Preferred and actual place of death in haematological malignancy

Objectives

Home is considered the preferred place of death for many, but patients with haematological malignancies (leukaemias, lymphomas and myeloma) die in hospital more often than those with other cancers and the reasons for this are not wholly understood. We examined preferred and actual place of death among people with these diseases.

Methods

The study is embedded within an established population-based cohort of patients with haematological malignancies. All patients diagnosed at two of the largest hospitals in the study area between May 2005 and April 2008 with acute myeloid leukaemia, diffuse large B-cell lymphoma or myeloma, who died before May 2010 were included. Data were obtained from medical records and routine linkage to national death records.

Results

323 deceased patients were included. A total of 142 (44%) had discussed their preferred place of death; 45.8% wanted to die at home, 28.2% in hospital, 16.9% in a hospice, 5.6% in a nursing home and 3.5% were undecided; 63.4% of these died in their preferred place. Compared to patients with evidence of a discussion, those without were twice as likely to have died within a month of diagnosis (14.8% vs 29.8%). Overall, 240 patients died in hospital; those without a discussion were significantly more likely to die in hospital than those who had (p≤0.0001). Of those dying in hospital, 90% and 75.8% received haematology clinical input in the 30 and 7 days before death, respectively, and 40.8% died in haematology areas.

Conclusions

Many patients discussed their preferred place of death, but a substantial proportion did not and hospital deaths were common in this latter group. There is scope to improve practice, particularly among those dying soon after diagnosis. We found evidence that some people opted to die in hospital; the extent to which this compares with other cancers is of interest.

Variations in specialist palliative care referrals: findings from a population-based patient cohort of acute myeloid leukaemia, diffuse large B-cell lymphoma and myeloma

Objective

To develop and implement a methodology for capturing complete haematological malignancy pathway data and use it to identify variations in specialist palliative care (SPC) referrals.

Methods

In our established UK population-based patient cohort, 323 patients were diagnosed with acute myeloid leukaemia, diffuse large B-cell lymphoma or myeloma between May 2005 and April 2008, and died before April 2010. A day-by-day calendar approach was devised to collect pathway data, including SPC referrals, to supplement routinely collected information on clinical presentation, diagnosis, treatment, response, and date and place of death.

Results

155 (47.9%) of the 323 patients had at least one SPC referral. The likelihood of referral increased with survival (OR 6.58, 95% CIs 3.32 to 13.03 for patients surviving ≥1 year compared to ≤1 month from diagnosis), and varied with diagnosis (OR 1.96, CIs 1.15 to 3.35 for myeloma compared to acute myeloid leukaemia). Compared to patients dying in hospital, those who died at home or in a hospice were also more likely to have had an SPC referral (OR 3.07, CIs 1.59 to 5.93 and 4.74, CIs 1.51 to 14.81, respectively). No associations were found for age and sex.

Conclusions

Our novel approach efficiently captured pathway data and SPC referrals, revealing evidence of greater integration between haematology and SPC services than previously reported. The likelihood of referral was much higher among those dying outside hospital, and variations in practice were observed by diagnosis, emphasising the importance of examining diseases individually.

Determinants of survival in patients with chronic myeloid leukaemia treated in the new era of oral therapy: findings from a UK population-based patient cohort

OBJECTIVES

To examine contemporary survival patterns in the general population of patients diagnosed with chronic myeloid leukaemia (CML), and to identify patient groups with less than optimal outcomes.

DESIGN

Prospective population-based cohort.

SETTING

The UK's Haematological Malignancy Research Network (catchment population 3.6 million, with >2000 new haematological malignancies diagnosed annually).

PARTICIPANTS

All patients newly diagnosed with CML, from September 2004 to August 2011 and followed up to 31 March 2013.

MAIN OUTCOME MEASURE

Incidence and survival.

RESULTS

With a median diagnostic age of 59 years, the CML age standardised (European) incidence was 0.9/100 000 (95% CIs 0.8 to 0.9), 5-year overall survival was 78.9% (72.3 to 84.0) and 5-year relative survival 88.6% (81.0 to 93.3). The efficacy of treatment across all ages was clearly demonstrated; the relative survival curves for those under 60 and over 60 years being closely aligned. Survival findings were similar for men and women, but varied with deprivation; the age and sex adjusted HR being 3.43 (1.89 to 6.22) for deprivation categories 4-5 (less affluent) versus 1-3 (more affluent). None of these differences were attributable to the biological features of the disease.

