Highly pathogenic avian influenza: Unprecedented outbreaks in Canadian wildlife and domestic poultry

Canada experienced a wave of HPAI H5N1 outbreaks in the spring of 2022 with millions of wild and farmed birds being infected. Seabird mortalities in Canada have been particularly severe on the Atlantic Coast over the summer of 2022. Over 7 million birds have been culled in Canada, and outbreaks continue to profoundly affect commercial bird farms across the world. This new H5N1 virus can and has infected multiple mammalian species, including skunks, foxes, bears, mink, seals, porpoises, sea lions, and dolphins. Viruses with mammalian adaptations such as the mutations PB2-E627K, E627V, and D701N were found in the brain of various carnivores in Europe and Canada. To date this specific clade of H5N1 virus has been identified in less than 10 humans. At the ground level, awareness should be raised among frontline practitioners most likely to encounter patients with HPAI.

18 Lyme disease as an emerging cause of Seventh Cranial Nerve Palsy (“Bell’s palsy”) in Nova Scotia

Introduction/Background

Lyme disease, a tick-borne zoonosis caused by the bacterium Borrelia burgdorferi, has emerged in Nova Scotia (NS) as a common illness. Since 2002 when Lyme disease was first diagnosed in NS, >1000 cases have been reported. Seventh cranial nerve palsy (CNP-7) is said to be the most common presentation of early disseminated Lyme disease in children in endemic areas.

Objectives

We aimed to determine the frequency of CNP-7 in NS and if physicians are considering Lyme disease as an etiology.

Design/Methods

A retrospective review of health records of children seen at the IWK Health Centre from 2000-2018 who were ≤18 years of age with an ICD-9 or 10 diagnosis of Bell’s palsy (CNP-7) was conducted. CNP-7 due to local infection, trauma, malignancy, or systemic neurologic disease was excluded.

Results

Of 237 ICD “Bell’s palsy” diagnoses, 66 cases were eligible, of which 60.6 % (n=40) were female. The median age was 10 years (range 0-16). Five cases of Lyme disease-associated CNP-7 were recognized (7.6%), all since 2013. No bilateral CNP-7 occurred; 59.1% of cases were on the left. Most children presented within 3 days of symptom onset (84.8%) to the emergency department (95.4%), and 56.1% subsequently saw a pediatric neurologist. The most common associated symptom with CNP-7 was headache (22.7%). Lyme disease was considered in the differential diagnosis in 34.8 % (n=23) of cases, and only since 2012. Systemic steroids were prescribed to 51.5 % (34/66) of children in the emergency department, for durations varying from 1 to 10 days. The most common steroid course length was 5 days. Antimicrobials were prescribed for 18 (27.3%) children including acyclovir, beta lactams and tetracyclines.

Resolution of the facial palsy findings was documented in 45 children, of whom 36 (54.5%) had complete resolution and 9 (13.6%) had partial resolution. Four children with Lyme disease associated CNP-7 had complete resolution, and one had partial resolution.

Conclusion

There does not appear to be a standard approach to diagnosis and management of CNP-7 in this pediatric health centre. Lyme disease is not regularly considered in the differential diagnosis, which is surprising given the high incidence of Lyme disease in NS. These findings will be shared with health care providers most likely to see CNP-7 in order to develop a standard algorithm to the initial presentation of 7th cranial nerve palsy in children.

Early detection of cognitive impairments with the Montreal Cognitive Assessment in patients with uncomplicated and complicated mild traumatic brain injury

OBJECTIVES

The Montreal Cognitive Assessement (MoCA) is a brief and standardized cognitive screening tool that has been used with several clinical populations. The aim of this study was to screen the early cognitive status of patients following mild traumatic brain injury (mTBI) with the MoCA.

METHODS

The MoCA was administered within the first 2 weeks post-injury to 42 patients with uncomplicated mTBI, 92 patients with complicated mTBI and 50 healthy controls.

RESULTS

Patients with complicated mTBI had a significantly lower performance (more impairments) on the total score of the MoCA than both the group with uncomplicated mTBI and the control group. Also, the group with uncomplicated mTBI had a significantly lower performance than controls. Moreover, age, education and TBI severity had a significant effect on the MoCA total score where younger, more educated and patients with less severe (higher GCS score) mTBI performed significantly better.

CONCLUSIONS

The MoCA may be clinically useful to acutely screen cognition following mTBI.

Prediction of behavioural and cognitive deficits in patients with traumatic brain injury at an acute rehabilitation setting

OBJECTIVE

The goal of this study was to identify factors that would predict short-term neuropsychological outcome in patients with traumatic brain injury (TBI) hospitalized in an acute rehabilitation setting.

METHODS

Data was collected in the context of an acute early rehabilitation setting of a trauma centre. A brief neuropsychological assessment was carried out for 348 patients within a month following their trauma.

RESULTS

Length of post-traumatic amnesia (PTA) was the best predictor of behavioural, memory and executive function variables within a month post TBI. The odds of being agitated, labile, irritable and disinhibited at one month post trauma were almost six times higher for those with PTA that lasted more than 7 days compared to those with a PTA of less than 24 hours. Also, the odds of having a higher mental manipulation score (less significant executive function impairment) were almost two times lower for those with frontal lesions, and three to six times lower for those with PTA of more than 24 hours. In addition, TBI severity, education and age were considered good predictors of some aspects of neuropsychological outcome.

CONCLUSION

This model may help clinicians and administrators recognize the probable post-traumatic deficits as quickly as possible and to plan interventions as well as post-acute discharge orientation accordingly and early on.

Cystic pancreatic neuroendocrine tumors: outcomes of preoperative endosonography-guided fine needle aspiration, and recurrence during long-term follow-up

BACKGROUND AND STUDY AIMS

The role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the diagnosis and management of cystic pancreatic neuroendocrine tumors (PNETs) is unclear. We aimed to compare clinical/endosonographic characteristics of cystic with solid PNETs, determine diagnostic accuracy of preoperative EUS-FNA, and evaluate recurrence rates after resection.

PATIENTS AND METHODS

All patients with cystic or solid PNET confirmed by EUS-FNA between 2000 and 2014 were identified. A matched case-control study compared 50 consecutive patients with cystic PNETs with 50 consecutive patients with solid PNETs, matched by gender and age at diagnosis of index cystic PNET. We compared clinical/endosonographic characteristics, assessed diagnostic accuracy of preoperative EUS-FNA for identifying malignancy, and analyzed tumor-free survival of patients with cystic and solid PNETs.

