Image-guided pleural biopsy: diagnostic yield and complications

BACKGROUND

Pleural biopsy and cytology are standard procedures for the investigation of pleural disease. Recent medical literature has suggested that image-guided pleural biopsy shows improved sensitivity for the diagnosis of pleural malignancy, when compared with the more commonly performed reverse bevel needle biopsy such as Abrams' needle. In our centre there has been an increasing trend towards performing image-guided pleural biopsies, and to our knowledge there is no large published series documenting the complication rate and diagnostic yield.

METHODS

The radiology and pathology databases were searched for all image-guided [computed tomography (CT) and ultrasound (US)] pleural biopsies from January 2001 to December 2004. All imaging and histology were reviewed, and final diagnostic information about patients was obtained from the respiratory multidisciplinary team database and patient notes. A record was made of complications following biopsy, presence of pleura in the biopsy, and adequacy of tissue for histological diagnosis.

RESULTS

A total of 82 patients underwent 85 image-guided pleural biopsies over a 4-year period. 80 cases were performed under CT and five under US guidance. The rate of new pneumothorax detected by chest radiography was 4.7%. No patient required a chest drain or blood transfusion to treat complications. In 10 (12%) cases, there was inadequate tissue to reach a confident histological diagnosis and in eight (9%) of these, no pleura was present. Assuming all suspicious and inadequate biopsies are treated as benign, which is the worst case scenario, image-guided pleural biopsy has a sensitivity and specificity of 76% and 100%, respectively, for the diagnosis of malignant disease.

CONCLUSIONS

Image-guided pleural biopsy is a safe procedure with few associated complications and has a higher sensitivity than previously published series for reverse cutting needle biopsy in the diagnosis of malignant pleural disease.

An unusual presentation of Crohn's disease

The first case of an inflamed, discharging urachal remnant associated with granulomatous appendicitis in which the patient was subsequently found to have Crohn's disease is described.

Sites, rates, and limits of starch digestion and glucose metabolism in growing cattle1

Growing cattle in the United States consume up to 6 kg of starch daily, mainly from corn or sorghum grain. Total tract apparent digestibility of starch usually ranges from 90 to 100% of starch intake. Ruminal starch digestion ranges from 75 to 80% of starch intake and is not greatly affected by intake over a range of 1 to 5 kg of starch/d. Starch apparently digested in the small intestine decreases from 80 to 34% as starch entering the small intestine increases from 0.2 to 2 kg/d. Starch apparently digested in the large intestine ranges from 44 to 46% of starch entering the large intestine. Approximately 70% of starch digested in the small intestine appears as glucose in the bloodstream. Within the range of starch intakes that do not cause rumen upsets, increasing starch (and energy) intake increases the amount of starch digested in the rumen, increases the supply of starch to the small intestine, increases starch digested in small intestine (albeit at reduced efficiency), and increases starch digested in the large intestine, such that total tract digestibility remains relatively constant. With increased starch intake, most of the starch is still digested in the rumen, but increasing amounts of starch escape ruminal and intestinal digestion, and disappear distal to the ileocecal junction. Again, within the range of starch intakes that do not cause rumen upsets, as starch intake increases, hepatic gluconeogenesis increases, glucose entry increases, and glucose irreversible loss increases, with a significant portion lost as CO2. The ability to increase use of dietary starch to support greater weight gains or improved marbling could come from increasing starch digestion in a healthy rumen or in the small intestine, but we conclude that the main limit to use of dietary starch to support live weight gain is digestion and absorption from the small intestine. Increased oxidation of glucose at greater starch intakes may alter energetic efficiency by sparing other oxidizable substrates, like amino acids.

Influence of soybean hull supplementation on rumen fermentation and digestibility in steers consuming freshly clipped, endophyte-infected tall fescue

