BACKGROUND & AIMS: :Transabdominal fine needle aspiration biopsy of a solitary space-occupying lesion in the liver produced smears containing irregular bundles of smooth muscle cells with granular or fibrillary cytoplasm and slightly pleomorphic nuclei. In a few bundles, aggregates of mature fat cells were present, which is characteristic for an angiomyolipoma. Histologic examination of the resected mass showed it to be a solitary angiomyolipoma of the liver. The diagnosis was further confirmed by immunohistochemical and electron microscopic studies.

背景与目标： : 经腹细针穿刺活检肝脏孤立性占位病变产生的涂片，其中包含不规则的平滑肌细胞束，具有颗粒状或原纤维的细胞质和轻度多形性核。在几束中，存在成熟脂肪细胞的聚集体，这是血管平滑肌脂肪瘤的特征。切除的肿块的组织学检查显示它是肝脏的孤立性血管平滑肌脂肪瘤。免疫组织化学和电子显微镜研究进一步证实了诊断。

BACKGROUND & AIMS: :Two-hundred and ninety-three patients without a previous vaginal delivery were randomized to intracervical/extra-amniotic application of 0.5 mg prostaglandin E2 (PGE2) or to gel only. Of the patients who received PGE2, 18.7% were admitted before the next morning due to spontaneous abortion, bleeding or pains. No other side-effect was observed. A statistically significant dilatation of the cervical canal was found in the prostaglandin group. Thirty percent of the treated patients did not need further dilatation of the cervix 25.4% were non-responders to PGE2 and 7.7% were hyper-responders. The number of uterine perforations, pelvic inflammatory disease (PID) or retained pregnancy products were not influenced by the pretreatment with PGE2.

背景与目标： : 两百九十三名先前没有阴道分娩的患者被随机分配到宫颈内/羊膜外应用0.5 mg前列腺素E2 (PGE2) 或仅凝胶。在接受PGE2的患者中，有18.7% 人因自然流产，出血或疼痛而在第二天早晨之前入院。未观察到其他副作用。在前列腺素组中发现了具有统计学意义的宫颈管扩张。30% 的接受治疗的患者不需要进一步扩张子宫颈，25.4% 是对PGE2无反应的患者，7.7% 是高反应的患者。Pge2预处理不会影响子宫穿孔，盆腔炎 (PID) 或保留的妊娠产物的数量。

BACKGROUND & AIMS: :In recent years, endobronchial ultrasound-guided TBNA (EBUS-TBNA) has emerged as an innovative technique for diagnosis and staging of lung cancer and has been successfully introduced into daily clinical practice with several advantages including minimally invasive approach, safe, cost-effective, real time image guidance, broad sampling capability, and rapid on-site evaluation (ROSE). Both cytological and histological approach could be useful to have material for diagnosis, immunohistochemical and molecular analyses which may be very important for targeted therapy with successful rate ranging from 89% to 98%. The utility of ROSE during EBUS-TBNA has been matter of debate. Indeed, although some evidence concluded that ROSE does not increase the diagnostic efficacy of EBUS-TBNA, other demonstrated that it improves the diagnostic yield of the procedure up to 30%, allows to avoid repetition of additional diagnostic procedures and reduces risk of complications. Furthermore the sample preparation by cytopathologist is optimized with the aid of direct macroscopic inspection, optimal smearing techniques, and triage of the sample permitting to obtain adequate tissue for diagnosis, ancillary techniques and molecular testing, when needed. Some pathological issues on EBUS-TBNA are reviewed and discussed with particular focus on ROSE and molecular testing.

