A Blinded Randomized Trial Comparing 2 Needle Gauges for Fine-Needle Biopsy of Thyroid Nodules.

OBJECTIVE: To compare diagnostic capability and patient pain between 25-gauge (25G) and 27G needles for ultrasound-guided fine-needle biopsy of thyroid nodules. STUDY DESIGN: Prospective blinded randomized trial. SETTING: Thyroid clinic in otolaryngology practice in a community. METHODS: A prospective randomized blinded trial was conducted on 148 thyroid nodules in 107 patients undergoing ultrasound-guided fine-needle biopsy. Needle gauge was randomized to individual nodule. Patients were blinded to the needle size used. All specimens were assessed via the Bethesda System for Reporting Thyroid Cytopathology and assigned a morphologic quantitative score based on number of thyroid cells and lymphocytes, amount of colloid, and degree of blood/fibrin artifact in each sample. Patient pain experience was scored. A chi-square test was used to compare nondiagnostic rates, and differences in cytologic morphology and pain scores were compared with 2-sample Student t tests. RESULTS: Of the 148 nodules, 77 were biopsied with 25G needles and 71 with 27G needles. Twenty-five percent (19/77) of the samples obtained with 25G needles yielded a nondiagnostic cytology result (Bethesda category 1) as compared with 11% (8/70) in the 27G group (P = .0282; 95% CI, 1.47%-25.97%). On average, samples from 25G needles had a higher blood/fibrin quantitative score (P = .043; 95% CI, -0.64 to -0.010). There were no differences in pain between groups. CONCLUSION: Use of a 27G needle for fine-needle biopsies is not only safe and feasible but desirable and highly recommended, as it yields better diagnostic information.

Bilateral adrenal gland enlargement secondary to histoplasmosis mimicking adrenal metastases: diagnosis with EUS-guided FNA.

While adrenal gland histoplasmosis has been previously diagnosed by fine needle aspiration utilizing the percutaneous approach, EUS-FNA has not been employed in the diagnosis of this infection affecting both adrenal glands. We report a patient with massive bilateral adrenal enlargement due to histoplasmosis that was diagnosed by EUS-FNA. Trans-duodenal and trans-gastric fine needle aspiration biopsy of both adrenal glands was performed. Rapid onsite cytopathologic evaluation (ROSE) revealed epithelioid histiocytes, singly and in clusters consistent with granulomas. Apparent intracytoplasmic inclusions suggestive of organisms were visible. A Gomori Methenamine Silver stain (GMS) revealed abundant small intracellular budding yeasts, morphologically consistent with Histoplasma; the patient was admitted for amphotericin B intravenous infusion. His fever abated on the second day after amphotericin B was started. His urine Histoplasma antigen was positive. Fungal cultures from both adrenal EUS-FNA samples grew Histoplasma capsulatum. After a one week hospital stay, he was discharged home on itraconazole 200 mg po bid for one year. Four months after initiation of treatment, his urine Histoplasma antigen was undetectable. Nine months after initial diagnosis, the patient regained his energy level, and returned to work with complete resolution of his initial symptoms. This case highlights that EUS-FNA with ROSE can be a highly effective tool in the diagnosis of uncommon infections of the adrenal glands.

A prospective audit program to determine blood component transfusion appropriateness at a large university hospital: a 5-year experience.

Predetermined transfusion guidelines, pretransfusion approval, and transfusion audits are useful tools in the education of those ordering blood components, potentially resulting in the reduction of inappropriate use of blood components. Our institution requires mandatory prospective audits for a proportion (10%) of packed red blood cell unit orders and all orders for fresh frozen plasma, platelets, and cryoprecipitate. Cases where the blood bank physician recommends against a transfusion and the ordering physician concurs, or when blood components are released against blood bank's recommendation, are referred to the transfusion committee. Transfusion committee members review the medical records to determine the circumstances surrounding the transfusion request as well as patient outcomes relating to their receiving or not receiving the transfusion. We analyzed 220 transfusion episodes brought before the transfusion committee from 2001 to 2005. The most requested blood component denied or changed was fresh frozen plasma. With only a few exceptions, the denial or change of blood components had no adverse effect on the patient. Nonetheless, these interventions were deemed appropriate by the transfusion committee. In most cases, blood components released based on the demand of the ordering physician, despite the advice of the blood bank physician, were deemed as inappropriate transfusions. This study therefore suggests that prospective audits of blood component orders can help reduce inappropriate transfusions and can be a valuable educational tool for the ordering physicians as well as for residents in training.