CONCLUSIONS

When therapy is freely provided, population-based survival for CML is similar to that reported in clinical trials, and age loses its prognostic significance. However, although most of the patients with CML now experience close to normal lifespans, those living in more deprived areas tend to have poorer outcomes, despite receiving the same clinical care. A significant improvement in overall population outcomes could be achieved if these socioeconomic differences, which may reflect the treatment compliance, could be eliminated.

An outburst from a massive star 40 days before a supernova explosion

Some observations suggest that very massive stars experience extreme mass-loss episodes shortly before they explode as supernovae, as do several models. Establishing a causal connection between these mass-loss episodes and the final explosion would provide a novel way to study pre-supernova massive-star evolution. Here we report observations of a mass-loss event detected 40 days before the explosion of the type IIn supernova SN 2010mc (also known as PTF 10tel). Our photometric and spectroscopic data suggest that this event is a result of an energetic outburst, radiating at least 6 × 10(47) erg of energy and releasing about 10(-2) solar masses of material at typical velocities of 2,000 km s(-1). The temporal proximity of the mass-loss outburst and the supernova explosion implies a causal connection between them. Moreover, we find that the outburst luminosity and velocity are consistent with the predictions of the wave-driven pulsation model, and disfavour alternative suggestions.

Light echoes reveal an unexpectedly cool η Carinae during its nineteenth-century Great Eruption

η Carinae is one of the most massive binary stars in the Milky Way. It became the second-brightest star in our sky during its mid-nineteenth-century 'Great Eruption', but then faded from view (with only naked-eye estimates of brightness). Its eruption is unique in that it exceeded the Eddington luminosity limit for ten years. Because it is only 2.3 kiloparsecs away, spatially resolved studies of the nebula have constrained the ejected mass and velocity, indicating that during its nineteenth-century eruption, η Car ejected more than ten solar masses in an event that released ten per cent of the energy of a typical core-collapse supernova, without destroying the star. Here we report observations of light echoes of η Carinae from the 1838-1858 Great Eruption. Spectra of these light echoes show only absorption lines, which are blueshifted by -210 km s(-1), in good agreement with predicted expansion speeds. The light-echo spectra correlate best with those of G2-to-G5 supergiants, which have effective temperatures of around 5,000 kelvin. In contrast to the class of extragalactic outbursts assumed to be analogues of the Great Eruption of η Carinae, the effective temperature of its outburst is significantly lower than that allowed by standard opaque wind models. This indicates that other physical mechanisms such as an energetic blast wave may have triggered and influenced the eruption.

Help-seeking behaviour in patients with lymphoma

Reducing cancer mortality is a priority for the UK Government and emphasis has been placed on introducing targets to ensure prompt diagnosis. Help seeking is the first step on the pathway to diagnosis and should occur promptly; however, patients with lymphoma take longer to seek help for symptoms than those with many other cancers. Despite this, the help seeking behaviour of these patients has not been investigated. This qualitative study examined the beliefs and actions about help seeking among 32 patients, aged 65 and over and newly diagnosed with lymphoma in West Yorkshire during 2000. Patients reported an extremely wide range of symptoms which were not always interpreted as serious or potentially caused by cancer. This, in association with a clear lack of knowledge about lymphoma, often led to help seeking being deferred. The range and characteristics of symptoms can largely be explained in terms of variations in the type, site and size of the lymphoma. The UK Government targets focus on the time after help seeking, yet for lymphoma it is also crucial to reduce the time taken to seek help. More education about the potential symptoms of this disease is needed among the general public.

Referral pathways and diagnosis: UK government actions fail to recognize complexity of lymphoma

To gain survival advantages potentially associated with prompt diagnosis, the UK government introduced identical waiting-time targets for all cancers, and guidelines to ensure that general practitioners make appropriate hospital referrals. For lymphoma, the evidence guiding these actions is limited. This study examined referral pathways in patients with lymphoma and variations in time to diagnosis by discipline of first referral. A case series study was conducted including all patients aged over 25 years, newly diagnosed with lymphoma in the UK county of West Yorkshire, during 2000. Data were extracted from primary care and hospital records of 189 patients. Referral pathways were described, and the number of days between first referral and diagnosis calculated. A distinct referral pathway did not exist; patients were initially referred to many disciplines. Surgical referrals predominated, and only 12% of patients were sent directly to haematology. Time to diagnosis varied by discipline and was shorter for patients sent to haematology than for most other common disciplines. UK government actions to ensure the prompt diagnosis of patients with lymphoma are not evidence-based. The complexity of the referral pathway in patients with lymphoma, which affects time to diagnosis, has been underestimated. Further government actions should be evidence-based, ensuring prompt diagnosis of lymphoma from whatever discipline patients originate.