Six steers (288.6 +/- 2.1 kg of BW) fitted with rumen and duodenal cannulas were used in a crossover design to evaluate intake, rumen fermentation, and site of nutrient digestion of freshly clipped, endophyte-infected (E+) Kentucky 31 tall fescue with or without soybean hull (SH) supplementation at 0.60% of BW (OM basis). Steers were placed in metabolism units within an environmentally controlled room and provided with free-choice access to fresh forage, water, and a vitamin/mineral supplement. The spring growth of E+ tall fescue was harvested daily during the experiment. Supplement was fed at 0700 with approximately 65% of the estimated daily forage. To maintain a fresh forage supply, additional forage was stored in a cooler and fed at 1900. Periods were 21 d with 14 d of adaptation and 7 d of digesta sample collection. Chromic oxide was used as a marker of duodenal digesta flow. Duodenal samples were taken 4 times daily with times shifting by 1 h each day to represent all 24 h of a day. Treatments were considered significant at P < 0.05. Supplementation of SH decreased forage OM intake from 1.64 to 1.41% of BW but increased total OM intake from 1.64 to 2.01% of BW. Apparent percentages (53.1%) and quantities (2,786 g/d) of rumen OM disappearance were not affected by supplementation. Percentages of total tract OM disappearance were not different (70.8%). Percentages of apparent rumen NDF disappearance also were not different (65.6%). Percentages of N disappearance were not different. Supplementation of SH resulted in increased total N (34.1 g/d) and microbial N (17.1 g/d) flowing to the duodenum. Rumen pH (6.5) was not affected, and rumen ammonia concentrations exhibited a time x treatment interaction in which SH decreased ammonia for 12 h after supplementation. Total VFA concentrations (103.9 mM) were unaffected. Liquid dilution rate (12.7%/h) and rumen OM fill (4.3 kg) were not different between treatments. Supplementation of SH at a rate of 0.60% of BW (OM basis) to calves consuming fresh E+ tall fescue decreased forage consumption but resulted in greater total intake, greater flow of N to the duodenum, and increased total tract OM disappearance.

A Metallocene-Pyrrolidinopyridine Nucleophilic Catalyst for Asymmetric Synthesis

[reaction: see text] A highly active chiral 4-aminopyridine nucleophilic catalyst, available in three steps from (S,S)-hexane-2,5-diol, was applied to the asymmetric Steglich rearrangement of O-aceylated azlactones (1 mol % loading, up to 76% ee).

Water-Soluble Calix[4]resorcarenes as Enantioselective NMR Shift Reagents for Aromatic Compounds

A tetra L-prolinylmethyl derivative of a tetra-sulfonated calix[4]resorcarene (1) is an effective chiral NMR solvating agent for water-soluble compounds with phenyl, pyridyl, bicyclic aromatic, or indole rings. These aromatic compounds form host-guest complexes with the calix[4]resorcarene in water. Complexation of substrates with the calix[4]resorcarene is likely promoted by hydrophobic effects, and bicyclic substrates have association constants with the calix[4]resorcarene larger than those of similar phenyl-containing compounds. Aromatic resonances of the substrates show substantial upfield shifts because of shielding from the aromatic rings of the calix[4]resorcarene, and several resonances in the 1H NMR spectra typically exhibit enantiomeric discrimination. The extent of enantiomeric discrimination depends in part on interactions of the substituent groups of the substrates with the prolinylmethyl groups of the calix[4]resorcarene. The effectiveness of a calix[4]resorcarene prepared from N-methyl-L-alanine (2) as a chiral NMR discriminating agent is compared to the L-prolinylmethyl derivative.

An Enantioselective NMR Shift Reagent for Cationic Aromatics

[structure: see text] The water-soluble tetra l-prolinylmethyl derivative of a tetrasulfonated calix[4]resorcarene is an effective chiral NMR solvating agent for compounds with bicyclic aromatic or indole rings. Complexation of bicyclic substrates with the calix[4]resorcarene is likely promoted by hydrophobic effects. The bicyclic substrates have larger association constants with the calix[4]resorcarene than similar phenyl-containing compounds. Substantial enantiomeric discrimination is observed for several resonances in the (1)H NMR spectra of these substrates.

Ultrasound guided cytological aspiration of supraclavicular lymph nodes in patients with suspected lung cancer

BACKGROUND

Lung cancer is the leading cause of death from cancer in the UK. Pathological diagnosis traditionally requires invasive procedures such as bronchoscopy, mediastinoscopy, or image guided biopsy. Ultrasound of the neck with fine needle aspiration cytology (FNAC) of enlarged but impalpable supraclavicular nodes has been used in patients with suspected lung cancer who have N2 or N3 disease on staging computed tomography (CT). If positive, this technique helps to both stage the patient and provide a cytological diagnosis.

METHODS

101 patients were enrolled prospectively over a 1 year period. FNAC was performed on all supraclavicular nodes over 5 mm in size using the capillary aspiration technique.

RESULTS

Sixty one of the 101 patients had enlarged supraclavicular nodes and underwent FNAC. The overall malignant yield was 45.5% of patients scanned and 75.4% of patients sampled. As a result of FNAC, 43 patients (42.6%) avoided more invasive procedures.

CONCLUSION

Ultrasound guided FNAC is a promising, relatively non-invasive technique for the staging and diagnosis of patients with lung cancer.

