Triple diagnosis in carcinoma of the breast: a replacement for open biopsy.

Using the combination of clinical diagnosis, mammography and fine-needle aspiration cytology (FNA) as a "triple diagnosis" to guide management of carcinoma of the breast, we retrospectively reviewed 46 patients with FNA diagnosis of carcinoma of the breast in Ramathibodi Hospital from 1993 to 1995. Pathological diagnosis was available in 36 cases and used as a gold standard. Clinical diagnosis alone was accurate in 28 of 36 cases. Mammography was available in 24 cases of which the diagnosis was accurate in 22 cases. Triple diagnosis was available in 19 cases and all were accurate. Using this approach and review of the literature, we suggest that triple diagnosis could replace an open biopsy in diagnosis of carcinoma of the breast.

Significantly reduced acid detection at 10 centimeters compared to 5 centimeters above lower esophageal sphincter in patients with acid reflux.

Ambulatory pH monitoring of the esophagus is carried out by positioning a pH sensor 5 cm above the lower esophageal sphincter (LES). There are several techniques to locate the LES, and each method has a different margin of error. This work used dual pH sensors to monitor simultaneously at two different levels (5 and 10 cm above the LES) in order to establish the possible magnitude of error that could arise from inaccurate placement of a pH probe. Thirty-four patients with symptoms of gastroesophageal reflux (GER) were studied. They were grouped as 20 patients with pathological reflux (GER group) and 14 patients with physiological reflux, based on a reflux score derived by Johnson and DeMeester for distal esophageal pH monitoring. When the reflux scores were compared, the difference between the two monitoring levels was statistically significant in the GER group (p < 0.001) but not in the physiological reflux group (p = 0.09). In the GER group, the difference in the Johnson and DeMeester score accounted for a change in clinical diagnosis in nine of the 20 patients if the pH probe was placed at 10 cm above the upper margin of LES. Proximal reflux episodes (10 cm above LES) were preceded by distal reflux episodes (5 cm above LES) in 97% (878/901) of cases. Accurate probe placement is essential in the diagnosis of GER.

Alternative method of positioning the pH probe for oesophageal pH monitoring.

The most reliable method of positioning a pH probe for oesophageal pH monitoring is to use manometry to determine the upper margin of the lower oesophageal sphincter and to place the probe 5 cm above this point. Manometry is expensive, however, requires special equipment and training, and is not widely available. An alternative cheaper way of determining the site of the lower oesophageal sphincter has been evaluated. A fine bore nasogastric tube with a latex balloon at its tip was inserted transnasally into the stomach. The balloon was inflated with 10 ml of water and the tube withdrawn until resistance was met. The distance from the nose (in cm) was noted and compared with the upper margin of the lower oesophageal sphincter as determined by oesophageal manometry. The manometric distance agreed closely with the balloon distance minus 1 cm (bias 0.29 cm; 95% CI of bias, 0.03 to 0.55 cm; 2 SD, limits of agreement, 1.58 cm). We conclude that where oesophageal manometry is not available, balloon localisation is a suitably accurate way of identifying the lower oesophageal sphincter.