Lymphoma: variations in time to diagnosis and treatment

This study examines illness trajectories of patients with lymphoma and assesses whether UK government targets to reduce waiting time for diagnosis and treatment are achievable and appropriate. One hundred and ninety-four patients, residents in West Yorkshire, aged more than 25 years and newly diagnosed with lymphoma during 2000 were included. Data collected from interviews, primary care and hospital records were used to examine time between critical events on the illness trajectory and characteristics of patients not meeting proposed targets. Forty-two per cent of patients did not receive a hospital appointment within 2 weeks of general practitioner referral, 26% were not treated within 1 month of diagnosis and 64% were not treated within 2 months of referral. Target achievement differed by diagnostic group, and trends were seen by age and deprivation. The interval from onset of symptoms to treatment averaged more than 1 year and approximately half of this occurred before first medical contact. Results suggest that significant improvements are needed to achieve targets. Although existing targets particularly address referral and treatment intervals, these were the shortest intervals on the trajectory. Generalized targets may be inappropriate and unachievable for lymphoma as they do not consider individual disease characteristics or allow for variations in the urgency with which treatment is needed.

Endoscopic resection of benign tumors of the papilla of vater

Most benign papillary tumors are adenomas which can potentially undergo the adenoma-carcinoma-sequence making complete removal mandatory for curative therapy. Endoscopic resection (papillectomy) of these lesions is being increasingly performed as a less traumatic alternative to surgery. Available data shows endoscopic papillectomy to be effective and safe in experienced hands with usually little morbidity and virtually no mortality. Success rates are around 80 % for lesions without intraductal involvement. Selected cases of limited distal intraductal involvement accessible after sphincterotomy may also be managed curatively by endoscopic resection. Endoscopic snare resection of entire lesions should be primarily regarded as a diagnostic procedure. It allows for an accurate histological diagnosis based on examination of the entire specimen rather than forceps biopsies and thus a reliable assessment of the need for surgical therapy. Subsequent surgery in operable patients is not precluded by previous endoscopic resection. Surgery is indicated in case of incomplete removal and if malignancy is present. The curative role of endoscopic papillectomy for early invasive carcinoma needs to be established. Histological features and individual risk for surgery are factors to be considered. Inoperable patients may still benefit from palliative endoscopic stenting. After endoscopic papillectomy has been completed, regular follow-up examinations including biopsies are warranted because of the risk of local recurrence. For benign looking papillary tumors, endoscopic papillectomy serves as a diagnostic tool and should be considered as first line procedure regardless of age. The following article details the approach to patients with benign papillary tumor and the technique of endoscopic papillectomy.

Endoscopic management of tumors of the major duodenal papilla: Refined techniques to improve outcome and avoid complications

BACKGROUND

Adenomas of the major duodenal papilla have malignant potential and are traditionally treated by pancreaticoduodenectomy. This is a report of our experience with endoscopic management and a description of techniques for decreasing complications and enhancing efficacy.

METHODS

Forty-one patients were referred for endoscopic management of papillary tumors. If there was no duct invasion and the appearance suggested a benign lesion, biductal sphincterotomy with pancreatic duct stent placement was performed. If the lesion could be elevated by injection of an epinephrine solution, piecemeal resection was performed. The base of the lesion was thermally ablated as needed. Resection/ablation together with stent removal was performed 1 month later.

RESULTS

Nine patients (22%) had lesions other than papillary adenoma or cancer. Malignant appearance, ductal stricturing, or extension into the ducts was found in 16 of 41 patients (39%) in whom biopsy specimens alone were obtained. Three patients with adenomas (7%) did not undergo endoscopic resection (because of extremely large lesions and/or comorbid illnesses). Thirteen patients with adenomas (32%) had endoscopic resection; 12 (92%) were lesion-free after 32 ERCPs (mean 2.7). Endoscopic management was unsuccessful in 1 patient (8%). Pancreatitis developed in 1 patient.

CONCLUSIONS

Endoscopically treatable papillary neoplasms can be identified on the basis of endoscopic, radiographic, and biopsy features. Preresection sphincterotomy, stent placement, elevation by epinephrine injection, and piecemeal resection may reduce complications and permit more aggressive treatment.

