Bird's nest filter causing symptomatic hydronephrosis following transmural penetration of the inferior vena cava.

We report a case of symptomatic hydronephrosis caused by transcaval penetration of a Bird's Nest filter. Perforation of the wall of the inferior vena cava (IVC) following insertion of a caval filter is a well-recognized complication. Whilst two cases of hydronephrosis have been described with Greenfield filters, no case involving a Bird's Nest filter has been reported previously.

Percutaneous lung biopsies: a survey of UK practice based on 5444 biopsies.

Percutaneous transthoracic lung biopsies are commonly performed for the investigation of lung masses. We describe current practice and complication rates in the UK. A postal questionnaire was sent to all centres in the British Thoracic Society directory. 157 replies (61% response rate) were received, providing data on 5444 biopsies. Mean number of biopsies performed per annum was 30.5 per centre; 8% of centres did not perform biopsies, 36% performed <25 biopsies per annum, 34% <50, 16% <100 and 6% >100. Consultant radiologists perform 91% of biopsies. Written consent was obtained at all centres. The operator obtained consent at 50% of centres. Written information for patients was provided at 35 (24%) centres. Biopsies are performed on a day case basis at 103 (71%) centres. Prior to biopsy the following were obtained routinely: CT scan (73% of centres), platelet count (73%), full clotting screen (70%), lung function (55%). Complications included pneumothorax (20.5% of biopsies), pneumothorax requiring chest drain (3.1%), haemoptysis (5.3%) and death (0.15%). The timing of post-procedure chest radiography was variable. Those centres that performed predominantly cutting needle biopsies had similar pneumothorax rates to centres performing mainly fine needle biopsies (18.9% vs 18.3%). There is great variation in practice throughout the UK. Most procedures are performed on a daycase basis. Small pneumothoraces are common but infrequently require treatment. National guidelines are needed to ensure consistency of standards.

Delayed spontaneous superior vena cava perforation associated with a SVC wallstent.

A patient was referred for superior vena cava (SVC) stenting prior to surgical biopsy of a mediastinal mass. A technically satisfactory insertion was followed 6 months later by cardiac tamponade with two legs of the Wallstent having perforated the wall of the SVC.

Metal mesh stents for ureteral obstruction caused by hormone-resistant carcinoma of prostate.

BACKGROUND: Long-segment ureteral obstruction by hormone-refractory carcinoma of the prostate is a difficult problem to manage. J-Stents often obstruct by compression. Metal mesh stents have been used successfully in the management of extrinsic ureteral obstruction caused by malignant disease. In this paper, we review our results in three patients in terms of the defined objective of palliation. PATIENTS AND METHODS: All three patients presented with painful obstructed kidneys and renal failure from long (7-10-cm) distal ureteral strictures responding to nephrostomy drainage. Endoluminal metal mesh stents of 7 to 8-mm diameter of various lengths (depending on the size of the stricture) were implanted after antegrade balloon dilatation of the stricture by a standard technique. The case notes were reviewed for technical success, preservation of the renal units, complications, and the impact on the overall quality of life. RESULTS: All three stents were placed without any complication and showed patency on contrast study. In one patient, the stent obstructed after 5 months, necessitating placement of a nephrostomy tube. In the remaining two patients, the stents obstructed within 3 months. During these 3 months, both patients had multiple admissions for stent-related complications and other symptoms of their disease. Overall quality of life was poor for these patients. CONCLUSION: Metal mesh ureteral stents give poor palliation in distal strictures caused by hormone-refractory carcinoma of the prostate. Permanent nephrostomy may be a more acceptable alternative in these patients with short life expectancies.

A urodynamic study of laser ablation of the prostate and a comparison of techniques.

OBJECTIVE: To evaluate the effect of laser ablation of the prostate on symptomatic and urodynamic parameters and to compare laser delivery systems. PATIENTS AND METHODS: The study comprised 81 patients of whom 79 were waiting for transurethral resection of the prostate (TURP) and two who presented in acute urinary retention. The 79 patients (median age 65 years, range 45-82) underwent pre-operative urodynamics and all patients completed American Urological Association (AUA) symptom score questionnaires before surgery. Visually-guided laser ablation of the prostate (VLAP) was performed and the urodynamics and symptom scores were repeated 3 months later. RESULTS: The improvements in symptom scores and flow rates were statistically significant and comparable with other published data. There were also significant improvements in voiding pressure. There were no significant differences between the various laser fibres used. There were few complications. CONCLUSION: The effectiveness of VLAP in improving symptoms and flow rates in patients with benign prostatic hyperplasia (BPH) is confirmed. The procedure also reduced voiding pressure, confirming the relief of bladder outflow tract obstruction. VLAP is confirmed as a safe and effective treatment for BPH. Continued follow-up is needed to determine the long-term effects.

