Fine-needle biopsy of pediatric lesions: a three-year study in an outpatient biopsy clinic

Diagnostic Cytology Laboratory, Inc., has an outpatient Fine Needle Biopsy Clinic, which evaluated 7,487 fine-needle biopsies (FNB) from January 1989 to February 1992. Two hundred eighty-eight (3.8%) of these specimens were collected from patients 19 years old or younger and this represents the largest study of this population in the scientific literature. The majority of these specimens were obtained from palpable masses in the head and neck region [lymph nodes (58.3%), thyroid (7.6%), and salivary gland (5.2%)] while a smaller number were collected from miscellaneous soft tissue (18.8%) and breast masses (10.1%). Thirteen (4.5%) (from 12 patients) were diagnosed as malignant by FNB and 275 (95.5%) (264 patients) were benign by FNB. This benign:malignant ratio (22:1) is significantly higher than has been reported from tertiary care institutions and is a reflection of the difference of this outpatient population. Two hundred nine of 276 patients (75.7%) had adequate follow-up, including 137 (49.6%) patients followed by observation, 48 (17.4%) patients followed by surgical biopsy, and 24 (8.7%) patients followed by some other modality: imaging studies, flow cytometry, or treatment. There was a single false positive diagnosis (a pilomatrixoma) and one (1) false negative interpretation (a cystic acinic cell carcinoma) resulting in a diagnostic sensitivity of 92.3% and a specificity of 99.6%. The positive predictive value was 92.3%, the negative predictive value was 99.6%, and the test efficiency was 99.3%. The utility, cost-effectiveness and uniqueness of the clinic population is discussed.

The teaching of medical ethics in oncology education

The teaching of medical ethics is an important aspect of oncology education. To prepare future physicians to cope with the many and complex ethical issues in the care of oncology patients, Dartmouth Medical School developed a two-hour medical ethics component in the required second-year course on the principles of oncology. The paper describes the goals and case method for the teaching of ethics.

Mechanism of the effects of glucocorticoids and mineralocorticoids on vascular smooth muscle contractility

We have previously demonstrated that receptors to both mineralocorticoids (MC) and glucocorticoids (GC) exist in the arterial wall and that treatment with GC markedly increases Na+ and Ca2+ influx in cultured aortic vascular smooth muscle (VSM) cells, whereas treatment with MC increases only Na+ influx. We now report the results of the study aimed at the elucidation of the mechanism(s) of these effects. Unidirectional influx of Na+ and Ca2+ was measured in cultured cells of rabbit aortic media, using 22Na and 45Ca as tracers, in the presence of ouabain. The cells were treated for different periods with dexamethasone (DEX) or aldosterone (ALDO) in physiologic or supraphysiologic concentrations, in the presence or absence of competitive inhibitors of GC-receptor binding, RU 486, or MC-receptor binding, K-prorenoate. DEX in 50 nM concentration increased Na+ influx by 98 +/- 18% and Ca2+ influx by 100 +/- 20%, and the maximum effect was seen after 48 hour cell-treatment. ALDO in 5 nM concentration increased Na+ influx by 90 +/- 12% and had no effect on Ca2+ influx, and the maximum effect was seen after 7-10 days of cell-treatment. The enhancing effect of both DEX and ALDO on the influx rate of Na+ was prevented by actinomycin D and by cycloheximide. RU 486 completely inhibited DEX from exercising its enhancing effect on Na+ influx, but diminished influx rate of Na+ increased by ALDO only by 25%. Prorenoate (PRN) did not have any effect on DEX-increased Na+ influx, but completely inhibited ALDO from exercising its effect.(ABSTRACT TRUNCATED AT 250 WORDS)

Glucocorticoids regulate Na+ transport in vascular smooth muscle through the glucocorticoid receptor-mediated mechanism