RESULTS

Cystic PNETs tended to be larger than solid PNETs (mean 26.8 vs. 20.1 mm, P = 0.05), more frequently nonfunctional (96 % vs. 80 %, P = 0.03), and less frequently associated with multiple endocrine neoplasia type 1 (10 % vs. 28 %, P = 0.04). With surgical pathology as reference standard, EUS-FNA accuracies for malignancy of cystic and solid PNETs were 89.3 % and 90 %, respectively; cystic PNETs were less associated with metastatic adenopathy (22 % vs. 42 %, P = 0.03) and liver metastasis (0 % vs. 26 %, P < 0.001). Cystic fluid analysis (n = 13), showed benign cystic PNETs had low carcinoembryonic antigen (CEA), Ki-67 ≤ 2 %, and no loss of heterozygosity. Patients with cystic and solid PNETs had similar recurrence risk up to 5 years after complete resection.

CONCLUSIONS

Cystic PNETs have distinct clinical and EUS characteristics, but were associated with less aggressive biological behavior compared with solid PNETs. EUS-FNA is accurate for determining malignant potential on preoperative evaluation. Despite complete resection, recurrence is observed up to 5 years following surgery.

Interim estimates of 2014/15 influenza vaccine effectiveness in preventing laboratory-confirmed influenza-related hospitalisation from the Serious Outcomes Surveillance Network of the Canadian Immunization Research Network, January 2015

Binary file ES_Abstracts_Final_ECDC.txt matches

Performance characteristics of EUS for locoregional evaluation of ampullary lesions

BACKGROUND

The accuracy of EUS in the locoregional assessment of ampullary lesions is unclear.

OBJECTIVES

To compare EUS with ERCP and surgical pathology for the evaluation of intraductal extension and local staging of ampullary lesions.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care referral center.

PATIENTS

All patients who underwent EUS primarily for the evaluation of an ampullary lesion between 1998 and 2012.

INTERVENTION

EUS.

MAIN OUTCOME MEASUREMENTS

Comparison of EUS sensitivity/specificity for intraductal and local extension with ERCP and surgical pathology by using the area under the receiver-operating characteristic (AUROC) curves and outcomes of the subgroup referred for endoscopic papillectomy.

RESULTS

We identified 119 patients who underwent EUS for an ampullary lesion, of whom 99 (83%) had an adenoma or adenocarcinoma. Compared with ERCP (n = 90), the sensitivity/specificity of EUS for any intraductal extension was 56%/97% (AUROC = 0.77; 95% confidence interval [CI], 0.64-0.89). However, when using surgical pathology as the reference (n = 102), the sensitivity/specificity of EUS (80%/93%; AUROC = 0.87; 95% CI, 0.76-0.97) and ERCP (83%/93%; AUROC = 0.88; 95% CI, 0.77-0.99) were comparable. The overall accuracy of EUS for local staging was 90%. Of 58 patients referred for endoscopic papillectomy, complete resection was achieved in 53 (91%); in those having intraductal extension by EUS or ERCP, complete resection was achieved in 4 of 5 (80%) and 4 of 7 (57%), respectively.

LIMITATION

Retrospective design.

CONCLUSIONS

EUS and ERCP perform similarly in evaluating intraductal extension of ampullary adenomas. Additionally, EUS is accurate in T-staging ampullary adenocarcinomas. Future prospective studies should evaluate whether EUS can identify characteristics of ampullary lesions that appropriately direct patients to endoscopic or surgical resection.

Role of endoscopic ultrasound fine-needle aspiration evaluating adrenal gland enlargement or mass

AIM: To report the clinical impact of adrenal endoscopic ultrasound fine-needle aspiration (EUS-FNA) in the evaluation of patients with adrenal gland enlargement or mass.

METHODS: In a retrospective single-center case-series, patients undergoing EUS-FNA of either adrenal gland from 1997-2011 in our tertiary care center were included. Medical records were reviewed and results of EUS, cytology, adrenal size change on follow-up imaging ≥ 6 mo after EUS and any repeat EUS or surgery were abstracted. A lesion was considered benign if: (1) EUS-FNA cytology was benign and the lesion remained < 1 cm from its original size on follow-up computed tomography (CT), magnetic resonance imaging or repeat EUS ≥ 6 mo after EUS-FNA; or (2) subsequent adrenalectomy and surgical pathology was benign.

RESULTS: Ninety-four patients had left (n = 90) and/or right (n = 5) adrenal EUS-FNA without adverse events. EUS indications included: cancer staging or suspected recurrence (n = 31), pancreatic (n = 20), mediastinal (n = 10), adrenal (n = 7), lung (n = 7) mass or other indication (n = 19). Diagnoses after adrenal EUS-FNA included metastatic lung (n = 10), esophageal (n= 5), colon (n = 2), or other cancer (n = 8); benign primary adrenal mass or benign tissue (n = 60); or was non-diagnostic (n = 9). Available follow-up confirmed a benign lesion in 5/9 non-diagnostic aspirates and 32/60 benign aspirates. Four of the 60 benign aspirates were later confirmed as malignant by repeat biopsy, follow-up CT, or adrenalectomy. Adrenal EUS-FNA diagnosed metastatic cancer in 24, and ruled out metastasis in 10 patients. For the diagnosis of malignancy, EUS-FNA of either adrenal had sensitivity, specificity, positive predictive value and negative predictive value of 86%, 97%, 96% and 89%, respectively.

CONCLUSION: Adrenal gland EUS-FNA is safe, minimally invasive and a sensitive technique with significant impact in the management of adrenal gland mass or enlargement.

Alterations in cyst fluid genetics following endoscopic ultrasound-guided pancreatic cyst ablation with ethanol and paclitaxel

BACKGROUND AND STUDY AIMS

Endoscopic ultrasound (EUS)-guided ethanol lavage with paclitaxel injection has been shown to be effective for the treatment of pancreatic cystic neoplasms; however, the evidence for effectiveness is based primarily on cyst resolution on imaging. The aim of this study was to evaluate changes in pancreatic cyst fluid DNA following EUS-guided pancreatic cyst ablation (PCA) with ethanol and paclitaxel.

PATIENTS AND METHODS

In a single-center, prospective study, patients with suspected benign pancreatic cysts (15 - 50 mm in diameter; ≤ 5 compartments) underwent EUS-PCA with ethanol and paclitaxel followed 3 months later by repeat EUS-FNA, cyst aspiration for repeat DNA analysis, and possible repeat EUS-PCA. Abdominal imaging was repeated 3 - 4 months and 12 months after the second EUS. Changes in baseline pancreatic cyst fluid DNA, procedural complications, and radiographic changes in cyst volume were evaluated.

