The diagnostic accuracy of 22-gauge and 25-gauge needles in endoscopic ultrasound-guided fine needle aspiration of solid pancreatic lesions: a meta-analysis.

BACKGROUND AND STUDY AIMS: It is uncertain if needle gauge impacts the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of pancreatic mass lesions. Our aim was to use meta-analysis to more robustly define the diagnostic accuracy of EUS-FNA for pancreatic masses using 22 G and 25 G needles. PATIENTS AND METHODS: Studies were identified by searching nine medical databases for reports published between 1994 and 2011, using a reproducible search strategy comprised of relevant terms. Only studies comparing the overall diagnostic accuracy of 22 G vs. 25 G EUS needles that used surgical histology or at least 6 months clinical follow up for a gold standard were included. Two reviewers independently scored the identified studies for methodology and abstracted pertinent data. When required, the original investigators were contacted to provide additional data. Pooling was conducted by both fixed-effects and random-effects models. Diagnostic characteristics (sensitivity, specificity, positive and negative likelihood ratios) with 95% confidence intervals (CIs) were calculated. RESULTS: Eight studies involving 1292 subjects met the defined inclusion criteria. Of the 1292 patients, 799 were in the 22 G group and 565 were in the 25 G group (both needles were used in 72 patients). The pooled sensitivity and specificity of the 22 G needle were 0.85 (95%CI 0.82-0.88) and 1 (95%CI 0.98-1) respectively. The pooled sensitivity and specificity of the 25 G needle were 0.93 (95%CI 0.91-0.96) and 0.97 (95%CI 0.93-0.99) respectively. The bivariate generalized linear random-effect model indicated that the 25 G needle is associated with a higher sensitivity (P = 0.0003) but comparable specificity (P = 0.97) to the 22 G needle. CONCLUSIONS: This meta-analysis suggests 25 G needle systems are more sensitive than 22 G needles for diagnosing pancreatic malignancy.

The impact of endoscopic ultrasonography with fine needle aspiration (EUS-FNA) on esophageal cancer staging: a survey of thoracic surgeons and gastroenterologists.

SUMMARY: Accurate staging of esophageal cancer is critical to achieving optimal treatment outcomes. End-oscopic ultrasound with fine needle aspiration (EUS-FNA) has emerged as a valuable tool for locoregional staging. However, it is unclear how different physician specialties perceive the benefit of EUS-FNA for esophageal cancer staging, and thus utilize this modality in clinical practice. A survey regarding utilization of EUS-FNA in esophageal cancer was distributed to 211 thoracic surgeons and 251 EUS-capable gastroenterologists. Seventy-six thoracic surgeons (36%) and 78 gastroenterologists (31%) responded to the survey. Most surgeons (75%) use EUS to stage potentially resectable esophageal cancer 75% of the time. Surgeons using EUS less often are less likely to have access to high-quality EUS services than their peers. Fewer surgeons believe EUS is the most accurate test for T and N-staging (84% and 71%, respectively) as compared with gastroenterologists (97% and 96%, P < 0.01 for both). Most endosonographers (68%) decide whether to dilate a malignant esophageal stricture to complete the staging exam on a case-by-case basis. Surgeons disagree as to whether involvement of celiac lymph nodes should preclude esophagectomy in distal esophageal cancer. While most thoracic surgeons have embraced EUS-FNA as the most accurate locoregional staging modality in esophageal cancer, this attitude is not fully reflected in utilization patterns due to a lack of quality EUS services in some centers. Controversial areas that warrant further study include dilation of malignant strictures to facilitate EUS staging, and the implication of involved celiac lymph nodes on management.

Acute myocardial infarction: an unusual culmination of rheumatic pancarditis and antiphospholipid antibody syndrome.

A 29-year-old man with history of antiphospholipid antibody syndrome (APS) and two prior episodes of acute rheumatic fever developed a third episode of acute rheumatic fever. This was complicated by acute myocardial infarction due to spontaneous arterial thrombosis of the left anterior descending and right coronary arteries. We postulate that rheumatic pancarditis created an inflammatory, thrombogenic environment that facilitated coronary artery thrombosis secondary to APS, a novel association. Our patient was left with significant left ventricular dysfunction at a young age, and cases such as this emphasize the need for early recognition and proper treatment of APS. Further, the pathogenesis of thrombosis in APS is incompletely understood, and the cellular and molecular basis for this, including the role of 'second hits', are areas needing further investigation.

Silhouettes elicit alarm calls from captive vervet monkeys (Cercopithecus aethiops).

In Part 1, we analyzed alarm calls produced by captive vervets (Cercopithecus aethiops) in response to naturally occurring stimuli. Females and juveniles regularly alarm called to airplanes, birds, and barking dogs. Juvenile females accounted for 60% of these alarm calls. In Part 2, we isolated several monkeys from the colony and presented them with life-sized silhouettes of a leopard, snake, eagle, baboon, vervet, and goose. Adult monkeys alarm called more than did juveniles. Alarm calls were elicited by leopard, snake, baboon, and vervet silhouettes, but none were elicited by eagle or goose silhouettes. Some leopard and snake alarm calls matched those recorded in the wild in the context of the vervets' natural predators. Results indicate that silhouette stimuli are a useful technique for eliciting monkey vocalizations in the laboratory.