背景与目标： : 近年来，支气管内超声引导的TBNA (EBUS-TBNA) 已成为肺癌诊断和分期的创新技术，并已成功引入日常临床实践，具有多种优势，包括微创方法，安全，成本效益，实时图像指导，广泛的采样能力，和快速现场评估 (ROSE)。细胞学和组织学方法对于具有用于诊断，免疫组织化学和分子分析的材料可能是有用的，这对于靶向治疗可能非常重要，成功率从89% 到98%。罗斯在EBUS-TBNA期间的效用一直是争论的问题。实际上，尽管一些证据得出结论，ROSE不会增加EBUS-TBNA的诊断功效，但其他证据表明，它可以将手术的诊断产量提高到30%，从而避免重复其他诊断程序并降低并发症的风险。此外，在需要时，通过直接宏观检查，最佳涂片技术和样品分类来优化细胞病理学专家的样品制备，以获得足够的组织进行诊断，辅助技术和分子测试。回顾并讨论了EBUS-TBNA上的一些病理问题，特别着重于玫瑰和分子测试。

BACKGROUND & AIMS: BACKGROUND:Hypertensive intracerebral haemorrhage (HICH) is the most common form of haemorrhagic stroke with the highest morbidity and mortality of all stroke types. The choice of surgical or conservative treatment for patients with HICH remains controversial. In recent years, minimally invasive surgeries, such as endoscopic evacuation and stereotactic aspiration, have been attempted for haematoma removal and offer promise. However, research evidence on the benefits of endoscopic evacuation or stereotactic aspiration is still insufficient. METHODS/DESIGN:A multicentre, randomised controlled trial will be conducted to compare the efficacy of endoscopic evacuation, stereotactic aspiration and craniotomy in the treatment of supratentorial HICH. About 1350 eligible patients from 10 neurosurgical centres will be randomly assigned to an endoscopic group, a stereotactic group and a craniotomy group at a 1:1:1 ratio. Randomisation is undertaken using a 24-h randomisation service accessed by telephone or the Internet. All patients will receive the corresponding surgery based on their grouping. They will be followed-up at 1, 3 and 6 months after surgery. The primary outcome is the modified Rankin Scale at 6-month follow-up. Secondary outcomes include: haematoma clearance rate; Glasgow Coma Scale 7 days after surgery; rebleeding rate; intracranial infection rate; hospitalisation time; mortality at 1 month and 3 months after surgery; the Barthel Index and the WHO quality of life at 3 months and 6 months after surgery. DISCUSSION:The trial aims to investigate whether endoscopic evacuation and stereotactic aspiration could improve the outcome of supratentorial HICH compared with craniotomy. The trial will help to determine the best surgical method for the treatment of supratentorial HICH. TRIAL REGISTRATION:ClinicalTrials.gov, ID: NCT02811614 . Registered on 20 June 2016.

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BACKGROUND & AIMS: BACKGROUND:Fine needle aspiration (FNA) cytology has been widely used for pathologic assessment of breast lesions. However, the examination suffers a risk of false-negative results owing to insufficient sample volumes, inaccurate sampling positions, nondefinitive cytologic features, or suboptimal cell preservation. One approach to improve its accuracy is using modern mass spectrometry to detect disease biomarkers, of which the tissue samples are collected through FNA. METHODS:The biological compounds in the FNA tissue samples were extracted and characterized by matrix-assisted laser desorption ionization time-of-flight/mass spectrometry (MALDI-TOF/MS). The results were further analyzed by principal component analysis. Distribution of lipid biomarkers on tissues was explored by imaging mass spectrometry. RESULTS:Lipid profiles of the tissue samples collected by FNA were rapidly obtained through MALDI-TOF/MS analysis. Phosphatidylcholines and triacylglycerols were detected as the predominant compounds in cancerous and normal regions, respectively. The samples were clearly classified by principal component analysis, based on the differences in their lipid profiles. Different lipid patterns were clearly viewed through the molecular imaging of normal and tumorous regions of breast tissue samples. CONCLUSION:The FNA-MALDI-TOF/MS approach can provide complementary information for pathological examinations and improve the accuracy of breast cancer diagnoses. Owing to the ease of operation and automation, it is possible to efficiently screen the lipid biomarkers in a large number of tissue samples by means of MALDI-TOF/MS.

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BACKGROUND & AIMS: :Pulmonary artery sarcoma (PAS) is a rare tumor that is often detected at an advanced stage, when disease is so widespread that a radical surgical procedure is no longer indicated. Therefore, less invasive biopsy techniques are required to establish a definitive preoperative diagnosis. Endobronchial ultrasound (EBUS) is useful for producing real-time images of both lymph nodes and the interior of pulmonary arteries adjacent to the bronchi. We report a case with masslike lesions in the pulmonary artery that were observed by EBUS and from which tissue was obtained by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) to establish a diagnosis of PAS.

