[Melanosis of the bladder-a rare diagnosis]

Melanosis of the urinary bladder is an extremely rare benign condition in which melanin deposits occur in the urothelial and stromal cells. We report such a case in which melanosis of the urinary bladder was detected in a 55-year-old woman with known multiple sclerosis during an extended workup due to urinary urgency complaints. The findings were confirmed by biopsy.

Rapid Deployment of Whole Slide Imaging for Primary Diagnosis in Surgical Pathology at Stanford Medicine: Responding to Challenges of the COVID-19 Pandemic

CONTEXT.—

Stanford Pathology began stepwise subspecialty implementation of whole slide imaging (WSI) in 2018 soon after the first US Food and Drug Administration approval. In 2020, during the COVID-19 pandemic, the Centers for Medicare & Medicaid Services waived the requirement for pathologists to perform diagnostic tests in Clinical Laboratory Improvement Amendments (CLIA)-licensed facilities. This encouraged rapid implementation of WSI across all surgical pathology subspecialties.

OBJECTIVE.—

To present our experience with validation and implementation of WSI at a large academic medical center encompassing a caseload of more than 50 000 cases per year.

DESIGN.—

Validation was performed independently for 3 subspecialty services with a diagnostic concordance threshold above 95%. Analysis of user experience, staffing, infrastructure, and information technology was performed after department-wide expansion.

RESULTS.—

Diagnostic concordance was achieved in 96% of neuropathology cases, 100% of gynecologic pathology cases, and 98% of immunohistochemistry cases. After full implementation, 8 high-capacity scanners were operational, with whole slide images generated on greater than 2000 slides per weekday, accounting for approximately 80% of histologic slides at Stanford Medicine. Multiple modifications in workflow and information technology were needed to improve performance. Within months of full implementation, most attending pathologists and trainees had adopted WSI for primary diagnosis.

CONCLUSIONS.—

WSI across all surgical subspecialities is achievable at scale at an academic medical center; however, adoption required flexibility to adjust workflows and develop tailored solutions. WSI at scale supported the health and safety of medical staff while facilitating high-quality patient care and education during COVID-19 restrictions.

Tumour budding is a strong and independent prognostic factor in pancreatic cancer

INTRODUCTION

Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive cancer that escapes detection and resists treatment. Tumour budding, defined as the presence of de-differentiated single tumour cells or small cell clusters at the invasive front of gastrointestinal carcinomas like colorectal, oesophageal, gastric and ampullary, is linked to adverse prognosis. Tumour budding has not yet been reported in PDAC.

AIM

To assess the frequency and prognostic impact of tumour budding in PDAC.

METHODS

Whole-tissue sections of 117 PDACs with full clinico-pathological and follow-up information, including postoperative therapy, were stained using a pancytokeratin marker. Tumour budding was assessed in 10 high-power fields (HPFs) by two pathologists. High-grade budding was defined as an average of >10buds across 10HPFs. Measurements were correlated to patient and tumour characteristics. The study was performed according to the REMARK guidelines.

RESULTS

Inter-observer agreement was considered strong (ICC=0.72). Low-grade budding was observed in 29.7% and high-grade budding in 70.3% cases. High-grade budding was linked to advanced pT classification (p=0.0463), lymphatic invasion (p=0.0192) and decreased disease-free (p=0.0005) and overall survival (p<0.0001). There was no association with pN, pM, R-status or blood vessel invasion. In multivariate analysis, the prognostic effect of tumour budding was independent of lymph node metastasis, lymphatic invasion and R-status (p<0.0001; HR (95% CI): 3.65 (2.1-6.4)).

CONCLUSIONS

Our results show that high-grade tumour budding occurs frequently in PDAC and is a strong, independent and reproducible, highly unfavourable prognostic factor that could be used to guide future individualised therapeutic approaches.

Direct measurement of sheet resistance Rsquare in cuprate systems: evidence of a fermionic scenario in a metal-insulator transition

The metal-insulator transition (MIT) has been studied in Ba(0.9)Nd(0.1)CuO(2+x)/CaCuO2 ultrathin cuprate structures. Such structures allow for the direct measurement of the 2D sheet resistance R( square), eliminating ambiguity in the definition of the effective thickness of the conducting layer in high temperature superconductors. The MIT occurs at room temperature for experimental values of R(square) close to the 25.8 kOmega universal quantum resistance. All data confirm the assumption that each CaCuO2 layer forms a 2D superconducting sheet within the superconducting block, which can be described as weak-coupled equivalent sheets in parallel.