RESULTS

A total of 22 patients (median age 67 years; 15 women) with cysts in the head or uncinate (n = 10), body or neck (n = 8), and tail (n = 4), measuring a median diameter of 25 mm (range 15 - 43 mm), underwent one (n = 22) or two (n = 9) EUS-PCA procedures. Baseline cyst DNA included mutations in 11 patients (50 %). Postablation cyst fluid (n = 19) showed elimination of all baseline mutations in eight patients, new mutations in three, and no changes in eight without a baseline mutation. The largest per-protocol postablation image-defined volume change (n = 20) from either of the follow-up abdominal imaging studies (n = 20) demonstrated complete response ( < 5 % original volume) in 10 patients (50 %), partial response (5 % - 25 % original volume) in 5 (25 %), and a persistent cyst (> 25 % original volume) in 5 (25 %). During a median follow-up of 27 months (range 17 - 42 months), adverse events from all EUS-PCAs (n = 31) included abdominal pain alone in four patients (13 %), pancreatitis in three (10 %), peritonitis in one (3 %), and gastric wall cyst in one (3 %). The adverse events were classified as moderately severe in four patients (three with pancreatitis, one with peritonitis).

CONCLUSION

EUS-PCA with ethanol and paclitaxel may possibly eliminate mutant DNA in neoplastic pancreatic cysts. This technique leads to complete or partial image-defined resolution in 75 % of cysts but may lead to rare adverse events.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT01643460).

Interim estimates of 2013/14 influenza clinical severity and vaccine effectiveness in the prevention of laboratory-confirmed influenza-related hospitalisation, Canada, February 2014

Binary file ES_Abstracts_Final_ECDC.txt matches

Phase II and gene expression analysis trial of neoadjuvant capecitabine plus irinotecan followed by capecitabine-based chemoradiotherapy for locally advanced rectal cancer: Hoosier Oncology Group GI03-53

PURPOSE

We designed this study in locally advanced rectal cancer to determine the pathological response, toxicity, and disease-free survival (DFS) with induction capecitabine plus irinotecan followed by capecitabine-based chemoradiotherapy (CRT) and analyze the gene expression of enzymes involved in the metabolism of capecitabine and irinotecan for associations with response and toxicity.

METHODS

Patients with T3/T4 or node positive rectal cancer were treated with capecitabine 1,000 mg/m(2) twice daily (BID) days 1-14, and irinotecan 200 mg/m(2) on day 1 every 21 days for 2 cycles, followed by capecitabine 825 mg/m(2) BID days 1-5 per week with concurrent radiotherapy 50.4 Gy in 28 fractions. Surgical resection occurred a median of 7.4 weeks after CRT. Gene expression levels or sequencing were used to analyze carboxylesterase-converting enzymes (CES1, CES2), thymidylate synthase (TS), thymidine phosphorylase (TP), dehydropyrimidine dehydrogenase (DPD), topoisomerase I (TOPO I), and uridine-diphosphate (UDP) glucuronosyl transferase 1A1 in pre- and post-treatment tumor and normal tissue samples.

RESULTS

Twenty-two patients were enrolled, and 18 completed neoadjuvant therapy and underwent R0 resection. Two patients with UGT1A1 7/7 had grade 3 and 4 neutropenic fever and sepsis. Pathological complete response (pCR) occurred in 6 of 18 patients (33 %) and 10 (56 %) had tumor and/or nodal downstaging. The 3-year DFS was 75.5 % (95 % CI, 39.7-91.8 %). Locoregional control rate was 100 %. We observed higher TP gene expression in pCR patients, but no correlations with toxicity.

CONCLUSIONS

This neoadjuvant regimen was safe and demonstrated significant antitumor activity. High TP tumor gene expression was associated with obtaining pCR.

Endoscopic ultrasound-guided fine-needle aspiration with or without flow cytometry for the diagnosis of primary pancreatic lymphoma - a case series

The role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with flow cytometry for the diagnosis of primary pancreatic lymphoma (PPL) has not been previously described. Our aims were to describe the EUS features of PPL and the role of EUS-FNA with and without flow cytometry in the diagnosis of 16 patients. When EUS-FNA with flow cytometry was compared with EUS-FNA without flow cytometry, the sensitivities for diagnosing non-Hodgkin's lymphoma were 84.6 % versus 30.8 %, respectively ( P = 0.01). EUS-FNA with flow cytometry is a valuable tool to diagnose PPL. Flow cytometry analysis complements traditional assessment by standard cytology.

Cardiac risk assessment before the use of stimulant medications in children and youth: A joint position statement by the Canadian Paediatric Society, the Canadian Cardiovascular Society, and the Canadian Academy of Child and Adolescent Psychiatry

Regulatory decisions and scientific statements regarding the management of attention-deficit hyperactivity disorder (ADHD) raise questions about the safety of medications and the appropriate pretreatment evaluation to determine suitability for treatment with medication. This is particularly true in the setting of known structural or functional heart disease. The present paper reviews the available data, including peer-reviewed literature, data from the United States Food and Drug Administration Web site on reported adverse reactions in children using stimulant medication, and Health Canada data on the same problem. A consensus-based guideline on appropriate assessment is provided, based on input from members of the Canadian Paediatric Society, the Canadian Cardiovascular Society and the Canadian Academy of Child and Adolescent Psychiatry, with specific expertise and knowledge in the areas of both ADHD and pediatric cardiology. The present statement advocates a thorough history and physical examination before starting stimulant medications, with an emphasis on the identification of risk factors for sudden death, but does not routinely recommend electrocardiographic screening or cardiac subspecialist consultation unless indicated by history or physical examination findings. A checklist for identifying children who are potentially at risk of sudden death (independent of ADHD or medications used to treat it) is provided. Although recommendations are based on the best evidence currently available, the committee further agrees that more research on this subject is necessary to optimize the approach to this common clinical scenario.

Laboratory diagnosis of mumps in a partially immunized population: The Nova Scotia experience

BACKGROUND

In 2007, Atlantic Canada experienced a large outbreak of mumps predominately in university students who had received a single dose of measles, mumps and rubella vaccine. The present study describes the performance characteristics of reverse transcriptase polymerase chain reaction (RT-PCR) on buccal and urine specimens and immunoglobulin M (IgM) serology in this partially immune population.

METHODS

Patients presenting with symptoms suspicious for mumps had a serum, urine and a buccal swab collected for diagnostic testing. Persons were classified as a 'confirmed' case according to the Public Health Agency of Canada's definition. Sera were tested using an enzyme-linked immunoassay. Detection of mumps virus in buccal swabs and urine samples was performed by RT-PCR.

RESULTS

A subset of 155 cases and 376 non-cases that had all three specimens submitted was used for calculating the performance characteristics. The sensitivity of RT-PCR on buccal swabs, urine specimens and IgM serology were 79%, 43% and 25%, respectively. The specificity of RT-PCR on buccal swabs, urine specimens and IgM serology was 99.5%, 100% and 99.7%, respectively. Only 12 of 134 (9%) patients had positive urine specimens in the presence of negative oral swabs.

CONCLUSION

RT-PCR on buccal swabs is the ideal specimen for diagnosis. Testing an additional urine sample in an outbreak setting did not increase the diagnostic yield significantly, but doubled testing volume and cost. In addition, the data suggest that, in this partially immune group, IgM serology has little value in the diagnosis of acute infection.