背景与目标： : 肺动脉肉瘤 (PAS) 是一种罕见的肿瘤，通常在晚期发现，当疾病如此广泛以至于不再需要根治性手术时。因此，需要较小的侵入性活检技术来建立明确的术前诊断。支气管内超声 (EBUS) 可用于产生淋巴结和支气管附近肺动脉内部的实时图像。我们报告了一例通过EBUS观察到的肺动脉肿块样病变，并通过支气管内超声引导的经支气管针吸活检 (EBUS-TBNA) 从中获得了组织，以确定PAS的诊断。

BACKGROUND & AIMS: :Increasing evidence suggests that treatment with the low molecular weight heparin enoxaparin during percutaneous coronary intervention (PCI) is safe and effective. We evaluated the incidence and consequences of periprocedural macroscopic thrombus formation on PCI equipment following antithrombin therapy with enoxaparin. Between April 2003 and December 2004, all patients undergoing cardiac catheterization following antithrombin therapy with enoxaparin were evaluated. All patients had blood sampled at the onset of procedure for subsequent measurement of anti-factor-Xa levels. Of the 4,504 patients who underwent PCI during this period, in 122 (3%) the procedure was performed within 8 hr of treatment with subcutaneous enoxaparin and no additional unfractionated heparin (UFH) was used periprocedurally. Of these, macroscopic thrombus was observed on PCI equipment in 6 patients (5%) necessitating withdrawal of all catheters and wires. All patients had therapeutic anti-factor-Xa levels at the time of PCI, and had been treated with double antiplatelet therapy with aspirin and clopidogrel. No periprocedural thrombus was observed in 356 patients who were >12 hr of the last dose of enoxaparin and received UFH at the time of PCI. Following observation of thrombus, additional anticoagulation with UFH resulted in significant epistaxis in one patient. In another patient, the procedure was complicated by distal coronary embolization. Percutaneous coronary intervention following antithrombin therapy with enoxaparin is associated with a 5% incidence of macroscopic thrombus formation on PCI equipment. The necessity for subsequent exchange of all equipment and/or the need for additional anticoagulation may have disastrous consequences for the patient. Our findings suggest that the safety of antithrombin therapy with low molecular weight heparin during PCI requires further evaluation.

背景与目标： : 越来越多的证据表明，在经皮冠状动脉介入治疗 (PCI) 中使用低分子量肝素依诺肝素治疗是安全有效的。我们评估了依诺肝素抗凝血酶治疗后PCI设备上围手术期宏观血栓形成的发生率和后果。在2003年4月和2004年12月之间，对所有接受依诺肝素抗凝血酶治疗后接受心脏导管插入术的患者进行了评估。所有患者在手术开始时均进行了血液采样，以随后测量抗因子-Xa水平。在此期间接受PCI的4,504例患者中，122 (3%) 在皮下依诺肝素治疗后8小时内进行手术，并且在手术过程中没有额外使用普通肝素 (UFH)。其中，在PCI设备上观察到6例需要撤出所有导管和导线的患者 (5%) 的宏观血栓。所有患者在PCI时均具有治疗性抗因子-Xa水平，并接受了阿司匹林和氯吡格雷的双重抗血小板治疗。在356例依诺肝素最后剂量> 12小时并在PCI时接受UFH的患者中未观察到围手术期血栓。观察到血栓后，UFH的额外抗凝治疗导致一名患者出现明显的鼻出血。在另一名患者中，该过程因远端冠状动脉栓塞而变得复杂。依诺肝素抗凝血酶治疗后的经皮冠状动脉介入治疗与PCI设备上肉眼血栓形成的5% 发生率相关。随后更换所有设备的必要性和/或需要额外的抗凝治疗可能会对患者造成灾难性的后果。我们的发现表明，在PCI期间使用低分子量肝素进行抗凝血酶治疗的安全性需要进一步评估。