Percutaneous balloon mitral valvuloplasty in comparison with open mitral valve commissurotomy for mitral stenosis during pregnancy

OBJECTIVES

We sought to compare the maternal and fetal outcomes of patients with severe mitral stenosis submitted to percutaneous balloon dilation versus open mitral valve commissurotomy (MVC) during pregnancy.

BACKGROUND

Heart failure in patients with mitral stenosis complicating pregnancy is a common problem in developing countries. Since 1984, percutaneous dilation of the mitral valve using a balloon catheter has become a therapeutic alternative to open heart surgery. Although the efficacy of percutaneous mitral valve balloon dilation is well established, its results have never before been compared with the results of commissurotomy during pregnancy.

METHODS

We compared the clinical and obstetric complications in 45 women who were treated with percutaneous mitral valve balloon dilation (group I, n = 21; from 1990 to 1995) or open MVC (group II, n = 24; from 1985 to 1990) for severe heart failure due to mitral stenosis during pregnancy.

RESULTS

In our study, percutaneous balloon dilation of the mitral valve had a success rate of 95% (Gorlin formula) and 90.5% (echocardiographic "pressure half-time" method), as demonstrated by the final mitral valve area achieved. This improvement was followed by a marked decrease in the mitral valve gradient, left atrial pressure and mean pulmonary artery pressure. Patients in both groups had similar improvements in symptoms. Patients who underwent percutaneous balloon dilation had significantly fewer fetal complications, with a reduction in fetal and neonatal mortality (1 death in group I vs. 8 in group II, p = 0.025).

CONCLUSIONS

Percutaneous balloon mitral valvuloplasty is safe and effective and appears to be preferable for the fetus, compared with open MVC during pregnancy.

[Heart surgery with extracorporeal circulation in pregnant women. Analysis of materno-fetal outcome]

PURPOSE

To analyze maternal and fetal outcome in pregnant undergone to cardiac surgery.

METHODS

We studied the evolution of 30 pregnant women submitted to cardiac surgery at the Hospital São Paulo, between Jan/81 and Dec/92 and, further, attended at this Hospital till the parturition. The following variables were analyzed: cardiopulmonary bypass, time of the procedure and time of the anoxia, patient temperature, surgical complications, and neonatal, maternal and fetal outcomes.

RESULTS

All patients had rheumatic heart disease and, in 17, mitral stenosis was the main anatomic abnormality. Mitral commissurotomy was performed in 24 patients, double comissurotomy (mitral and aortic) in 1 patient and valve replacement was performed in 5. Cardiopulmonary bypass was utilized in all procedure; occurrence of surgical complications (p < 0.001) and the prolonged surgical time (p = 0.009) were related to the fetal mortality. There was 4 (13.3%) maternal deaths and 10 (33.3%) fetal deaths related to the surgery.

CONCLUSION

The indication of cardiac surgery in pregnant women is heart failure, refractory to conventional therapy; cardiopulmonary bypass is associated with high fetal mortality.

Successful use of deep hypothermic circulatory arrest in pregnancy

A woman pregnant for 21 weeks underwent an emergency operation because of an aortic arch aneurysm that had ruptured into her left lung. Cardiopulmonary bypass and deep hypothermia were used and she needed 37 minutes of circulatory arrest at a core temperature of 19 degrees C. Both the mother and fetus survived, and a normal baby was delivered by cesarean section at the 39th week of gestation.

Paragangliomas of the sellar region: report of two cases

Two cases of paraganglioma arising from the parasellar region are presented. Both occurred in middle-aged women who sought treatment of headaches but who had no endocrinological dysfunction; one case was associated with ophthalmoplegia from cavernous sinus involvement. Diagnosis in both cases was confirmed by typical histological appearance and cytochemical demonstration of immunoreactive chromogranin in tumor cells. The pathological features and possible pathogenesis of parasellar paragangliomas are discussed.