High-grade dysplasia in Barrett's oesophagus: natural history and review of clinical practice

BACKGROUND

Management of high-grade dysplasia in Barrett's oesophagus is controversial: surgery carries an appreciable morbidity/mortality, high-grade dysplasia may not progress to cancer and endoscopic ablation is an emerging option.

AIM

To review Barrett's oesophagus-related high-grade dysplasia management and outcome over a 10-year period.

METHODS

This was a retrospective case note review of 36 patients identified from a pathology database.

RESULTS

There were 31 men of mean age 67 years. Endoscopic surveillance identified nine. Median follow-up was 21 months. Seven patients had no further intervention because of age/comorbidity. The other 29 had repeat endoscopic biopsies, nine showing cancer (six oesophagectomized). Of the 20 remaining patients with persisting high-grade dysplasia, eight had surgery (histology showed cancer in six), seven continued endoscopic surveillance (high-grade dysplasia regressed in four) and five had 'curative' argon ablation. An intensive biopsy protocol was not followed in 55% of endoscopies. Prevalent cancers occurred in 44% with an annual incidence of 5% over 5 years. All cause mortality was 39% (14 of 36, eight of 14 from cancer).

CONCLUSIONS

Management of high-grade dysplasia was not uniform. Unsuspected cancer was common in high-grade dysplasia patients undergoing surgery but 13% regressed under surveillance. High-grade dysplasia patients have a high mortality but 43% did not die from cancer.

Synthesis of Planar Chiral Phosphapalladacycles by Highly Enantioselective Transcyclopalladation

The first highly enantioselective synthesis of planar chiral ferrocene phosphapalladacycles was performed by high-yielding asymmetric transcyclopalladation with cobalt oxazoline palladacycles (COP). Use of di-mu-acetatobis[(eta5-(S)-(pR)-2-(2'-(4'-isopropyl)oxazolinyl)cyclopentadienyl-C1,N3')(eta4-tetraphenylcyclobutadiene)cobalt]dipalladium(II), followed by acetate/chloride ligand exchange, gave (pS)-di-mu-chloro[2-(2-dicyclohexylphosphino)phenylferroene-C1,P)dipalladium(II) (95% ee). Similarly, diastereomeric di-mu-acetatobis[(eta5-(S)-(pS)-2-(2'-(4'-tert-butyl)oxazolinyl)cyclopentadienyl-C1,N3')(eta4-tetraphenylcyclobutadiene)cobalt]dipalladium(II) led to the enantiomeric (pR)-phosphapalladacycle (95% ee), revealing the control of these reactions by the element of planar chirality in COP. The reactions were extended to the synthesis of (pS)- and (pR)-di-mu-chloro[2-(2-diphenylphosphino)phenylferroene-C1,P)dipalladium(II) (78 and 92% ee, respectively). In all cases, the palladium-free precursors to COP were recovered for recycling.

A ferrocene based palladacyclic precatalyst for the Suzuki cross-coupling of aryl chlorides

Addition of palladium acetate to 2-(dicyclohexylphosphino)-phenylferrocene gave palladacycle 16 that is a very effective precatalyst for the Suzuki cross-coupling of aryl chlorides at room temperature (1 mol% 16) or 60 degrees C (> or = 0.01 mol% 16).

Catalytic asymmetric rearrangement of allylic N-aryl trifluoroacetimidates. A useful method for transforming prochiral allylic alcohols to chiral allylic amines

[reaction: see text] A useful method for the conversion of prochiral allylic alcohols to chiral allylic amines of high enantiopurity is reported. N-(4-Methoxyphenyl)trifluoroacetimidates are excellent substrates for the palladium(II)-catalyzed allylic imidate rearrangement as the allylic trifluoroacetamide products can be deprotected in two steps to provide chiral nonracemic allylic amines. Di-mu-chlorobis[(eta(5)-(S)-(pR)-2-(2'-(4'-isopropyl))oxazolinylcyclopentadienyl,1-C,3'-N))(eta(4)-tetraphenylcyclobutadiene)cobalt]dipalladium (6a, COP-Cl) is a superior catalyst because it does not require activation with silver salts and provides rearranged allylic trifluoroacetamides in good yields and high enantiomeric purities.