Infected pancreatic pseudocysts with colonic fistula formation successfully managed by endoscopic drainage alone: report of two cases

Fistulization of pancreatic pseudocysts into surrounding viscera is a well-known phenomenon and usually requires surgical management. We report two cases of pancreatic pseudocysts that developed spontaneous fistulas to the colon with resulting fever and abdominal pain. The patients were managed nonoperatively with a combination of endoscopic drainage and antibiotics, and their pseudocysts and fistulas resolved. The patients have remained symptom-free for a mean of 14 months of follow-up.

Endoscopic treatment of pancreatic duct stones using a 10F pancreatoscope and electrohydraulic lithotripsy

BACKGROUND

Endoscopic therapy with adjunctive extracorporeal shock wave lithotripsy fails to provide clearance of pancreatic duct stones in up to 25% of symptomatic patients. Direct contact lithotripsy may provide an additional option for removal of refractory stones. We report our initial experience using a prototype 10F "baby" endoscope to administer electrohydraulic lithotripsy.

METHODS

Five patients failing extracorporeal shock wave lithotripsy and one patient with recurrent pancreatic duct stones after surgery were selected to undergo endoscopic electrohydraulic lithotripsy. After pancreatic sphincterotomy and balloon dilation (8 or 10 mm), the 10F endoscope was introduced and electrohydraulic lithotripsy was used to fragment stones under direct visualization.

RESULTS

Six patients underwent 9 intraductal electrohydraulic lithotripsy procedures. Complete or partial pancreatic duct clearance was accomplished in all but one. No complications from the lithotripsy procedure were noted. The 5 patients with partial or complete duct clearance experienced complete relief of abdominal pain of at least 6 months' duration following their final procedure.

CONCLUSION

Electrohydraulic lithotripsy within the pancreatic duct provides an adjunctive endoscopic option for treatment of patients with symptomatic pancreatic duct stones. Our initial experience suggests that electrohydraulic lithotripsy therapy can successfully fragment stones refractory to conventional endoscopic stone extraction methods or extracorporeal shock wave lithotripsy. Further experience is necessary to establish the risks of electrohydraulic lithotripsy within the pancreatic duct.

Endoscopically placed Gianturco endoprosthesis in the treatment of malignant and benign biliary obstruction

Since the introduction of the Z-stent by Cesare Gianturco in 1985, the prominent role of endoscopically placed transpapillary endoprostheses as the treatment of choice to relieve malignant biliary obstruction has stimulated much interest and research in the evolution of his initial design. This article reviews the efficacy and limitation of prior Z-stent models in their attempt to relieve malignant and benign biliary obstructions and previews improvements in the design currently being evaluated in a large, multicenter trial.

Pancreatic stones: treat or ignore?

Painful, chronic pancreatitis is of complex etiology, but increasing clinical experience suggests that removal of pancreatic duct stones in many cases significantly improves patients' symptoms. The development and refinement of therapeutic endoscopic retrograde choledochopancreatography have permitted improved access to the pancreatic duct, which makes the development of new techniques of stone fragmentation and fragment removal a much more successful nonsurgical intervention. A major step forward has been the understanding of the safety and efficacy of pancreatic sphincterotomy, which is necessary for the removal of these difficult stones. The recognition that extracorporeal shock wave lithotripsy can be delivered safely with good efficacy has revolutionized the nonsurgical management of pancreatic duct stones. Nevertheless, advanced and sophisticated therapeutic endoscopy is necessary to achieve clearance of the duct, which can generally be accomplished in the majority of selected patients. State-of-the-art treatments are described, and some new approaches using pancreatoscopy and electrohydrolic lithotripsy are discussed. Newly recognized long term complications are reviewed. Finally, it must be recognized that chronic pancreatitis is an ongoing disease that does not have a simple treatment or cure, and frequently represents a process of remissions and relapses requiring interventions and problem solving.

Dilated common channel syndrome: endoscopic diagnosis, treatment, and relationship to choledochocele formation

BACKGROUND

Choledochoceles (type III biliary cysts) are cystic dilations of the terminal common bile duct or common pancreatobiliary channel. Although no size criteria have been defined, it is generally assumed these must be large. However, we describe patients who do not meet the perceived size criteria for choledochoceles, but who nonetheless have a dilated common pancreatobiliary channel.

METHODS

We reviewed the presenting symptoms, endoscopic and radiographic findings, and response to endoscopic therapy of patients meeting our criteria for the dilated common channel syndrome.