Nurse-administered propofol sedation for upper endoscopic ultrasonography

BACKGROUND

Limited data exist regarding the safety of nurse-administered propofol sedation (NAPS) for advanced endoscopy.

AIMS

To evaluate the frequency of and the risk factors for complications associated with NAPS for upper endoscopic ultrasound (EUS).

METHODS

Consecutive upper EUS examinations using NAPS were retrospectively identified. Clinical data and adverse events were recorded. Univariate and multivariable repeated measures logistic regression models were used to identify independent risk factors for complications.

RESULTS

Among 806 EUS procedures, the mean procedure duration, time for sedation induction, and postprocedure recovery time were: 34 +/- 20 min, 3.6 +/- 1.4 min, and 27 +/- 23 min, respectively. A decline in systolic blood pressure (SBP) to <90 mm Hg occurred in 104 patients (13%). Six patients (0.7%) had a decline in oxygen saturation (SpO(2)) to <90%. Four patients (0.5%; 95% confidence interval [CI] 0.14-1.27) required assisted positive pressure ventilation. There were no major complications. The minor complication rate from sedation was 21% (95% CI 17.2-25.3). All of the complications were clinically insignificant. Overall complication risk was not related to age, dose, or procedure time. Sedation-related complication rates for advanced experience-level (> or =100 NAPS procedures) nurses were lower compared to the least-experienced (< or =30 NAPS procedures) nurses (17.2%vs 25.4%, odds ratio [OR] 0.61, 95% CI 0.41-0.92).

CONCLUSIONS

NAPS for upper EUS is safe and may be performed without major complications. Four patients (0.5%) required assisted ventilation. Minor complications occurred in 21% of patients, but were not associated with patient age, propofol dose, or procedure time.

Nurse-administered propofol sedation for upper endoscopic ultrasonography

BACKGROUND

Limited data exist regarding the safety of nurse-administered propofol sedation (NAPS) for advanced endoscopy.

AIMS

To evaluate the frequency of and the risk factors for complications associated with NAPS for upper endoscopic ultrasound (EUS).

METHODS

Consecutive upper EUS examinations using NAPS were retrospectively identified. Clinical data and adverse events were recorded. Univariate and multivariable repeated measures logistic regression models were used to identify independent risk factors for complications.

RESULTS

Among 806 EUS procedures, the mean procedure duration, time for sedation induction, and postprocedure recovery time were: 34 +/- 20 min, 3.6 +/- 1.4 min, and 27 +/- 23 min, respectively. A decline in systolic blood pressure (SBP) to <90 mm Hg occurred in 104 patients (13%). Six patients (0.7%) had a decline in oxygen saturation (SpO(2)) to <90%. Four patients (0.5%; 95% confidence interval [CI] 0.14-1.27) required assisted positive pressure ventilation. There were no major complications. The minor complication rate from sedation was 21% (95% CI 17.2-25.3). All of the complications were clinically insignificant. Overall complication risk was not related to age, dose, or procedure time. Sedation-related complication rates for advanced experience-level (> or =100 NAPS procedures) nurses were lower compared to the least-experienced (< or =30 NAPS procedures) nurses (17.2%vs 25.4%, odds ratio [OR] 0.61, 95% CI 0.41-0.92).

CONCLUSIONS

NAPS for upper EUS is safe and may be performed without major complications. Four patients (0.5%) required assisted ventilation. Minor complications occurred in 21% of patients, but were not associated with patient age, propofol dose, or procedure time.

Utility of a repeated EUS at a tertiary-referral center

BACKGROUND

The utility of a repeated EUS by experts is not known.

OBJECTIVE

To define the utility of a repeated EUS for the same indication.

DESIGN

A retrospective case series.

SETTING

Tertiary-referral hospital in Indianapolis, Indiana.

PATIENTS

Consecutive subjects, with and without cancer, who, between January 2000 and September 2006, underwent an initial EUS elsewhere within 6 and 12 weeks of a repeated EUS at our hospital.

INTERVENTIONS

A repeated EUS.

MAIN OUTCOME MEASUREMENTS

Clinical impact of a repeated EUS.

RESULTS

Of 8936 EUS examinations, 73 repeated procedures (0.8%) were identified, and 24 were excluded. The 49 initial EUS procedures (26 men, median age 59 years) were done in Indiana (n = 44) or another state (n = 5) by one of 15 physicians in private practice (n = 48) or at a teaching hospital (n = 1). An EUS-guided FNA (EUS-FNA) was performed during an initial EUS in 21 patients (no biopsy diagnostic for cancer) and was not attempted in 14 patients. The principle indication for a repeated EUS (n = 35) was for an EUS-FNA after the initial tissue sampling was benign, nondiagnostic, or not done. A second EUS had no clinical impact in 18 patients (37%). In the remaining 31 patients (63%), a repeated EUS provided a new or changed clinical diagnosis (n = 12), the initial diagnosis of primary pancreatic cancer (n = 5) or GI stromal tumor (GIST) (n = 1) after a previous nondiagnostic biopsy; or the initial diagnosis of primary (n = 4) or metastatic (n = 2) pancreatic cancer, metastatic esophageal cancer (n = 1), hilar cholangiocarcinoma (n = 1), GIST (n = 1), or pancreatic neuroendocrine tumor (n = 1), or an initial aspiration of a pancreatic cyst (n = 3) after a previous EUS-FNA was not able to be performed.

LIMITATIONS

A retrospective design; a small number of nonpancreatic indications.

CONCLUSIONS

In this study, a repeated EUS at a tertiary-referral center had a clinical impact in 63% of patients when performed by experts for a similar clinical indication.

Pancreatic cystic neuroendocrine tumors: preoperative diagnosis with endoscopic ultrasound and fine-needle immunocytology

BACKGROUND

Pancreatic cystic neuroendocrine tumors (CNETs) are rare premalignant conditions. Computed tomography (CT) occasionally demonstrates the hypervascular border characteristic of NETs. Endoscopic ultrasound (EUS) with fine-needle aspiration and immunocytology may be a more consistent means to establish the diagnosis, but no data on the role of EUS are available. This report represents the largest series of CNETs treated to date, documents the role of EUS in preoperative diagnosis, and describes current management.

METHODS

Retrospective review of our experience with CNETs treated at an academic center between 1999 and 2006.

RESULTS

Thirteen patients with CNETs were identified. One had symptoms consistent with a functional tumor; the others were nonfunctional. Twelve were detected by CT; only three had peripheral hypervascularity. Nine were studied with preoperative EUS/immunocytology; each of these demonstrated strong staining for chromogranin and synaptophysin. All were resected: four by pancreaticoduodenectomy, one by total pancreatectomy, and one by enucleation. Perioperative morbidity occurred in 39%. Perioperative mortality was 0%. Average follow-up was 3.3 + 0.5 years. One patient had late hepatic recurrence and ultimately died of disease. Two developed recurrent NET in the context of MEN I and required additional surgery. Twelve are alive with no evidence of disease.