The incidence of hypertension in conditions of chronic glucocorticoid (GC) excess is very high, though the mechanism whereby GC elevate blood pressure is far from being understood. We have recently found that GC markedly increase influx of Na+ in vascular smooth muscle (VSM) cells. We and other investigators have previously described receptors for GC in arterial tissues, and we have now examined whether the effect of GC on Na+ transport in VSM is mediated through these receptors. Vascular smooth muscle cells were cultured from rabbit aortas. The cells were treated for 48 h with 10(-7) mol/L dexamethasone (DEX), in the presence or absence of RU 486, a competitive inhibitor of DEX binding to its receptor, or progesterone, an allosteric accelerator of DEX dissociation from the receptor. Unidirectional influx of Na+ was measured with 22Na as tracer. Dexamethasone more than doubled the influx rate of Na+, RU 486 completely prevented this increase, and progesterone reduced the DEX-induced increase by approximately 80%. The time of the cell exposure to DEX necessary for the DEX effect to occur was 4 to 6 h, with a maximal effect at 48 h, suggesting a genomic effect. Addition of protein synthesis inhibitors, actinomycin D or cycloheximide, to VSM cells cultured in the presence of DEX prevented the increase of Na+ influx by DEX.(ABSTRACT TRUNCATED AT 250 WORDS)

Development of a culturally sensitive rural practicum

Wanting to increase their students' awareness of and experience with providing culturally sensitive care in a rural setting, the authors developed a nursing elective course. They discuss the structure, goals, and outcomes of the course.

The ethical role of the consultant

In the United States, physicians are Increasingly functioning In the consultative role. This change in role Is undoubtedly a result of a surge in the numbers of specialists, the relative decreasing number of primary care physicians, and the emergence of tertiary care centers as primary treatment providers. This change In the style of practicing medicine has led to role confusion In attending physician-patient-consultant relationships.

Fine-needle aspiration biopsy of small round blue cell tumors of childhood

One hundred twenty-eight palpable and deep-seated fine-needle aspiration biopsies (FNAB) were done on pediatric patients at James Whitcomb Riley Hospital for Children and Indiana University Hospital between 1985 and 1988. During that 4-year period, 71 (56%) benign and 49 (38%) malignant diagnoses were made. Only eight (6%) of the FNAB were considered inadequate. Thirty-nine (80%) of the malignant aspirates were small round blue cell tumors of childhood (SRBCT). The SRBCT consisted of 21 (54%) lymphomas, 7 (18%) Ewing's sarcomas, 3 (8.5%) neuroblastomas, 3 (8.5%) rhabdomyosarcomas, 2 (5.0%) medulloblastomas, 2 (5.0%) Wilms' tumors, 1 (3.0%) retinoblastoma, and 1 (3%) granulocytic sarcoma. Fifteen (38%) of the SRBCT aspirates were obtained to render a primary diagnosis and 24 (62%) documented recurrence. Various combinations of electron microscopy, immunocytochemistry, and other special stains were used to confirm the diagnosis in 11 (28%) cases. These cases consisted of five lymphomas, two rhabdomyosarcomas, two Ewing's sarcomas, one neuroblastoma, and one granulocytic sarcoma. The technique of FNAB is a successful diagnostic tool for documenting primary and recurrent SRBCT in a pediatric population.

Fine needle aspiration of rhabdomyosarcoma of the heart. Light and electron microscopic findings and histologic correlation

Fine needle aspiration (FNA) biopsy was performed on a 12-year-old child with intractable cardiac arrhythmias and a mediastinal mass. The cytologic, immunocytochemical and electron microscopic findings on the aspirated material established an initial diagnosis of cardiac rhabdomyosarcoma. Subsequent histologic material confirmed the cytologic diagnosis. The findings are presented, and the use of FNA to definitively establish a preoperative diagnosis of cardiac rhabdomyosarcoma is discussed.

Moral theory and neurology

This article presents an outline of a general moral theory and shows its relationship to the concepts of paternalism and that of valid consent and refusal. The authors then show how this theory and these concepts can be usefully applied to the moral problems that neurologists often face in determining how to act when they have distressing information for their patients. Finally, a procedure is provided for determining when it is morally justified to deceive patients by withholding information about their diagnoses, prognoses, or about their prospective treatments.

Decisions to withhold or terminate treatment

Decisions to withhold or terminate treatment are common clinical dilemmas in patients dying from diseases of the nervous system. Decision making for such patients must be based upon ethical principles. Under the doctrine of valid consent and refusal, competent patients have the right to refuse life-sustaining therapies. For incompetent patients, this right may be exercised through their previously executed advanced directives or through appointed proxy decision makers. Physicians have the duty to assess the potential benefits and harms of various treatment options and to clearly communicate this information to patients and their proxies in a supportive manner. The authors illustrate the application of ethical principles in neurologists' management of patients in persistent vegetative states, dementia, and end-stage neuromuscular disease.