RESULTS

Of 2847 patients undergoing ERCP, 100 (3.5%) had the dilated common channel syndrome. Common presenting symptoms and signs included abdominal pain in 97%, abnormal liver function test(s) in 66%, and a history of acute or recurrent pancreatitis in 46%. A bulge was visible above the papilla in 88%, with a dilated common bile duct in 54% and a dilated pancreatic duct in 28%. After endoscopic unroofing of the common channel, 77% had complete and long-lasting resolution of symptoms, 18% had partial or transient improvement, and 5% had no change.

CONCLUSIONS

Although classic choledochoceles are rare, a lesser degree of dilation of the common channel is more frequent than generally appreciated. We postulate that this finding represents an "incomplete," acquired form of choledochocele, possibly caused by underlying papillary stenosis. Whatever the etiology and appropriate term, the presence of a dilated common channel predicts a high rate of clinical response to endoscopic therapy.

Endoscopic pancreatic sphincterotomy: indications, outcome, and a safe stentless technique

BACKGROUND

Endoscopic pancreatic sphincterotomy is less widely practiced than biliary sphincterotomy, in part because of the lack of firm data regarding its indications and safety. In addition, recent reports of ductal and parenchymal changes occurring after pancreatic stenting raise concerns about the standard practice of stent placement at the time of pancreatic sphincterotomy. We report our experience with pancreatic sphincterotomy and describe the use of a technique involving overnight nasopancreatic drainage rather than stenting.

METHODS

We reviewed the records of the 164 pancreatic sphincterotomies performed on 160 patients at our institution between January 1, 1991, and October 1, 1996, comparing procedures done with overnight nasopancreatic catheter placement with those done with stenting or no drainage. We also examined the long-term clinical outcome of patients after pancreatic sphincterotomy.

RESULTS

Of the 164 sphincterotomies, 98 were done with overnight nasopancreatic drainage, 50 with stent placement, and 16 with no drainage. Complications (all pancreatitis) were significantly more frequent in the group with no drainage (12.5%) as compared with those with drainage (0.7%); p < 0.003. Nasopancreatic drainage was as safe as stent placement, with no complications after 98 procedures. Pancreatic sphincterotomy was effective when used as primary therapy, with 64% of patients so treated experiencing complete and long-lasting resolution of symptoms after the procedure.

CONCLUSIONS

Pancreatic sphincterotomy is safe and effective, although pancreatic drainage is required to reduce the incidence of pancreatitis. Overnight nasopancreatic drainage is the method of choice, as it carries as low a complication rate as stent placement, but without the need for a repeat procedure, and presumably without the risk of ductal and parenchymal damage.

Endoscopic sphincterotomy for stones by experts is safe, even in younger patients with normal ducts

OBJECTIVE

To provide current information on the risks of endoscopic sphincterotomy for stone.

SUMMARY BACKGROUND DATA

In recent years (since the popularity of laparoscopic cholecystectomy), endoscopic sphincterotomy has been used increasingly for the management of bile duct stones in relatively young and healthy patients. The validity of this trend has been questioned using data on short-term complications derived from earlier decades that involved more elderly and high-risk patients.

METHODS

Seven academic centers collected data prospectively using a common database. Complications within 30 days of the procedures were documented by standard criteria.

RESULTS

Of 1921 patients, 112 (5.8%) developed complications; two thirds of these events were graded as mild (<3 days in hospital). There was no evidence of increased risk in younger patients or in those with smaller bile ducts. There was only one severe complication and there were no fatalities in 238 patients age <60, with bile duct diameters of <9 mm.

CONCLUSION

Sphincterotomy for stones can be performed very safely by experienced endoscopists.

Endoscopic management of pseudocysts of the pancreas

Endoscopic pseudocyst management should not be regarded as an exercise in applied technology. Rather, it is of vital importance for the clinician to be thoroughly aware of the many considerations in patient selection and to understand the available treatment alternatives prior to undertaking such a venture. Despite these considerations, it is our opinion that endoscopic pseudocyst management at present is the method of choice in the majority of patients requiring drainage of symptomatic pseudocysts.

Multidisciplinary approach to pseudoaneurysms complicating pancreatic pseudocysts. Impact of pretreatment diagnosis

OBJECTIVE

To determine the effectiveness of thin-section, dynamic-contrast computed tomography and angiography in detecting the presence of pancreatic pseudoaneurysms.

DESIGN

This case series consisted of 57 patients who were being examined for endoscopic drainage of pancreatic pseudocysts.

