Percutaneous Pancreatic Biopsies-Still an Effective Method for Histologic Confirmation of Malignancy.

PURPOSE: To determine the accuracy and safety of the percutaneous biopsy of pancreatic mass lesions. MATERIALS AND METHODS: Over a 12-year period clinical parameters, imaging, pathologic results, and complications were assessed in patients undergoing percutaneous biopsies pancreatic lesions. RESULTS: One hundred fifty-three patients underwent pancreatic biopsy. The preferred modality for performing the biopsy was ultrasound (93%, n=143) followed by computerized tomography (7%, n=10). Histologic diagnosis was achieved in 147 patients, of which 3 (2%) were benign and 144 (94%) were malignant. Complications included a single death from overwhelming hemorrhage and 2 patients with morbidity (hematoma and cerebrovascular accident). The sensitivity and specificity of percutaneous biopsies was 90% and 95%, respectively. CONCLUSIONS: Ultrasound-guided and computerized tomographic-guided percutaneous biopsy of pancreatic lesions is an effective and safe method to confirm or refute malignancy in suspicious pancreatic lesions. Endoscopic ultrasound-guided Tru-Cut may have the added advantage of avoiding the risk of peritoneal soiling.

Local anesthesia before IV catheterization.

BACKGROUND: Intradermal buffered lidocaine is known to be effective in producing local anesthesia prior to IV catheterization. Recently, intradermal bacteriostatic normal saline has been suggested as a possible alternative. OBJECTIVE: To compare the efficacy of intradermal bacteriostatic normal saline with that of intradermal buffered lidocaine in providing local anesthesia to adult patients prior to IV catheterization. METHODS: In a randomized, double-blind, parallel-design, quasiexperimental study, we compared pain ratings of adult patients receiving either intradermal buffered lidocaine or intradermal bacteriostatic normal saline before IV catheterization. We measured pain at venipuncture through the use of a verbal numeric rating scale, used the test to compare group differences, and performed an analysis of covariance to test for outcome differences related to age, sex, and race or ethnicity. RESULTS: The final sample (N = 148) was 65% women and 82% white, with a mean age of 52 years (range, 19 to 80 years). Demographic characteristics between the two treatment groups were similar. Intradermal buffered lidocaine was demonstrated to be significantly superior to intradermal bacteriostatic normal saline in reducing the pain of IV catheterization (P = 0.007). Differences in pain ratings between the two groups were not associated with age, sex, race or ethnicity, catheter size, or location of the IV site. CONCLUSIONS: Intradermal buffered lidocaine was superior to intradermal bacteriostatic normal saline in providing local anesthesia prior to IV catheterization in this group of predominately white adults and should be the solution of choice for venipuncture pretreatment.

A simple, safe technique for the drainage of pancreatic pseudocysts.

BACKGROUND: A number of methods are available for the drainage of pancreatic pseudocysts, including percutaneous, endoscopic and open approaches. In Leicester, we developed a combined radiological and endoscopic technique (predating the use of endoscopic/ultrasound) to allow drainage of pancreatic pseudocysts into the stomach. The aim of the study was to evaluate the long-term results of this approach. METHODS: This is a retrospective study of patients undergoing combined endoscopic/ultrasound-guided percutaneous stenting between 1994 and 2007. Data were extracted from case records and our computerised radiology database. RESULTS: Thirty-seven combined endoscopic/ultrasound-guided procedures were undertaken. Median patient age was 52 years (range 26-84 years). Nineteen pseudocysts were secondary to acute pancreatitis and 18 were in patients with chronic pancreatitis. The diameter of pseudocysts on pre-procedure imaging ranged from 4 to 21 cm (median 11 cm). Median duration of hospital stay was 7 days (range 1-44 days) and 30-day mortality was 0%. Stents were inserted in 70.3% of patients (n= 26). Of those patients stented during the combined procedure, three developed infection of the pseudocyst, necessitating open cystgastrostomy within the first month. During a mean follow-up period of 41 months, two patients developed recurrent pseudocysts which were successfully drained with a further combined procedure (16 and 43 months). Repeat imaging in the remainder of patients failed to show any evidence of a persistent or recurrent pseudocyst beyond 2 months. CONCLUSION: Combined radiological and endoscopic drainage is safe, cost-effective and highly efficient in preventing recurrent pseudocyst formation.