CONCLUSIONS

EUS-guided immunocytology with staining for neuroendocrine markers is an accurate method to establish the diagnosis of CNET preoperatively. Short- and long-term outcomes after resection are excellent.

Endoscopic ultrasound-guided fine needle aspiration and cyst fluid analysis for pancreatic cysts

CONTEXT

Endoscopic ultrasound (EUS) with EUS-guided fine needle aspiration (EUS-FNA) has been increasingly utilized to differentiate malignant/pre-malignant pancreatic cysts from those that are benign or have low malignant potential.

OBJECTIVE

To determine the utility of EUS morphology, EUS-FNA cytology and cyst fluid analysis to distinguish mucinous cystic neoplasms from non-mucinous cystic neoplasms based on histopathology following surgical resection.

DESIGN

A retrospective, single center case series.

PARTICIPANTS

Patients who underwent EUS and EUS-FNA of known or suspected pancreatic cysts followed by surgical resection. The final diagnosis was based on histopathology.

SETTING

Patients were divided in two groups: mucinous cystic neoplasms and non-mucinous cystic neoplasms. Patients with intraductal papillary mucinous tumors were excluded.

MAIN OUTCOME MEASURES

Clinical profiles and EUS findings.

RESULTS

Forty-eight patients (mean age: 52 years; 29 females, 19 males) were identified: 16 mucinous cystic neoplasms and 32 non-mucinous cystic neoplasms. There were more women in the mucinous cystic neoplasm group compared to the non-mucinous cystic neoplasm group (88% vs. 47%; P=0.011) but the two groups were otherwise similar. The sensitivity, specificity and frequency of cases correctly identified of EUS-FNA cytology for the diagnosis of mucinous cystic neoplasms were 12.5% (95% CI: 2.2-37.2%), 90.6% (95% CI: 75.0-97.5%) and 64.6% (95% CI: 50.4-77.0%), respectively. Median cyst fluid CEA for the mucinous cystic neoplasm group (277 ng/mL; n=14) was significantly higher (P=0.002) than the non-mucinous cystic neoplasm group (1.5 ng/mL; n=21). Cyst fluid CEA greater than 800 ng/mL had a sensitivity of 42.9% (95% CI: 21.3-67.4%) and specificity of 95.2% (95% CI: 75.6-99.9%) for the diagnosis of mucinous cystic neoplasm. On the other hand, a cyst fluid CEA greater than a best cut-off ranging from 3.5 to 8.5 ng/mL had a sensitivity of 92.9% (95% CI: 66.5-100%), a specificity of 66.7% (14/21; 95% CI: 45.2-83.0%), and an accuracy of 81.1% with a frequency of cases correctly identified of 77.1% (95% CI: 60.7-88.2%).

CONCLUSIONS

EUS-FNA cytology and cyst fluid CEA greater than 800 ng/mL are insensitive but highly specific for differentiating mucinous cystic neoplasms from non-mucinous cystic neoplasms. EUS morphology alone cannot distinguish between the two groups.

Endoscopic ultrasound-guided fine-needle aspiration of ascites

BACKGROUND & AIMS

The aim of this study is to report a large single-center experience with endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) of ascites.

METHODS

Consecutive patients at our institution in whom EUS-guided paracentesis was performed between January 1997 and July 2005 were identified retrospectively. All procedures were performed by or under the supervision of 1 of 5 experienced endosonographers with available on-site cytopathology.

RESULTS

Sixty consecutive patients (33 men; mean age, 67 y) were identified. Previously attempted percutaneous paracentesis was unsuccessful in 3 of 6 patients. Ascites confirmed by EUS FNA was visible in 28 of 54 (52%) computerized tomography, 3 of 11 (27%) transabdominal ultrasound, and 4 of 8 (50%) magnetic resonance imaging examinations before EUS. Transgastric (n = 55) or transduodenal (n = 5) EUS-guided paracentesis (mean, 8.9; range, 1-40 mL) revealed malignancy in 16 (27%) from primary pancreatic (n = 9), gastric (n = 2), urothelial (n = 1), esophageal (n = 1), gallbladder (n = 1), bile duct (n = 1) cancer, and lymphoma (n = 1). The cytology from 2 patients was atypical (1 suspicious for malignancy and 1 considered reactive) and the remaining 42 were benign. Potential complications occurred in 2 of 60 (3%) patients with self-limited fever. Of the 8 of 60 (13%) patients who underwent subsequent surgery, 3 had metastatic pancreatic adenocarcinoma (n = 2) and metastatic small intestinal carcinoid (n = 1) to the peritoneum after negative EUS-FNA cytology.

CONCLUSIONS

EUS frequently identifies ascites missed by other imaging studies. EUS-guided paracentesis may identify malignancy in a subset of patients. Negative ascitic fluid cytology from EUS FNA does not exclude possible peritoneal carcinomatosis.

Plasma dopamine and noradrenaline variations in response to stress

Dopamine (DA) the precursor of noradrenaline (NA) has been shown to have many functions such as its influence on endorphins activity and its association with hedonic impact, anxiety and depression. However with regard to the sympathetic nervous system activity, the role of DA has merely been considered as being the precursor of NA. We have shown in a previous study a positive correlation between the resting plasma level of NA and those found during exposure to a physical stress. No explanation was proposed to explain this finding. Enhanced sympathetic nervous system activity has been shown to increase the secretion of NA as well as DA. It is not known however if the secretion of DA during exposure to stress parallels that of NA. What are the interactions between the two amines and also between values at rest and during exposure to stress? For that reason a test was used which consisted of blowing cold wind (4 degrees C at 60 km/h) on the face of a group of subjects and measuring plasma concentration of the two amines before, during and after the test. For a given individual, the increase of either plasma NA or DA in response to the cold wind stress parallels the resting plasma concentrations of these two amines respectively. Low level of one amine at rest coincides with low increase during the stress. Furthermore the results have shown that when the plasma level of either one of these two amines is high in response to stress, the values of the other amine are small; both amines are not high or low at the same time. The literature suggests that dopamine beta hydroxylase (DBH), the enzyme which catalyzes the synthesis of NA from DA, may provide an explanation to our findings. Lower DBH activity of this enzyme would result in a lower NA and a greater DA storage and secretion. Further investigation is needed to verify this possibility.

Endoscopic ultrasound-guided fine-needle aspiration of left adrenal gland masses

BACKGROUND AND STUDY AIM

Although the left adrenal gland is readily visible by endoscopic ultrasound (EUS), there are few published data on the utility of EUS-guided fine-needle aspiration (EUS-FNA) of this site. The aim of this study was to report our experience of EUS-FNA of left adrenal gland masses.

PATIENTS AND METHODS

In this retrospective case series, we reviewed our EUS and cytology databases to identify consecutive patients who underwent EUS-FNA of the left adrenal gland between January 1997 and January 2004. Medical records were reviewed and the results of EUS examinations and cytological investigations were abstracted.