SETTING

All patients were examined in a tertiary care, teaching hospital.

PATIENTS

Fifty-seven consecutive patients were examined for 2 years. Follow-up ranged from 6 months to 2 years.

INTERVENTIONS

All patients underwent thin-section, high-speed, dynamic-contrast computed tomography. Those patients with findings that were consistent with the presence of a pseudoaneurysm underwent angiography. Embolization was attempted if a pseudoaneurysm was present. Endoscopic retrograde cholangiopancreatography was used to determine pancreatic ductal anatomy before operation.

MAIN OUTCOME MEASURE

No undetected pseudoaneurysm has complicated this series of endoscopically drained pseudocysts.

RESULTS

Five patients had findings that were consistent with a pancreatic pseudoaneurysm on computed tomography. Angiographic findings confirmed a pseudoaneurysm in four patients, and angiographic embolization was successful in three. Four patients underwent resection, while one was treated with embolization and endoscopic stenting of a compressed pancreatic duct. There were no mortalities.

CONCLUSIONS

Before endoscopic drainage of a pancreatic pseudocyst, a thin-section, high-speed, dynamic-contrast computed tomographic scan is essential. If there are findings consistent with the development of a pseudoaneurysm, angiography must be performed. This allows delineation of the arterial anatomy, as well as the option of performing angiographic embolization. While patients with pseudoaneurysms in the body and tail of the pancreas underwent resection, angiographic embolization alone was an acceptable alternative when the lesion was located in the head of the pancreas.

Combined modality treatment of symptomatic pancreatic ductal lithiasis

OBJECTIVE

To assess the efficacy and safety of the removal of pancreatic duct stones by a combined modality approach in patients with pancreatic ductal lithiasis and recurrent abdominal pain.

DESIGN

Retrospective review with a mean follow-up of 19 months (range, 1 to 56 months).

SETTING

A tertiary care, private community hospital with a university affiliation.

PATIENTS

The records of patients who presented to the hospital or who were referred with recurrent abdominal pain and who were demonstrated to have pancreatic ductal lithiasis between 1989 and 1994 were reviewed. Patients were assessed by their clinical response to pancreatic duct stone extraction by a variety of therapeutic interventions.

RESULTS

Fifteen patients were included in the study. One patient was excluded from analysis because of a concurrent choledochocele. Two patients required operative decompression and stone extraction for endoscopically inaccessible stones. Six patients were treated with endoscopic management alone, and six were treated with a combination of extracorporeal shock wave lithotripsy and endoscopic stone retrieval. Twelve patients had complete clearance of the pancreatic duct. One patient had a stone that was not removed, but adequate pancreatic ductal decompression was achieved. The remaining patient had incomplete clearance of pancreatic stone fragments following extracorporeal shock wave lithotripsy but had adequate ductal drainage. No patient has required further therapy or hospitalization for abdominal pain. No complications occurred as a result of any intervention in this study.

CONCLUSIONS

A multidisciplinary combined modality approach is a safe and effective method for extracting pancreatic duct stones in symptomatic patients. Stone extraction and reestablishment of adequate ductal drainage appear to relieve symptoms in some patients.

Endoscopic management of cystic duct fistulas after laparoscopic cholecystectomy

Two patients are reported who developed bile ascites as a result of cystic duct fistulas following laparoscopic cholecystectomy. Both patients were successfully treated with endoscopic retrograde cholangiopancreatography, utilizing sphincterotomy and nasobiliary tube placement. Characteristics of this syndrome and advantages of this form of therapy are emphasized.

Endoscopic needle aspiration biopsy at ERCP in the diagnosis of biliary strictures

We have developed a ball-tipped catheter with a retractable 22-gauge, 7-mm long needle to perform endoscopic needle aspiration (ENA) for cytology and compared this technique to brush cytology of malignant-appearing biliary strictures during ERCP. Of 31 patients, 26 had proven malignant strictures involving the common bile duct and 5 had benign lesions. All 31 patients had ENA and 29 were brushed. Positive ENAs were obtained in 16 of 26 patients (61.5%) and positive brushings in 2 of 24 (8.3%). With the addition of two suspicious ENAs for pancreatic adenocarcinoma, 73% of patients had positive or suspicious cytology for malignancy by combined ENA and brush with a specificity of 100%. Although ENA appeared to be more sensitive in diagnosing cholangiocarcinoma, it proved to be most effective in the diagnosis of pancreatic adenocarcinoma when compared with brush cytology. One patient with cholangiocarcinoma in our series was diagnosed by brush cytology only, with a negative ENA, supporting our recommendation of using both endoscopic brushings and ENA for cytology when evaluating biliary strictures.