Audit of pleural biopsies: an argument for a pleural biopsy service.

We audited 203 consecutive pleural biopsies performed by medical and geriatric firms over a 3-yr period in our hospital (1987-9). For firms without a special respiratory interest only two to three biopsies per yr were performed, compared with 23 per yr for a respiratory team. Twenty percent of biopsies failed to obtain pleural tissue, 50% revealed normal or non-diagnostic pleural changes and 30% provided a diagnosis. For the respiratory team that performed a third (68) of the biopsies the failure rate for obtaining pleura was 9% compared with 27% for other teams. In view of this disparity a pleural biopsy service was offered by the respiratory team during routine bronchoscopy lists. A repeat audit (1990-2) following the introduction of this service revealed that 60% (84) of 141 biopsies were performed by the respiratory team with their failure rate for obtaining pleura being lower at 6% as compared to 16% for the general physicians. Thirty-one percent of biopsies provided a definitive diagnosis, being higher for those performed by the respiratory team (37%) as opposed to 23% for general physicians.

Primary B-cell immunoblastic lymphoma of pancreas.

Extranodal lymphoma may present as an abdominal mass without evidence of disease elsewhere. Predominant pancreatic involvement with lymphoma is rare. Presenting as a pancreatic mass, it may be difficult to differentiate if from carcinoma. Ultrasound-guided fine needle biopsy and immunocytochemistry are helpful in establishing a histological diagnosis. It is important to differentiate lymphoma from carcinoma, because lymphoma is treated differently and has a better prognosis.

Case report: duodeno-pericardial fistula.

A case of spontaneous duodeno-pericardial fistula is described. An elderly female presented with pericarditis. The chest radiograph demonstrated a pneumopericardium. The patient died before further investigation and a duodeno-pericardial fistula was found at necropsy. This condition has not previously been described.

Lymphatic abnormalities in Alagille's syndrome.

Chylous pleural effusions developed in a patient with Alagille's syndrome who had dysplasia of the lymphatic system. Lymphatic abnormalities are not a recognised feature of Alagille's syndrome.

Cholesterol embolization following angiography.

A case of cholesterol embolism following mesenteric angiography is reported. Although usually associated with a difficult study in atheromatous vessels this lethal complication occurred in an otherwise uncomplicated examination. This serves as a reminder of the attendant hazards of vascular studies in such patients and emphasizes the need for a careful technique to minimize any vessel wall trauma.

The radiographic differentiation of pulmonary oedema.

A radiographic scoring system has been reported to have a high diagnostic accuracy in the differentiation of pulmonary oedema of renal, cardiac and capillary origin. In the present study, a similar scoring system was used in 51 patients with radiographic appearances of pulmonary oedema due to renal failure (n = 16), cardiac failure (n = 13) and to adult respiratory distress syndrome (ARDS) (n = 22). Evidence of increased pulmonary capillary permeability to transferrin was sought in all patients using a double-isotope method to derive a protein accumulation index (PAI). Using the clinical diagnosis of each type of pulmonary oedema as the "gold standard", sensitivity, specificity and accuracy for the chest radiographic scoring system in pulmonary oedema of cardiac origin were 46, 84 and 75%, respectively. For renal patients these values were 63, 86 and 78% and for ARDS, 89, 33 and 77%. For the PAI in ARDS, sensitivity was 85%, specificity 67% and accuracy 86%. The radiographic scoring system failed to distinguish between pulmonary oedema of renal and cardiac origin and cannot be considered of diagnostic value, but it was more successful in assessment of ARDS. Radiographic appearances suggestive of capillary injury and increased capillary permeability to transferrin occurred in all groups and such findings are not specific to ARDS as currently defined.

Mammography in symptomatic breast disease.

The contribution of mammography to the diagnosis of breast cancer was examined in 5080 patients with various breast symptoms. There were 562 breast cancers within this group. The sensitivity of mammography was 88%. Only 18 cancers were detected by mammography alone, and of these 3 were in the other breast. 7 of the remaining 15 cancers had clinical signs which would have been pursued to open biopsy in the absence of mammography. Clinical examination is of paramount importance in the management of patients with symptomatic breast disease. Mammography is most useful when applied in specific situations rather than to screen every patient with breast symptoms.

Breast self-examination for the early detection of breast cancer.

The early results are presented from a programme of education for Breast Self-Examination (BSE) for self-referral; 32,000 women in one health district, between the ages of 40 and 65 years, were invited by letter for education in BSE. Since the study began (1981-85), 153 breast cancers have been diagnosed, and they have been compared with the 153 breast cancers in the same age group presenting in the same health district immediately prior to the start of the study. A significant amelioration of prognostic factors is seen in the study group. However, at this time there is no significant difference in survival between the Study and the Control groups. The benign to cancer biopsy ratio is 1.2:1.