RESULTS

Our searches resulted in the identification of a series of 38 consecutive patients who underwent EUS for the evaluation of a lung mass (n = 14), a pancreatic mass (n = 14), obstructive jaundice (n = 1), dysphagia (n = 2), an ampullary adenoma (n = 1), celiac block (n = 1), or a left adrenal gland mass (n = 5). The mean maximal left adrenal mass diameter was 24 mm (range 7-66 mm). Diagnoses after EUS-FNA (the mean number of passes was 3.6) were: metastatic lung cancer (n = 2), esophageal adenocarcinoma (n = 1), melanoma (n = 1), renal cell carcinoma (n = 1), and pancreatic neuroendocrine tumor (n = 1); primary pheochromocytoma (n = 1); benign adrenal tissue (n = 21); and granulomatous inflammation (n = 1). Nine aspirations (24 %) were nondiagnostic. The absence of a discrete adrenal mass on EUS occurred more frequently in patients with nondiagnostic biopsies than in those with diagnostic biopsies (56 % vs. 7 %; odds ratio 23.4, 95 %CI 3.5 - 157.0; P = 0.004). No complications were noted.

CONCLUSIONS

EUS-FNA of the left adrenal gland is safe and can be useful for the evaluation and staging of suspected malignancy. Nondiagnostic biopsies are more common when sampling diffusely enlarged glands, compared with glands with a focal mass.

EUS-guided Trucut biopsy of suspected nonfocal chronic pancreatitis

BACKGROUND

The diagnosis of early chronic pancreatitis (CP) is difficult, and the role of EUS-FNA cytology for this indication remains unclear. The aim of this study is to determine the utility and the safety profile of EUS-guided Trucut biopsy (EUS-TCB) for the histologic diagnosis of suspected nonfocal CP.

METHODS

After radial EUS, patients with suspected CP (> or =3 EUS criteria) underwent attempted transgastric EUS-TCB of the pancreas. Histopathologic specimens were examined by one pathologist and were classified as nondiagnostic, normal pancreas, and probable or definite CP. Within 1 week after EUS, ERCP was performed by an endoscopist blinded to the EUS results. The severity of CP by ERCP was stratified by the Cambridge classification. Agreement between tests for the diagnosis of CP was evaluated by a kappa statistic.

RESULTS

Of 45 patients screened, 15 declined and 30 (12 men and 18 women, mean age 44 years) underwent diagnostic EUS. Of these, 18 (60%) had suspected CP and 16 underwent attempted biopsy. Calcific pancreatitis in two patients precluded EUS-TCB. EUS-TCB results were as follows: probable CP (1), normal pancreas (8), nondiagnostic (6), device malfunction (1). Complications after EUS-TCB occurred in two patients with normal pancreatic biopsies were the following: acute pancreatitis (1) and abdominal pain without pancreatitis (1), both of whom were hospitalized and discharged within 23 hours. Six patients refused ERCP and two (per protocol) did not undergo ERCP. For the remaining 22, agreement between diagnostic EUS and ERCP was moderate (kappa, 0.40). Agreement between EUS and ERCP with EUS-TCB were poor (kappa, 0) and fair (kappa, 0.25), respectively.

CONCLUSIONS

Transgastric EUS-TCB of suspected nonfocal CP infrequently demonstrates histologic CP in clinically suspected disease. Because of potential complications and limited diagnostic yield, this technique is not currently recommended for evaluation of these patients.

S/MAR-binding properties of Sox2 and its involvement in apoptosis of human NT2 neural precursors

DNA fragmentation in apoptosis, especially in lymphocytic cells, is initiated at scaffold/matrix attachment regions (S/MARs) and is preceded by the degradation of nuclear proteins. The present study was performed to establish whether the same mechanism occurred in human NT2 cells subjected to oxygen and glucose deprivation (OGD). We analyzed the integrity of c-myc S/MAR containing a base-unpairing region (BUR)-like element, which we established to be a binding site of the transcription factor Sox2. An accumulation of DNA breaks in close proximity to this element and a degradation of Sox2 were observed early in the OGD-induced apoptotic response. Identification of Sox2 as a novel c-myc BUR-binding protein was achieved through yeast one-hybrid screening and the Sox2/DNA interaction was confirmed by electrophoretic mobility shift assay and immunoprecipitation with Sox2 antibody. Our data support the notion that early proteolysis of unique BUR-binding proteins might represent a universal mechanism that renders these DNA sites vulnerable to endonucleolysis.

Influence of personality traits on plasma levels of cortisol and cholesterol

The literature reports many organic malfunctions that are associated with elevated plasma cortisol and cholesterol levels. The present investigation was concerned with the influence of personality on plasma levels of cortisol and cholesterol. To that effect these variables were determined in a group of 20 subjects who answered the Big-Five Inventory for measurements of personality traits. It was found that: among the 5 personality traits, extraversion was positively correlated to plasma levels of cortisol and cholesterol while the correlation was negative for neuroticism. The positive correlation between extraversion and plasma cortisol and cholesterol, as well as with the responses to stress as shown in a previous study, are similar to findings previously reported on type A individuals. Further studies are needed with a larger group of subjects to conclude to a direct causal relationship between extraversion and the high levels of plasma cortisol and cholesterol, or a predisposition to some organic malfunctions as is the case for type A.

Endoscopic ultrasound for esophageal and gastroesophageal junction cancer: Impact of increased use of primary neoadjuvant therapy on preoperative locoregional staging accuracy

Initial treatment of locally advanced esophageal and gastroesophageal junction (GEJ) malignancies for selected patients at some institutions has recently changed from surgical resection to neoadjuvant therapy. The aim of this study is to evaluate the impact of this change in treatment strategy on both the overall disease profile and locoregional endoscopic ultrasound (EUS) staging accuracy for a cohort of patients managed with primary surgical resection over a 10-year period at our institution. All subjects at our institution who underwent primary esophagectomy from 1993 to 2002 following preoperative EUS for known or suspected esophageal and/or GEJ cancers were identified. Patients with dysplasia alone, prior upper gastrointestinal tract surgery, preoperative neoadjuvant therapy, cancer of the gastric cardia or recurrent malignancy were excluded. EUS findings and staging results were compared to surgical pathology following resection. The impact of the gradually increased use of primary chemoradiation during the second half of the study was assessed. Of the 286 operations performed, 184 subjects were excluded. The remaining 102 underwent primary surgical resection a median of 18 days following EUS staging for adenocarcinoma (88%) or squamous cell carcinoma (12%) of the esophagus (69%) or GEJ (31%). Overall EUS locoregional T and N staging accuracy was 72% and 75% respectively; accuracy for T1, T2, T3 and T4 cancer was 42%, 50%, 88% and 50% respectively. Despite an increased frequency of pathologically confirmed T1 and T2 cancers (P = 0.005) and an insignificant trend toward increased N0 malignancy (P = 0.05) during the second half of the study period, no statistically significant changes in T (P = 0.07) or N (P = 0.82) staging accuracies for EUS or disease characteristics were noted between the first and second half of the study period. Despite both inaccurate radial EUS staging and increased relative use of primary surgery for early cancers, recent increased use of primary neoadjuvant therapy did not change overall disease characteristics and accuracy of locoregional EUS staging of esophageal and GEJ cancers managed with primary surgical resection.