Symptomatic choledochoceles in adults. Endoscopic retrograde cholangiopancreatography recognition and management

During a 2-year interval, we identified 10 patients with symptoms of pancreaticobiliary disorders and small choledochoceles by endoscopic retrograde cholangiopancreatography. Patients ranged from 36 to 89 years of age. Eight were female. Seven presented with recurrent, acute pancreatitis, two presented with biliary colic, and one presented with cholangitis. Dilated common bile ducts were seen in four patients, and no other biliary lesions were demonstrated in any patients. Five patients were shown to have normal gallbladders by ultrasonographic or computed tomographic criteria. Choledochoceles were identified endoscopically as a bulge above or involving the ampulla. Diagnosis was confirmed by cholangiography. All patients underwent successful unroofing of the choledochocele and sphincterotomy of the common bile duct. One pancreatic sphincterotomy was performed for pancreatic ductal obstruction. We encountered no complications. Hospital stays ranged from 1 to 4 days. Follow-up intervals ranged from 2 to 20 months. At this time, no patients have had any recurrence of symptoms, and none has required rehospitalization or surgery.

Biliary patency imaging after endoscopic retrograde sphincterotomy with gallbladder in situ. Clinical impact of nonvisualization

We prospectively performed nuclear biliary patency imaging (HIDA scanning) in 62 patients who had undergone endoscopic retrograde sphincterotomy for management of pancreaticobiliary disease with their gallbladders in situ. Elective cholecystectomy was not recommended because of advanced age, comorbidity, or absence of gallstones. All patients had patent cystic ducts at endoscopic retrograde cholangiopancreatography balloon cholangiography. Eighteen (29.1%) of 62 patients had nonvisualizing HIDA scans, and in 44 (70.9%) of 62 visualization was normal or delayed. Six cholecystectomies were required for colic (n = 1), acute cholecystitis (n = 4), and acute cholecystocholedochal fistula with cholangitis (n = 1). Among the patients with cholelithiasis and nonvisualization (n = 13), five (38.5%) required surgery, whereas only one (4.8%) of 21 patients with cholelithiasis and visualization required surgery. Nonvisualizing HIDA scans are frequent (30%) after endoscopic retrograde sphincterotomy and have no clinical relevance in patients without cholelithiasis but predict the need for cholecystectomy within 16 months in 38.5% of patients with cholelithiasis.

Immunological conservation of phycobilisome rod linker polypeptides

Monospecific polyclonal antibodies raised against the phycobilisome rod linker polypeptides of Nostoc sp. were used to assess structural similarities among phycobilisome linker proteins from diverse, phycobilisome-containing organisms. While a remarkable conservation of antigenic determinants was demonstrated for two of these rod linker proteins, the third linker polypeptide appeared to be conserved only among closely related species.

The immunologically conserved phycobilisome-thylakoid linker polypeptide

We have isolated phycobilisomes from two classes of red algae, several subdivisions of the cyanobacteria, and the cyanelles of Cyanophora paradoxa. In addition to the major light harvesting biliproteins, these phycobilisomes also contain several other polypeptides, the largest of which ranges from 75 to 120 kilodaltons in the different species surveyed. This protein, previously isolated and characterized from three species, was shown to be the final emitter of excitation energy in phycobilisomes and is also thought to be involved in the attachment of the phycobilisomes to the thylakoid membrane. We have obtained polyclonal antibodies to the 95 kilodalton polypeptide isolated from phycobilisomes of the cyanobacterium, Nostoc sp. This protein shares no common antigenic determinants with either the alpha or beta subunits of allophycocyanin, or any of the other biliproteins, as determined by the sensitive Western immunoblotting technique. However, this antiserum cross-reacts with the highest molecular weight polypeptide of all the rhodophytan and cyanobacterial phycobilisomes tested. That these proteins are immunologically related, but are unrelated to other biliproteins, is reminiscent of previous immunological studies of biliproteins which showed that while the three major spectroscopically distinct classes of biliproteins (phycoerythrin, phycocyanin, and allophycocyanin) shared no common antigenic determinants, there was a strong antigenic determinant to specific biliprotein classes which crossed taxonomic divisions.

