Transesophageal echocardiography of intracardiac thrombus in congenital heart disease and atrial flutter: the importance of thorough examination of the Fontan.

Transesophageal echocardiography (TEE) is used in atrial flutter or fibrillation (AFF) before electric cardioversion to detect intracardiac thrombi. Previous studies have described the use of TEE to diagnose intracardiac thrombi in the left atrium and left atrial appendage, which has an incidence of 8 % among patients without congenital heart disease (CHD). In their practice the authors have noted a significant incidence of intracardiac thrombi in other structures of patients with CHD and AFF. This study aimed to determine the incidence and location of intracardiac thrombi using TEE in patients with CHD requiring electric cardioversion of AFF and to compare the use of TEE and transthoracic echo (TTE) to detect intracardiac thrombus in this population. A retrospective chart review of TEE and TTE findings for all patients with CHD who had electric cardioversion of AFF at our institution from 2005 to 2013 was conducted. The diagnosis, presence, and location of intracardiac thrombus were determined. The TEE and TTE results were compared. The study identified 27 patients with CHD who met the study entry criteria at our institution between 2005 and 2013. Seven of these patients had a single ventricle with Fontan palliation. All the patients presented with AFF and had TEE before electric cardioversion. No patients were excluded from the study. The patients ranged in age from 2 to 72 years (median, 21 years) and weighed 17-100 kg (median, 65 kg). The duration of AFF before TEE and attempted cardioversion ranged from 1 day to 3 weeks (median, 3.5 days). Intracardiac thrombus was present in 18 % (5/27) of the patients and in 57 % (4/7) of the Fontan patients with AFF. No embolic events were reported acutely or during a 6-month follow-up period. Among patients with CHD who present with AFF, a particularly high incidence of intracardiac thrombi is present in the Fontan patients that may be difficult to detect by TTE. Thorough TEE examination of the Fontan and related structures is indicated before electric cardioversion of AFF. The incidence of intracardiac thrombus in CHD patients is more than double that reported in non-CHD patients.

Pulmonary tuberculosis outbreak in a pediatric population.

Community-based outbreaks of Mycobacterium tuberculosis are uncommon in the United States but represent a dramatic type of epidemic that can lead to considerable investigations. Most of our knowledge regarding spread of tuberculosis (TB) has accumulated from the study of outbreaks. We describe the most recent outbreak of TB in Genesee County, Michigan. In February 2007, isoniazid-sensitive infectious pulmonary TB was identified in a 45-year-old African American grandmother who frequently provided care for her grandchildren and other children. The source case was reported to the Genesee County Health Department, which started an investigation to identify family and social contacts. We reviewed past medical records of contacts and prioritized them for evaluation based on the period of exposure to the index case. Health department staff screened contacts using clinical evaluation, tuberculin skin test, and chest radiography when indicated. Results were reviewed, and data were analyzed using descriptive inferential and epidemiological statistics.

Accuracy and added value of triage beyond segregating potentially neoplastic effusions in immediate wet preparation.

OBJECTIVE: To sudy the accuracy and value of immediate wet preparation (WP) procedure on effusion and washing cytologic specimens. STUDY DESIGN: Two hundred specimens were identified over 3 months in our cytology laboratory, including 102 pleural effusion, 59 peritoneal effusion, 28 pelvic washing and 11 pericardial fluid specimens. WP slides were prepared, stained with toluidine blue (TB) and .. evaluated. Findings were reported as negative, suspicious or positive for malignant cells. For negative specimens, the remaining prepared slides were stained together. For suspicious or positive interpretation, slides were stained separately. Accuracy and additional benefits from this immediate triage step were studied. RESULTS: Interpretation ofslides resulted in 152 negative, 34 positive and 14 suspicious for malignancy. Analysis for additional values resulted in immediate interpretation relayed to clinicians, additional fluid centrifuged for adequate sediment in samples with scant cellularity, selection of bloody specimens for acid washing procedures, selection of cases to optimize cell block preparation when pivotal histologic evaluation or immunohistochemistry was anticipated and selection of cases for potentially needed ancillary studies. Accuracy, sensitivity, specificity and positive and negative predictive values were high. CONCLUSION: WP using the TB is accurate, sensitive and highly specific and has considerable value beyond segregating potential neoplastic cases.

Fine needle aspiration of head and neck masses in the operating room: accuracy and potential benefits.

Fine needle aspiration (FNA) in the operating room is a convenient optional diagnostic approach. Our objective of this study was to evaluate the accuracy and study the potential benefits of fine needle aspiration in the operating room. Retrospective review of all intraoperative FNA that were requested and performed by pathologists over 20-month period was carried out. Immediate smears were interpreted by the cytopathology team after staining with Diff Quik stain. All cases were reviewed and correlation with subsequent tissue diagnosis was done. Accuracy was calculated and potential benefits were discussed. The number of aspirates was 32. Adequate material for immediate and final interpretation was achieved in 31 cases (sensitivity 97%). In 20 cases (63%), malignancy was diagnosed while a benign diagnosis was rendered in 12 (37%). All cases had a follow up tissue diagnosis. No false-positive cases were identified (specificity 100%). The information gained from this approach was considered helpful to the surgeons. We concluded that FNA of head and neck masses in the operating room is an accurate and sensitive diagnostic approach. The service provides helpful information to surgeons and is an additional optional diagnostic approach.