Study on the correlation of the autonomic nervous system responses to a stressor of high discomfort with personality traits

The present study investigated Eysenck's predictions concerning the correlation of personality to arousal at higher levels of stress. Twenty young adults were exposed to a physical stress causing great discomfort, specifically a cold wind (4 degrees C at 60 km/h) exposure to the face for 3 min. Autonomic nervous system (ANS) responses were measured by continuous heart rate and plasma catecholamine determinations before, during and after the test. At the end of the test, the participants gave a rating of discomfort on a 0 to 10 scale. The personality traits were assessed with the Big-Five Inventory test (BFI). Results indicated that higher levels of trait extraversion were positively correlated with discomfort ratings and with the increased heart rate and the noradrenaline responses. Neuroticism was negatively correlated to discomfort and the autonomic responses. These findings tend to support Eysenck's theory on the role of personality on arousal at higher levels of stress. It is also proposed that the better tolerance to this severe stress observed with neuroticism is correlated to a certain habituation process caused by light to moderate arousal frequently experienced by participants with this personality trait during their daily activities.

Comparison of endoscopic ultrasonography and multidetector computed tomography for detecting and staging pancreatic cancer

BACKGROUND

Accurate preoperative detection and staging of pancreatic cancer may identify patients with locoregional disease that is amenable to surgical resection.

OBJECTIVE

To compare endoscopic ultrasonography and multidetector computed tomography (CT) for the detection, staging, and resectability of known or suspected locoregional pancreatic cancer.

DESIGN

Prospective, observational, cohort study.

SETTING

Single, tertiary referral hospital in Indianapolis, Indiana.

PATIENTS

120 participants with known or suspected locoregional pancreatic cancer.

INTERVENTIONS

Endoscopic ultrasonography followed by multidetector CT was performed in all patients. Patients with known or suspected pancreatic cancer deemed potentially resectable by 1 or both tests were considered for surgery.

MEASUREMENTS

Detection, staging, and resectability of pancreatic cancer. Surgically resected pancreatic cancer with negative microscopic histologic margins was considered resectable.

RESULTS

Of 120 patients enrolled, 104 (87%) underwent endoscopic ultrasonography and CT. Of the 80 patients with pancreatic cancer, 27 (34%) were managed nonoperatively, and 53 (66%) treated surgically had resectable (n = 25) or unresectable (n = 28) cancer. For the 80 patients with cancer, the sensitivity of endoscopic ultrasonography (98% [95% CI, 91% to 100%]) for detecting a pancreatic mass was greater than that of CT (86% [CI, 77% to 93%]; P = 0.012). For the 53 surgical patients, endoscopic ultrasonography was superior to CT for tumor staging accuracy (67% vs. 41%; P < 0.001) but equivalent for nodal staging accuracy (44% vs. 47%; P > 0.2). Of the 25 resectable pancreatic tumors in patients recommended for surgery, endoscopic ultrasonography and CT correctly identified 88% and 92%, respectively, as resectable. Of the 28 unresectable pancreatic tumors in patients recommended for surgery, endoscopic ultrasonography and CT correctly identified 68% and 64%, respectively, as unresectable.

LIMITATIONS

Radiologists who read the scans and endosonographers were not blinded to previous radiographic information. Because of the modest sample size, CIs of the sensitivity estimates were sometimes wide.

CONCLUSION

Compared with multidetector CT, endoscopic ultrasonography is superior for tumor detection and staging but similar for nodal staging and resectability of preoperatively suspected nonmetastatic pancreatic cancer.

The characteristics of asymptomatic female adolescents at high risk for depression: the baseline assessment from a prospective 8-year study

OBJECTIVES

This longitudinal 8-year study assesses potential predictors of major depressive disorder (MDD) in a cohort of healthy adolescent females at high familial risk for MDD. The objective of this study was to ascertain whether risk factors for female onset MDD would differentiate youth at high or usual risk for MDD, prior to the onset of depressive symptomology.

METHODS

Subjects (ages 12-15 years) were assigned to a high (n=43) or usual (n=40) risk group according to maternal history of MDD. Depressive symptomatology (Beck Depression Inventory, Hamilton Rating Scale for Depression), pubertal development (Pubertal Developmental Staging Questionnaire), social support (Social Support Scale), and cognitive vulnerability (Depressive Experiences Questionnaire) were assessed.

RESULTS

High risk and usual risk group demonstrated no significant differences in demographic variables such as age, body mass index, and grade. Significantly more youth in the high risk group (n=40, 93%) had started menstruation, compared to youth in the usual risk group (n=31, 77.5%). There were no significant differences between the groups on measures of dysphoric cognitive style, perceived overall number of social supports, or satisfaction with social support.

CONCLUSIONS

Females at high familial risk for the onset of depression have significant differences in pubertal development, but not in demographics, depressive symptoms, social supports, or dysphoric cognitive style, when compared to females at usual risk for depression. These findings suggest that in prevention trials for depression in asymptomatic young women no non-biological risk factors for MDD aid in identifying females at higher risk for MDD.

Regulation of DNaseY activity by actinin-α4 during apoptosis

DNaseY, a Ca(2+)- and Mg(2+)-dependent endonuclease, has been implicated in apoptotic DNA degradation; however, the molecular mechanisms controlling its involvement in this process have not been fully elucidated. We have obtained evidence from yeast two-hybrid screening and coimmunoprecipitation experiments that DNaseY interacted physically with actinin-alpha4 and this interaction significantly enhanced its endonuclease activity. Accordingly, simultaneous overexpression of both proteins in PC12 cells dramatically increased the rate of apoptosis in response to teniposide' VM26. However, overexpression of DNaseY alone neither triggered apoptosis nor facilitated cell death in response to VM26 or serum deprivation. Instead, the overexpression of DNaseY increased the production of single-strand DNA breaks and evoked a profound upregulation of DNA repair pathways. Taken together, our results point to a novel regulatory mechanism of DNaseY activity and offer an explanation for why cells must first cleave key DNA repair and replication proteins before the successful execution of apoptosis.