Synthesis of monodentate ferrocenylphosphines and their application to the palladium-catalyzed Suzuki reaction of aryl chlorides

Racemic and enantiopure ((p)()S)-1-bromo-2-methylferrocene 6 were synthesized in 4 steps from 2-(4,4-dimethyloxazolinyl)ferrocene and (S)-2-(4-methylethyloxazolinyl)ferrocene, respectively (46 and 81% overall yield). Bromolithium exchange and addition of ClPR(2) gave the corresponding racemic or enantiopure 2-methylferrocenyl phosphine ligands 2-MeFcPR(2) 11 (R = Ph), 12 (R = Cy), and 13 (R = (t)Bu) in 28-93% yield. Use of PCl(3) gave the C(3)-symmetric phosphine (2-MeFc)(3)P 5 from ((p)()S)-6(72% yield) but racemic 6 did not lead to the formation of triferrocenyl phosphines. Combination of 5 and Pd(2)(dba)(3) gave an active catalyst for the Suzuki reaction of aryl chlorides, for example, 4-chlorotoluene and phenylboronic acid reacted at only 60 degrees C in dioxane (86% yield). Other examples are reported together with the use of 12 in this same protocol. From the X-ray crystal structure of 5 the cone angle was determined as 211 degrees. With this, and the electronic character of 11, 12, and other phosphines (derived from nu(CO) of trans-[(R(3)P)(2)Rh(CO)Cl]), an analysis is made of the steric and electronic influences on ligand activity in the Suzuki reaction.

Pancreatic exocrine secretion in steers infused postruminally with casein and cornstarch

Our objective was to evaluate the effect of postruminal protein infusion on pancreatic exocrine secretions. One Holstein, two crossbred, and five Angus steers (305 +/- 5 kg) with pancreatic pouch-duodenal reentrant cannulas and abomasal infusion catheters were used in a replicated 4 x 4 Latin square. All steers were abomasally infused with 1,050 g/d of raw cornstarch with treatments of 0, 60, 120, or 180 g/d of sodium casein suspended in water to yield 6,000 g/d of infusate daily. Steers were limit-fed (1.5 x NEm; 12 equal portions daily) a 90% corn silage, 10% supplement diet formulated to contain 12.5% CP. Periods consisted of 3 d of adaptation to infusion, 7 d of full infusion, 1 d of collection, and 7 d of rest. Pancreatic juice was collected in 30-min fractions continuously for 6 h. Total juice secreted and the pH of individual fractions were recorded, a 10% subsample was retained to form a composite sample, and remaining fluid was returned to the duodenum. Juice composite samples were stored (-30 degrees C) until analyzed for total protein and activities of alpha-amylase, trypsin, and chymotrypsin. Casein infusion linearly increased alpha-amylase concentration (182 to 271 units/mL; P < 0.02; 17.5 to 24.6 units/mg of protein; P < 0.03) and secretion rate (26,847 to 41,894 units/h; P < 0.01). Total juice secretion (155 g/h), pH of pancreatic juice (8.13), secretion rate of protein (1,536 mg/h), and concentration of protein (10.2 mg/mL) in pancreatic secretions were not affected (P > 0.05) by casein infusion. Similarly, casein infusion did not change 0.05) trypsin and chymotrypsin concentrations (1,379 and 349 units/L or 0.134 and 0.033 units/mg of protein, respectively) or secretion rates (206 and 52 units/h, respectively). Abomasal infusion of protein with starch stimulated a greater pancreatic secretion of alpha-amylase activity into the intestine than infusion of starch alone.

Intestinal starch disappearance increased in steers abomasally infused with starch and protein

Steers (379 +/- 10 kg) with ruminal, duodenal, and ileal cannulas were used in a 5 x 5 Latin square digestion trial to quantify and evaluate the relationship between intestinal protein supply and intestinal starch disappearance. Treatments were infusions of 0, 50, 100, 150, or 200 g/d of casein along with 1,042 g/d of raw cornstarch. Abomasal infusions were accomplished by passing tubing and a pliable retaining washer through the reticular-omasal orifice into the abomasum. Steers were fed a 93% corn silage, 7% supplement diet that contained 12% crude protein at 1.65% body weight in 12 equal portions/d. Periods lasted 17 d (12 d for adaptation, 2 d of collections, and 3 d of rest). The quantity and percentage of organic matter and protein disappearance from the small intestine increased linearly (P < 0.03) with infused casein. Greater quantities of starch disappeared with increased casein infusion (P < 0.01). The infusion of 200 g/d of casein increased small intestinal starch disappearance by 226 g/d over the control. Casein infusion did not affect the quantity or percent of organic matter, starch, or protein disappearance in the large intestine. Treatments did not change ruminal ammonia N, ruminal pH, or plasma glucose concentrations. Starch disappearance from the small intestine was increased with greater protein flow to the duodenum of steers.