Duplex Criteria for Grading of External Carotid Stenosis.

BACKGROUND: External carotid artery (ECA) stenosis is an independent mortality predictor. Additionally, concomitant ECA and internal carotid artery (ICA) stenosis progression has been associated with an increased risk of ipsilateral ischemic events in asymptomatic patients. Universally accepted ECA duplex velocity criteria, for the prediction of stenosis, do not exist. METHODS: Consecutive patients undergoing angiography and carotid duplex assessments were compared (n = 140). ICA, common carotid artery (CCA), and ECA peak systolic velocities (PSVs) were recorded. ECA/CCA PSV ratio was calculated. These parameters were compared with angiographic ECA measurements. Receiver-operator curve analysis was used to determine optimal criteria in identifying ECA stenosis of >50%. RESULTS: In patients with little ipsilateral ICA disease, for the detection of ECA stenosis of ≥50%, an ECA PSV >148 cm/sec provided a sensitivity of 80%, specificity of 76.2%, and an overall accuracy of 77.1%. An ECA/CCA PSV ratio of 1.45 demonstrated a sensitivity of 73.7%, specificity of 66.7%, and an accuracy of 68.2%.In patients with ICA stenosis ≥50%, for the detection of ECA stenosis of ≥50%, an ECA PSV >179 cm/sec provided a sensitivity of 50%, specificity of 79.6%, and overall accuracy of 71.3%. An ECA/CCA PSV ratio of ≥1.89 provided a sensitivity of 71.9%, specificity of 72.7%, and overall accuracy of 72.5%. CONCLUSIONS: ECA PSV and ECA/CCA PSV ratios appear as useful metrics for the prediction of unilateral high-grade ECA stenosis.

Are systolic velocity duplex metrics negatively affected by flow aliasing in areas of critical internal carotid artery stenosis.

Purpose: Duplex scanning is a useful noninvasive screening tool for the detection of carotid bifurcation disease. Internal carotid artery (ICA) peak systolic velocity (PSV) and ICA/common carotid artery (CCA) PSV ratios are proven metrics determining 70%-99% ICA stenosis. A potential disadvantage of using dramatically increasing systolic velocity measurements in areas of critical arterial stenosis is flow aliasing. Diastolic velocity should be less influenced by this flow artifact. We evaluate ICA and CCA end diastolic velocity (EDV) metrics in predicting severe ICA stenosis and document the prevalence of an aliasing artifact in a population of patients with critical ICA stenosis. Methods: Consecutive patients undergoing carotid duplex assessments and contrast angiography were compared (n = 140). ICA and CCA PSV and EDV were recorded as was evidence of the flow aliasing of ICA waveforms. ICA/CCA PSV and EDV ratios were calculated. Duplex parameters were compared with angiographic ICA measurements. Receiver-operator characteristic curve (ROC) analysis was used to determine optimal criteria to identify ICA stenosis of 70% to 99%. Results: Of 256 carotid bifurcation duplex studies, critical angiographic stenosis was present in 105 arteries. Only four completed arterial duplex scans demonstrated flow aliasing. In three of these patients, systolic metrics were non-diagnostic versus ICA/CCA EDV ratios. An ICA/CCA EDV ratio of 2.3 provided the best combination of sensitivity 73.8% and specificity 75.18%. Conclusion: ICA/CCA diastolic ratios reliably determine 70% or greater ICA stenosis. Flow aliasing infrequently complicates ICA PSV.

A Systematic Review of Perforated Appendicitis and Phlegmon: Interval Appendectomy or Wait-and-See?

Patients with appendiceal abscess or phlegmon have been traditionally managed with antibiotics and radiologically guided drainage of the abscess. Many studies have questioned the need for interval appendectomy. A systematic review of the nonsurgical treatment of patients with an appendiceal abscess or phlegmon was undertaken. The rate of recurrence after nonsurgical management, morbidity and length of hospital stay was measured. PubMed and Cochrane databases were queried to identify 21 studies reporting the morbidity of nonsurgical treatment of appendiceal phlegmon or abscess, and five studies reporting the morbidity of performing interval appendectomy. Repeat nonsurgical management was compared with that of performing interval appendectomy. The studies included a total of 1943 patients, of which 1400 patients were managed nonsurgically and 543 patients underwent interval appendectomy. Nonoperative treatment had a mean recurrence of 12.4 per cent, a morbidity of 13.3 per cent, and the length of hospital stay was 9.6 days. The mean morbidity rate and length of hospital stay for patients who underwent interval appendectomy was 10.4 per cent and 5.0 days, respectively. Interval appendectomy and repeat nonoperative management in case of recurrence are associated with similar morbidity; however, elective interval appendectomy implies additional operative costs to prevent recurrence in one of eight patients.

Phyllodes tumor of the breast: role of CD10 in predicting metastasis.

BACKGROUND: Phyllodes tumors are classified as benign, borderline, and malignant according to a group of histological features. The expression of many biological markers has been explored to discriminate between different grades of phyllodes tumor and to predict their behavior. The immunohistochemical expression of CD10 has been shown to discriminate between benign and other grades of phyllodes tumor but has not been evaluated as a predictor of metastasis. The purpose of this study was to evaluate the usefulness of immunohistochemical staining of stromal CD10 in predicting the likelihood of metastasis in phyllodes tumors. METHODS: The expression of CD10 was studied in 43 phyllodes tumors (16 benign, 10 borderline, and 17 malignant) using immunohistochemistry to evaluate whether differences in expression correlated with the presence of, and or, development of distant metastasis. RESULTS: Metastasis occurred in six malignant phyllodes tumors. The expression of CD10 significantly (P<0.05) correlated with the occurrence of distant metastasis. CONCLUSIONS: The expression of CD10 can be used to predict the occurrence of distant metastasis in phyllodes tumors of the breast.

Management of cancer during pregnancy: obstetric and neonatal outcomes.

OBJECTIVE: This study aimed to assess the management and the obstetric and neonatal outcomes of pregnancies complicated by cancer. METHODS: A retrospective analysis of patients with cancer during pregnancy who were treated at King Hussein Cancer Center and King Abdullah University Hospital in Jordan between January 2002 and December 2009 was conducted. The medical records of patients with invasive cancer diagnosed during pregnancy and their newborns were reviewed to retrieve information on treatment and obstetric and neonatal outcomes. Numerical data were tested for normal distribution using Kolmogorov-Smirnov. Statistical analyses were conducted using SPSS 18.0. RESULTS: A total of 46 patients with a diagnosis of cancer in pregnancy were treated. The most common tumor types were breast cancer, hematologic malignancies, and gastrointestinal malignancies. In 17 patients, a miscarriage or a termination of pregnancy occurred in the first trimester. In 25 of 46 patients, a single or a combination of treatment modalities was commenced. The distribution of therapies was as follows: chemotherapy alone, n = 5; surgery alone, n = 7; surgery and chemotherapy, n = 6; surgery and radiation therapy, n = 1; surgery with chemotherapy and radiation therapy, n = 3; chemotherapy and radiation therapy, n = 1; interferon, n = 1; and hormonal therapy, n = 1. The mean (SD) gestational age at delivery was 35.7 (2.7) weeks. The mean birth weight was 2580 (870) g. Preterm delivery occurred in 17 patients. There were 4 neonatal deaths, 2 of them delivered at 33 weeks, 1 delivered at 34 weeks, and 1 delivered at 35 weeks gestation. There were no congenital malformations. CONCLUSIONS: The remarkable finding is a high rate of iatrogenic preterm delivery with a high rate of neonatal mortality. Delivery should be postponed preferably until after a gestational age of 35 weeks.