Efficacy of venous reconstruction in patients with adenocarcinoma of the pancreatic head

Pancreaticoduodenectomy is often avoided in patients with portal or superior mesenteric venous involvement due to the perception that venous resection is complex, morbid, and carries a poor long-term survival. Our recent experience using state-of-the-art imaging and strict resection criteria show that venous reconstruction increases operative time, transfusion requirements, intensive care unit stay, and total hospital length of stay, but has no significant impact on operative morbidity rates, mortality rates, or the incidence of positive histologic margins. Kalpan-Meier life table analysis shows similar survival curves when compared to a contemporary cohort of patients who do not undergo venous reconstruction.

Response to thermal stress and personality

Tolerance to cold and heat exposure shows large variations for which there is still insufficient explanation. On the other hand the relationship between the responses to mental stress and individual personality is well documented. The aim of this study was then to find if personality traits have some influence on the responses to environmental temperature exposure. A group of 20 young adults were exposed for 90 min to cold (10 degrees C) while skin temperature (Ts), oxygen consumption and discomfort rating were recorded. In a second experiment they were exposed to heat (40 degrees C) for 90 min when the sweat rate and the discomfort rating were recorded. Prior to these tests the Big Five Personality Test was used to measure the personality traits of the subjects. The results show significant negative correlation between neuroticism and the O(2) consumed, the discomfort rating and Ts for the test in the cold, while extraversion was positively related to O(2) consumption but not to Ts and discomfort rating. In response to heat, neuroticism predominance was associated with greater discomfort, reduced tolerance and diminished sweat rate. The discomfort rating, in this case, was negatively related to extraversion. It is proposed that the reduced O(2) consumption in the cold and the lower rate of sweating in the heat observed with neuroticism, are caused by enhanced activity of the sympathetic nervous system. Further investigation is required to assess the validity of this proposal. Overall, the present investigation shows that physical environmental stresses, in common with mental stress, could be in some ways related to personality traits.

Endoscopic ultrasound-guided fine needle aspiration cytology of solid liver lesions: a large single-center experience

OBJECTIVES

The aim of this study was to report the sensitivity, cytological diagnoses, endoscopic ultrasound (EUS) features, complications, clinical impact, and long term follow-up of a large single-center experience with endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of benign and malignant solid liver lesions.

METHODS

A database of cytologic specimens from EUS-FNA was reviewed to identify all hepatic lesions aspirated between January, 1997, and July, 2002. Procedural indications, prior radiographic data, patient demographics, EUS examination results, complications, and follow-up data were obtained and recorded.

RESULTS

EUS-FNA of 77 liver lesions in 77 patients was performed without complications. Of these 77 lesions, 45 (58%) were diagnostic for malignancy, 25 (33%) were benign, and seven (9%) were nondiagnostic. A total of 22 lesions were confirmed as negative for malignancy by follow-up (mean 762 days, range 512-1556 days) or intraoperative examination; however, seven lesions could not be classified as benign or malignant. Depending on the status of the seven unclassified lesions, sensitivity of EUS-FNA for the diagnosis of malignancy ranged from 82 to 94%. When compared with benign lesions, EUS features predictive of malignant hepatic masses were the presence of regular outer margins (60% vs 27%; p = 0.02) and the detection of two or more lesions (38% vs 9%; p = 0.03). Of the 42 patients with malignancy identified by EUS-FNA and other available imaging records, EUS detected the malignancy in 41% of patients with previously negative examinations. For the 45 subjects with cytology positive for malignancy, EUS-FNA changed management in 86% of subjects.

CONCLUSION

EUS-FNA of the liver is a safe and sensitive procedure that can have a significant impact on patient management. Prospective studies comparing the accuracy and complication rate of EUS-FNA and percutaneous fine needle aspiration (P-FNA) for the diagnosis of liver tumors are needed.

Endoscopic ultrasound-guided fine needle aspiration cytology of solid liver lesions: a large single-center experience

OBJECTIVES

The aim of this study was to report the sensitivity, cytological diagnoses, endoscopic ultrasound (EUS) features, complications, clinical impact, and long term follow-up of a large single-center experience with endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of benign and malignant solid liver lesions.

METHODS

A database of cytologic specimens from EUS-FNA was reviewed to identify all hepatic lesions aspirated between January, 1997, and July, 2002. Procedural indications, prior radiographic data, patient demographics, EUS examination results, complications, and follow-up data were obtained and recorded.

RESULTS

EUS-FNA of 77 liver lesions in 77 patients was performed without complications. Of these 77 lesions, 45 (58%) were diagnostic for malignancy, 25 (33%) were benign, and seven (9%) were nondiagnostic. A total of 22 lesions were confirmed as negative for malignancy by follow-up (mean 762 days, range 512-1556 days) or intraoperative examination; however, seven lesions could not be classified as benign or malignant. Depending on the status of the seven unclassified lesions, sensitivity of EUS-FNA for the diagnosis of malignancy ranged from 82 to 94%. When compared with benign lesions, EUS features predictive of malignant hepatic masses were the presence of regular outer margins (60% vs 27%; p = 0.02) and the detection of two or more lesions (38% vs 9%; p = 0.03). Of the 42 patients with malignancy identified by EUS-FNA and other available imaging records, EUS detected the malignancy in 41% of patients with previously negative examinations. For the 45 subjects with cytology positive for malignancy, EUS-FNA changed management in 86% of subjects.

CONCLUSION

EUS-FNA of the liver is a safe and sensitive procedure that can have a significant impact on patient management. Prospective studies comparing the accuracy and complication rate of EUS-FNA and percutaneous fine needle aspiration (P-FNA) for the diagnosis of liver tumors are needed.

Immunomodulating effects of peptidic fractions issued from milk fermented with Lactobacillus helveticus

The effect of peptides released during the fermentation of milk on the humoral immune system and on fibrosarcoma growth was studied. Lactobacillus helveticus was able to release peptidic compounds during milk fermentation due to its high proteolytic activity, as was shown by the degree of proteolysis and size-exclusion HPLC elution profiles. Three fractions of these compounds were separated and fed to mice during different periods (2, 5, and 7 d). The humoral immune response was assessed by following the number of IgA-secreting cells, and the antitumor activity was monitored by studying the regression of subcutaneously implanted fibrosarcomas. Feeding during 2 and 7 d with the medium-sized fraction (Fraction II) significantly increased the IgA-producing cells in the intestines, whereas feeding with the large compound fraction (Fraction I) during 5 d and the small compound fraction (Fraction III) during all three feeding periods provided similar increases. A double dose of Fraction II showed the highest IgA-producing cell count. The increase by Fraction III was shown to be caused by the presence of L-Tryptophan. Fraction II significantly decreased the size of fibrosarcoma when previously fed during 7 d, and feeding with Fraction I during 5 d decreased significantly its size after 35 d of growth. Although the mechanisms by which lactic acid bacteria enhance the immune system are not clear, this study clearly shows that bioactive compounds released in fermented milks contribute to the immunoenhancing and antitumor properties of these products. The release of bioactive peptides by lactic acid bacteria can have important implications on the modulation of the cellular immune response.