Pregnancy in patients with prosthetic heart valves: the effects of anticoagulation on mother, fetus, and neonate

Maternal and fetal complications in a consecutive series of 60 pregnancies in 49 patients with prosthetic heart valves were prospectively evaluated. Group 1 consisted of 40 pregnancies in 31 patients who were taking oral anticoagulants. No oral anticoagulation was used in 20 pregnancies in 19 patients (group 2). In group 1 there were three instances of acute valvular thrombosis during the 35 pregnancies in patients with mechanical prostheses, with two maternal deaths. There were two episodes of cerebral embolism, one in group 1 and one in group 2. Patients with isolated aortic valve replacement had fewer maternal complications (2 of 13) than patients with isolated mitral valve replacement (15 of 42) without statistical significance. Severe bioprosthesis dysfunction occurred in 4 of 25 pregnancies (one rupture and three stenosis) with two maternal deaths, one in the puerperium and the other in the postoperative period of cardiac surgery during pregnancy. When analyzing obstetric events we observed seven spontaneous abortions and one hydatidiform mole. All spontaneous abortions occurred in group 1. The incidences of prematurity and low birth weight were significantly higher in group 1 than in group 2 (46.6% vs 10.5%, p less than 0.05, and 50% vs 10.5%, p less than 0.05, respectively). Moreover, there was a significant association between prematurity and the mother's New York Heart Association functional class (61.5% in classes III and IV vs 22.2% in classes I and II, p less than 0.05). There were five neonatal deaths, all in group 1 (p = NS vs group 2). Three infants had warfarin-related congenital defects.(ABSTRACT TRUNCATED AT 250 WORDS)

Outcome of thyroid function in newborns from mothers treated with amiodarone

Amiodarone, a drug extensively used as an antiarrhythmic agent, contains 37% iodine and causes several thyroid abnormalities. The transplacental passage of amiodarone occurs with chronic therapy; we describe in this report the outcome of 9 pregnant women who used amiodarone (200 mg/day) for treatment of resistant tachycardia and the follow-up of their newborns. All women were clinically euthyroid at the 3rd trimester and showed expected values of thyroid hormones (mean +/- SD: total T4, 228 +/- 45 nmol/L; total T3, 4.0 +/- 0.65 nmol/L; TSH, 4.0 +/- 1.8 mU/L; negative thyroid antibodies). At birth all newborns were normal on routine examination with no goiter or corneal changes. T4 and TSH, measured on dried umbilical blood spots were normal or borderline-normal in 8 of 9 babies. Only 1 neonate presented clearly abnormal values of T4 and TSH (96 mU/L); on clinical grounds the baby was normal, without signs of hypothyroidism. At 1 month of life, T4 and TSH were normal. Follow-ups at 3, 6, and 12 months were normal. We conclude that is not necessary to discontinue treatment with amiodarone in pregnant women with resistant tachycardia, but it is imperative to evaluate the thyroid function of the newborn, since transient hypothyroidism may occur.

[Maternal mortality due to heart disease]

A retrospective study on maternal mortality in pregnant women with cardiac disease over a period of eleven years (January 1979 to December 1989) was undertaken. The objective was an analysis of the main aspects of this association. Cardiac disease was diagnosed in 694 patients (4.2%) of a total of 16,423 admitted to the Obstetrics Department of the Escola Paulista de Medicina. As for etiology, rheumatic disease (52.3%); Chagas's disease (19.3%) and congenital disease (8.1%) were the most frequent causes. There were 51 maternal deaths, according to FIGO's definition (1967), corresponding to a maternal mortality rate of 428.2/100,000 livebirths during the same period. Twelve of these maternal deaths were due to cardiac disease (maternal mortality rate of 100.8/100,000 livebirths). The statistical analysis identified the following aspects associated with maternal mortality among patients with cardiac disease: primigravida, lack of adequate prenatal care, and cardiac surgery performed previously to and/or during pregnancy. Congestive heart failure with pulmonary edema (41.7%) and thromboembolism (25.0%) were the most frequent causes of maternal death among patients with cardiac disease. The NYHA functional classification was not a good parameter for pregnancy prognosis: eleven patients (91.7%) were considered as belonging to the favorable group before they became pregnant. Most maternal deaths occurred during the first 72 hours after delivery. Therefore, this period was considered most critical for maternal mortality in patients with cardiac disease. No relation-ship was found among the factors: maternal age, race, marital status, delivery and maternal mortality among patients with cardiac disease.(ABSTRACT TRUNCATED AT 250 WORDS)