Implementation and evaluation of a palliative care resource scheme within a district general hospital.

This article explores the development, implementation and evaluation of a palliative care resource scheme in a district general hospital in Mid Gamorgan, Wales. The evolution of the resource scheme and how the hospital specialist palliative care team identified the need for improved patient care on hospital wards is discussed, in addition to how using their specialist role combined with education can implement change. The project evolved from initially recruiting two nurses on an in-house educational programme, to what has since become a formal arrangement with the local university, whereby students can access taught palliative care modules at degree and diploma levels as part of a distance learning degree in cancer care and a distance learning post- graduate certificate in palliative care. The resource enhances the knowledge of the practitioners who have completed it and also formalizes and expands the working links between education and clinical practice. It is hoped to continue and develop the scheme to further enhance the collaborative partnerships.

Ultrasound changes within the liver after total pancreatectomy and intrahepatic islet cell autotransplantation.

OBJECTIVE: Intrahepatic infusion is the most common method of islet autotransplantation. Structural and functional changes within the liver may result from a number of factors, including embolization of the terminal branches of the portal vein, the effects of high insulin concentration on surrounding hepatocytes or responses to the death of admixed exocrine tissue. Awareness of the potential changes in the appearance of the liver on ultrasonography (USS), together with an assessment of liver function, is important in the postoperative surveillance of these patients. METHODS: We retrospectively reviewed 83 patients who underwent total pancreatectomy between 1993 and 2006. Thirty-three patients had total pancreatectomy alone (control group) and 50 patients underwent total pancreatectomy and islet autotransplantation (islet group). The islets were infused into the left lobe of the liver through the middle colic or recannalated umbilical vein. All patients underwent USS as part of their hepaticojejunostomy surveillance (initially every 6 months and then yearly). RESULTS: "Echogenic nodularity" of the liver was observed in 25% of the islet group of patients and in none of the control group patients (P=0.03). These USS changes occurred from 6 to 12 months after islet autotransplantation and were not associated with any significant loss of liver function or increase in insulin requirements. The islet group had significantly less insulin requirement compared with the control group (P<0.01). CONCLUSION: Echogenicity with a nodular appearance is a common ultrasonographic finding in the liver after intrahepatic islet autotransplantation. These changes do not seem to adversely affect liver function or insulin requirement. Appreciating these changes is important to avoid misinterpretation or over-interpretation of postoperative USS images.

The value of urine screening in a young adult population.

BACKGROUND: GPs in England and Wales are required to perform screening urinalysis on all newly registered patients. The value of this practice, however, is unclear. OBJECTIVE: The purpose of this study was to identify the prevalence of persistent urine abnormalities and to establish the added value of screening for both haematuria and proteinuria in a large cohort of young adults in the UK. METHODS: Urine screening was carried out in a cohort of young adults in a student health centre and a university hospital nephrology unit in a large British city. University students enrolling for health screening in a university health centre over a 2-year period were tested for haematuria and/or proteinuria by dipstick urinalysis. Subjects with persistent urine abnormalities were evaluated for the presence of significant renal tract pathology. RESULTS: Of 3808 students screened, 3570 provided an initial urine sample; 220 were abnormal. Of these, 38 (1% of original cohort) had persistent abnormalities (haematuria, 14; proteinuria, 16; both, eight). Subjects with isolated haematuria or proteinuria did not have significant pathology. In contrast, all the students with both haematuria and proteinuria had identifiable renal disease. CONCLUSIONS: Our findings do not support the value of routine screening for proteinuria or haematuria in young adults. However, the combination of haematuria and proteinuria is a powerful predictor for parenchymal renal disease. Thus, if proteinuria is detected, further testing for haematuria should be performed.