BACKGROUND & AIMS: :Intra-luminal thrombus has been suggested to play a role in the progression of abdominal aortic aneurysm (AAA). The aims of this study were twofold. Firstly, to assess the reproducibility of a computer tomography (CT)-based technique for measurement of aortic thrombus volume. Secondly, to examine the determinants of infrarenal aortic thrombus volume in a cohort of patients with aortic dilatation. A consecutive series of 75 patients assessed by CT angiography with maximum aortic diameter > or = 25 mm were recruited. Intra-luminal thrombus volume was measured by a semi-automated workstation protocol based on a previously defined technique to quantitate aortic calcification. Intra- and inter-observer reproducibility were assessed using correlation coefficients, coefficient of variation and Bland-Altman plots. Infrarenal aortic thrombus volume percentage was related to clinical, anatomical and blood characteristics of the patients using univariate and multivariate tests. Infrarenal aortic thrombus volume was related to the severity of aortic dilatation assessed by total aortic volume (r = 0.87, P < 0.0001) or maximum aortic diameter (r = 0.74, P < 0.0001). We therefore examined the clinical determinates of aortic thrombus expressed as a percentage of total aortic volume. Aortic thrombus percentage was negatively correlated with serum high density lipoprotein (HDL, r = -0.31). By ordinal multiple logistic regression analysis serum HDL below median (< or = 1.2 mM: ) was associated with aortic thrombus percentage in the upper quartile adjusting for other risk factors (odds ratio 5.3, 95% CI 1.1-25.0). Infrarenal aortic thrombus volume can be measured reproducibly on CT. Serum HDL, which can be therapeutically raised, may play a role in discouraging aortic thrombus accumulation with implications in terms of delaying progression of AAA.

背景与目标： : 腔内血栓已被认为在腹主动脉瘤 (AAA) 的进展中起作用。这项研究的目的是双重的。首先，评估基于计算机断层扫描 (CT) 的主动脉血栓体积测量技术的可重复性。其次，在一组主动脉扩张患者中检查肾下主动脉血栓体积的决定因素。连续招募了75例通过CT血管造影评估的主动脉最大直径> 或 = 25毫米的患者。腔内血栓体积是通过基于先前定义的定量技术的半自动工作站协议测量的，以定量主动脉钙化。使用相关系数，变异系数和Bland-Altman图评估观察者内和观察者间的可重复性。使用单变量和多变量测试，肾下主动脉血栓体积百分比与患者的临床，解剖和血液特征有关。肾下主动脉血栓体积与主动脉总体积 (r = 0.87，P <0.0001) 或主动脉最大直径 (r = 0.74，P <0.0001) 评估的主动脉扩张严重程度有关。因此，我们检查了以总主动脉体积百分比表示的主动脉血栓的临床决定。主动脉血栓百分比与血清高密度脂蛋白 (HDL，r = -0.31) 呈负相关。通过有序多元逻辑回归分析，血清HDL低于中位数 (<或 = 1.2 mM:) 与调整其他危险因素的上四分位数的主动脉血栓百分比相关 (优势比5.3，95% CI 1.1-25.0)。可以在CT上重复测量肾下主动脉血栓体积。可以在治疗上升高的血清HDL可能在阻止主动脉血栓积聚方面发挥作用，从而延迟AAA的进展。

BACKGROUND & AIMS: :Our institution has used the DeBakey VAD Child as a bridge to heart transplantation in select pediatric patients. Pump thrombus is a potentially serious complication with few available treatment options. Only surgical device exchange or the use of tissue plasminogen activator are reported in the literature. We report the use of clopidogrel as an alternative thrombolytic agent in the presence of pump thrombus in an adolescent patient with a DeBakey VAD Child heart pump.

