained remission of the liver disease.

Biochemical markers and bone densitometry in inflammatory bowel disease.

AIMS: Bone mineral density is reduced in patients with inflammatory bowel disease. The possible causes of this situation are delayed puberty, malabsorption, and corticosteroid use, among others. No published data exist regarding the use of biochemical markers and bone densitometry to assess osteopenia in these patients in Spain. METHODS: We studied 54 patients (24 men and 30 women), 22 with Crohn's disease and 32 with ulcerative colitis. Age, type of disease and average daily dose of prednisone-equivalent corticosteroids were evaluated. Lumbar bone mineral density was assessed quantitative digital radiography densitometry. The bone resorption marker urine D-pyridinoline and the bone formation marker serum osteocalcin were also assessed. RESULTS: Mean age was 36.61 +/- 13.37 years. Daily corticosteroid dose was correlated with D-pyridinoline (r = 0.413; p < 0.01), and D-pyridinoline was inversely correlated with osteocalcin (r = -0.304; p < 0.01). There was a negative correlation between bone mineral density and corticosteroid dose. There was no relationship between biochemical markers and bone densitometry findings in these patients. There were no differences in terms of bone densitometry findings or biochemical markers between the two types of inflammatory bowel disease. CONCLUSIONS: D-pyridinoline correlated inversely with osteocalcin. Daily corticosteroid dose correlated directly with D-pyridinoline, and inversely with bone mineral density.