Role of the Colorless Polypeptides in Phycobilisome Assembly in Nostoc sp

We have identified the function of the ;extra' polypeptides involved in phycobilisome assembly in Nostoc sp. These phycobilisomes, as those of other cyanobacteria, are composed of an allophycocyanin core, phycoerythrin- and phycocyanin-containing rods, and five additional polypeptides of 95, 34.5, 34, 32, and 29 kilodaltons. The 95 kilodalton polypeptide anchors the phycobilisome to the thylakoid membrane (Rusckowski, Zilinskas 1982 Plant Physiol 70: 1055-1059); the 29 kilodalton polypeptide attaches the phycoerythrin- and phycocyanin-containing rods to the allophycocyanin core (Glick, Zilinskas 1982 Plant Physiol 69: 991-997). Two populations of rods can exist simultaneously or separately in phycobilisomes, depending upon illumination conditions. In white light, only one type of rod with phycoerythrin and phycocyanin in a 2:1 molar ratio is synthesized. Associated with this rod are the 29, 32, and 34 kilodalton colorless polypeptides; the 32 kilodalton polypeptide links the two phycoerythrin hexamers, and the 34 kilodalton polypeptide attaches a phycoerythrin hexamer to a phycocyanin hexamer. The second rod, containing predominantly phycocyanin, and the 34.5 and 29 kilodalton polypeptides, is synthesized by redlight-adapted cells; the 34.5 kilodalton polypeptide links two phycocyanin hexamers. These assignments are based on isolation of rods, dissociation of these rods into their component biliproteins, and analysis of colorless polypeptide composition, followed by investigation of complexes formed or not formed upon their recombination.

Hypercalcemia complicating small-cell carcinoma

Hypercalcemia is a common paraneoplastic syndrome complicating some varieties of lung cancer. It has rarely been reported with small-cell carcinoma of the lung. Seven cases of hypercalcemia complicating small-cell carcinoma of the lung are described; clinical features indicate that significant bone or bone marrow involvement is present in all cases. Parathormone assays were found to be generally in the normal range, though inappropriate for the levels of hypercalcemia.

Intrahepatic hematoma after aspiration liver biopsy. A prospective randomized trial using two different needles

The purpose of this study was twofold: (1) to determine the incidence of intrahepatic hematoma after liver biopsy by the aspiration technique and (2) to compare the incidence of hematoma after biopsy with a needle of 1.6 mm vs 1.9 mm OD. Fifty-one patients were randomly assigned to be biopsied with the smaller needle and 46 with the larger. Hematomas, diagnosed by development of characteristic transient defects on liver scans done shortly after biopsy, occurred in two (4%) of those biopsied with the smaller needle and in none of those biopsied with the larger. This difference is not statistically significant. Neither patient who developed a hematoma had changes in vital signs, CBC, or serum alkaline phosphatase. One had a fivefold rise in SGOT; n the other, the SGOT remained normal. If these results are considered with those of other prospective trials of similar design, the overall incidence of intrahepatic hematoma after aspiration biopsy may be estimated to be 2.3% when needles of 1.6-2.0 mm (OD) are used. Many of these go undetected because, justifiably, scans are not routinely done shortly after biopsies.

Pulmonary hypertension as a presentation of hepatocarcinoma. Report of a case and brief review of the literature

A case, unique in the literature, is reported in which a primary carcinoma of the liver presented a right-sided heart failure and pulmonary hypertension. The diagnosis of hepatocarcinoma was established by needle biopsy of the liver. Later, postmortem examination demonstrated that the pulmonary arterial tree was severely compromised by multiple tumor microemboli, despite the persistent lack of characteristic roentgenographic abnormality in our patient. In reviewing the literature, we found rare cases of occult renal cell carcinoma, choriocarcinoma and one of occult hepatocarcinoma, which presented as pulmonary embolism. These were diagnosed by pulmonary embolectomy, human chorionic gonadotrophin levels or autopsy, respectively. In another small group of reported cases of known carcinoma (gastric, breast, colonic) the patients had a clinical picture of "idiopathic" pulmonary hypertension or of pulmonary hypertension with pulmonary metastases. Pulmonary hypertension in these cases resulted from carcinomatous lymphangitis and/or tumor microembolization, as in our case. We report this case to emphasize the necessity of including occult carcinoma in the differential diagnosis of pulmonary hypertension and right ventricular failure.

Olfactory mucosa in herpes simplex encephalitis

The olfactory mucosa was examined in three patients dying from herpes simplex encephalitis. It showed changes attributed to infection by the herpes simplex virus. It is suggested that in some patients encephalitis may be a complication of infection of the olfactory mucosa.