背景与目标： : 我们的机构已将DeBakey VAD儿童用作某些儿科患者进行心脏移植的桥梁。泵血栓是一种潜在的严重并发症，几乎没有可用的治疗选择。文献中仅报道了手术设备交换或组织纤溶酶原激活剂的使用。我们报告了在患有DeBakey VAD儿童心脏泵的青少年患者中，在存在泵血栓的情况下使用氯吡格雷作为替代溶栓剂。

BACKGROUND & AIMS: :Foreign body aspiration (FBA) causes death in more than 300 children every year in the United States. Morbidity and mortality are increased in children due to narrow airways and immature protective mechanisms. Factors to consider in pediatric dentistry are: (1) the patient's age and behavior; (2) presence and extent of disability; (3) local anesthesia; (4) body positioning; and (5) loose teeth. FBA requires prompt recognition and early treatment to minimize potentially serious and sometimes fatal consequences. The purpose of this case report was to describe the aspiration of a stainless steel crown in a 5-year-old boy during conscious sedation. It also discusses how a prompt and accurate diagnosis, early referral, and immediate treatment helped prevent serious complications.

背景与目标： : 在美国，异物吸入 (FBA) 每年导致300多名儿童死亡。由于气道狭窄和保护机制不成熟，儿童的发病率和死亡率增加。儿科牙科要考虑的因素是 :( 1) 患者的年龄和行为; (2) 残疾的存在和程度; (3) 局部麻醉; (4) 身体定位; (5) 牙齿松动。FBA需要及时识别和早期治疗，以最大程度地减少潜在的严重后果，有时甚至是致命的后果。该病例报告的目的是描述一名5岁男孩在有意识镇静期间对不锈钢冠的抽吸。它还讨论了及时准确的诊断，早期转诊和立即治疗如何帮助预防严重的并发症。

BACKGROUND & AIMS: BACKGROUND:Revision total elbow arthroplasty (TEA) is a challenging procedure that is becoming increasingly common. In our unit, we regard it as essential to exclude infection as the underlying cause of TEA loosening. In all patients with arthroplasty loosening, we undertake a careful history and examination, perform radiographs, monitor inflammatory markers, and undertake a joint aspiration. If any investigation suggests infection as the etiology, then a 2-stage revision is undertaken. Open biopsies are not routinely performed. The aim was to ascertain from our outcomes whether it is safe to perform a single-stage revision for presumed aseptic loosening using these criteria. METHODS:A retrospective review of a consecutive series of revision TEAs was performed in our unit over a 10-year period (2008-2018). Single-stage revisions performed for presumed aseptic loosening were identified. Case notes, radiographs, bloods, aspiration results, and microbiology of tissue samples taken at revision were reviewed. RESULTS:A total of 123 revision elbow arthroplasty cases were performed in the study period. Sixty cases were revised for preoperatively proven infection, instability, or implant failure and were excluded from this study. In 63 cases, aseptic loosening was diagnosed based on history, clinical examination, blood markers, and aspiration. There were 21 dual-component and 42 single-component revisions. In the dual-component revision group, tissue samples taken at the time of revision were positive in only 1 case (5%). In the single-component revision group, positive culture samples were present in 3 cases (7%). χ2 analysis showed no significant difference between single- and dual-component revisions (P = .76). No cases with positive culture samples from either group have required subsequent revision surgery. CONCLUSION:Given the results of this study, we conclude that is safe to perform single-stage revision arthroplasty for implant loosening based on history, examination, normal inflammatory markers, and negative aspiration results without the need for open biopsy.

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BACKGROUND & AIMS: :Subvalvar left ventricular aneurysms are rare and occur predominantly in black Africans. A submitral left ventricular aneurysm was diagnosed on cross sectional echocardiography in a black woman born in the United Kingdom. The left parasternal long axis view showed a highly echogenic mass apparently attached to the wall of a dilated left atrium, but the apical two-chamber view showed that this was thrombus in the apex of a left ventricular aneurysm. The patient subsequently underwent surgical correction.

背景与目标： 瓣膜下左心室动脉瘤很少见，主要发生在非洲黑人。在英国出生的一名黑人妇女中，通过横截面超声心动图诊断出二尖瓣下左心室动脉瘤。左胸骨旁长轴视图显示出高度回声的肿块，显然附着在扩张的左心房壁上，但顶两室视图显示这是左心室动脉瘤顶点的血栓。患者随后接受了手术矫正。

BACKGROUND & AIMS: AIMS:To determine the accuracy of the bedside volume-viscosity swallow test (V-VST) for clinical screening of impaired safety and efficacy of deglutition. METHODS:We studied 85 patients with dysphagia and 12 healthy subjects. Series of 5-20 mL nectar (295.02 mPa.s), liquid (21.61 mPa.s) and pudding (3682.21 mPa.s) bolus were administered during the V-VST and videofluoroscopy. Cough, fall in oxygen saturation > or =3%, and voice changes were considered signs of impaired safety, and piecemeal deglutition and oropharyngeal residue, signs of impaired efficacy. RESULTS:Videofluoroscopy showed patients had prolonged swallow response (> or =1064 ms); 52.1% had safe swallow at nectar, 32.9%, at liquid (p<0.05), and 80.6% at pudding viscosity (p<0.05); 29.4% had aspirations, and 45.8% oropharyngeal residue. The V-VST showed 83.7% sensitivity and 64.7% specificity for bolus penetration into the larynx and 100% sensitivity and 28.8% specificity for aspiration. Sensitivity of V-VST was 69.2% for residue, 88.4% for piecemeal deglutition, and 84.6% for identifying patients whose deglutition improved by enhancing bolus viscosity. Specificity was 80.6%, 87.5%, and 73.7%, respectively. CONCLUSIONS:The V-VST is a sensitive clinical method to identify patients with dysphagia at risk for respiratory and nutritional complications, and patients whose deglutition could be improved by enhancing bolus viscosity. Patients with a positive test should undergo videofluoroscopy.

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BACKGROUND & AIMS: OBJECTIVES:To determine the difference in aspiration rates between gastrically and transpylorically fed patients in the intensive care unit. DESIGN:A prospective controlled study of critically ill patients randomized to receive either a gastrically placed feeding tube or a transpylorically placed feeding tube. SETTING:University teaching hospital's medical intensive care unit. The study was conducted over 14 months. PATIENTS:Fifty-four critically ill subjects (with an overall 40% mortality) with similar baseline age, severity of illness, and nutritional needs requiring enteral nutrition, with 51 completing the study. INTERVENTIONS:All feeds were tagged with technetium-99m radiolabeled sulfur colloid, and the pulmonary secretions or lungs of each patient were scanned on a daily basis to determine whether aspiration had occurred. Patients were fed according to their assigned tube placement which was verified daily by continuous electromyography. MEASUREMENTS AND RESULTS:Of 27 gastrically fed patients 2 (7%) had evidence of scanned feed in pulmonary secretions or the lung, compared to 3 of 24 (13%) transpylorically fed patients (n.s.). Clinical suspicion of aspiration was insensitive and detected only 60% of isotopically documented aspirations with a positive predictive value of 27%. CONCLUSION:There was no difference in aspiration rates between gastrically and transpylorically fed critically ill patients.

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BACKGROUND & AIMS: PURPOSE:This study was designed to assess retrospectively short- and mid-term outcomes of the use of a suture-mediated closure device to close the antegrade access in patients undergoing percutaneous aspiration thrombectomy with large catheters for acute leg ischemia. METHODS:Between November 2005 and February 2010, a suture-mediated active closure system (ProGlide(®) 6F, Abbott) was placed before arterial sheath (mean 9 F, range 6-12 F) introduction in 101 patients (74 men, 73 %, mean age 70.1 ± 12.6 years standard deviation). Data regarding mortality, complications, and factors contributing to vascular complications at the access site was collected for 6 month after the intervention to detect device-related problems. As a coincidence, 77 patients had follow-up visits for a duplex ultrasound. RESULTS:There were a total of 19 vascular complications (19 %) at the puncture site, all of which were of hemorrhagic nature and none of which consisted of vessel occlusion. Two major outcome complications (2 %) occurred. A retroperitoneal hematoma and a serious inguinal bleeding required additive treatment and did not result in permanent sequelae. Nine cases involved death of which eight were not attributable to the closure and one remained unclear. Successful closure was achieved in 95 patients (94 %); additional manual compression was sufficient in the majority of the remaining patients. Numerous factors contributing to vascular complications were encountered. CONCLUSIONS:With acceptable short- and mid-term outcomes, the "preclose" technique can be a reliable option for the closure of a large antegrade femoral access even for patients at a high risk of vascular complications, such as those undergoing aspiration thrombectomy.

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