Blood thrombogenicity in type 2 diabetes mellitus patients is associated with glycemic control

OBJECTIVES

This study was designed to determine whether blood thrombogenicity is related to chronic glycemic control in type 2 diabetes mellitus (T2DM).

BACKGROUND

Type 2 diabetes mellitus is associated with accelerated atherosclerosis and a high rate of arterial thrombotic complications. Whether increased blood thrombogenicity is associated with glycemic control has not been properly tested.

METHODS

Forty patients with T2DM with hemoglobin A1c (HbA1c) > or =7.5% were selected. Maintaining their current hypoglycemic therapies, patients were randomized into a conservative (diet modification plus placebo) or intensive (diet modification plus troglitazone) hypoglycemic regimen for three months. Blood thrombogenicity was measured at baseline and after three months with the Badimon ex vivo perfusion chamber and assessed as platelet-thrombus formation. The repeated measurements allowed every patient to be his/her own control.

RESULTS

Patients in both groups (48% and 74% of the conservative and intensive groups, respectively) improved glucose control (HbA1c reduction > or =0.5%), showing a significant decrease in blood thrombogenicity. A significant positive correlation was observed between the reduction in thrombus formation and the reduction in HbA1c (r = 0.47, p < 0.01). The reduction in HbA1c achieved by both treatments was comparable. Patients without glycemic improvement showed no change in blood thrombogenicity. Improved glycemic control was the only significant predictor of a decrease in blood thrombogenicity.

CONCLUSIONS

In T2DM, there is an association between improved glycemic control and blood thrombogenicity reduction. The effect of glycemic control on the thrombotic complications of T2DM patients deserves further investigation.

Rotational atherectomy for in-stent restenosis: acute and long-term results of the first 100 cases

OBJECTIVES

This study evaluated the clinical safety and long-term results of rotational atherectomy (RA) followed by low-pressure balloon dilatation (percutaneous transluminal coronary angioplasty [PTCA]) for the treatment of in-stent restenosis (ISR).

BACKGROUND

In-stent restenosis is associated with a high incidence of recurrence after interventional treatment. Because ISR is due to neointimal hyperplasia, rotational ablation may be a more effective treatment than PTCA.

METHODS

Between November 1995 and November 1996, 100 consecutive patients with first-time ISR were treated by RA. Quantitative coronary angiography and intravascular ultrasound (IVUS) were used to analyze the acute procedural results. The incidence of repeat in-stent restenosis and target vessel revascularization (TVR) at follow-up was determined.

RESULTS

Procedural success without any major in-hospital complications was achieved in 100% of cases. Slow flow was observed in 3% and creatine kinase-MB enzyme elevation >3x normal occurred in 2%. The mean burr-to-artery ratio was 0.68+/-0.18 and adjuvant balloon dilatation was performed at 4.2+/-2.1 atm. Minimum luminal diameter increased from 0.86+/-0.28 mm to 1.89< or =0.21 mm after RA and to 2.56+/-0.29 mm after adjunct PTCA. Quantitative IVUS analysis showed that 77% of the luminal gain occurred due to rotational ablation of the restenotic tissue and only 23% occurred after adjunct balloon dilation, and further stent expansion did not contribute to the luminal enlarge. ment. At a mean follow-up of 13+/-5 months, repeat in-stent restenosis occurred in 28% of patients with TVR of 26%. Univariate predictors of repeat restenosis were burr-to-artery ratio <0.6, ISR in <90 days of stenting, ostial lesion, stent for a restenotic lesion and diffuse type ISR.

CONCLUSIONS

Rotational atherectomy is a safe and feasible technique for treatment of ISR and is associated with a relatively low recurrent restenosis in comparison to historical controls of balloon angioplasty.

Inflammatory profile in unstable angina versus stable angina in patients undergoing percutaneous interventions

BACKGROUND

Inflammatory markers have been shown to be elevated in acute coronary syndromes. Recently, interleukin-6 was demonstrated to be elevated in unstable angina compared with stable angina. However, the effect of percutaneous coronary interventions on the levels of inflammatory markers is less well known.

METHODS AND RESULTS

In this study, we measured the levels of interleukin-6 and interleukin-1 by using enzyme-linked immunosorbent assays in patients with angina pectoris undergoing coronary interventions and in healthy control subjects. Interleukin-6 was significantly elevated in patients with unstable angina compared with patients with stable angina (P= .01). There were no significant differences between the levels of interleukin-1 in patients with unstable angina versus patients with stable angina and healthy control subjects. Furthermore, at 1-month follow-up after percutaneous coronary interventions, there were no longer any significant differences between the levels of interleukin-6 in patients with unstable angina versus patients with stable angina and healthy control subjects.

CONCLUSIONS

These data suggest that interleukin-6 levels may correlate with instability of atheromatous plaques and that the decrease of interleukin-6 levels after percutaneous coronary interventions may represent plaque reendothelialization and stabilization.

Cystic neutrophilic granulomatous mastitis: A clinicopathologic study of a distinct entity with supporting evidence of a role for Corynebacterium-targeted therapy

Cystic neutrophilic granulomatous mastitis (CNGM) is a distinct histopathologic entity characterized by neutrophilic and granulomatous inflammation surrounding clear cystic spaces. Rare gram-positive bacilli are sometimes identified within these cystic spaces. Studies in the literature have identified these gram-positive bacilli to be Corynebacterium species. We describe the clinicopathologic features of 7 cases of CNGM, including a case with evidence of Corynebacterium amycolatum. Patients were young to middle aged parous women ranging in age from 28 to 53 years (median age: 41 years). Gram-positive bacilli were identified in 4 cases, all within cystic spaces. Microbial culture from a 41-year old Hispanic woman grew Corynebacterium species on multiple occasions and Corynebacterium amycolatum was identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) on two separate occasions. Antibiotic susceptibility testing performed both times showed resistance to multiple antibiotics and susceptibility to vancomycin. Follow-up of all patients (range 3-12 months, median 6 months) showed a widely variable clinical course and varying response to a variety of treatment modalities. Five of the seven CNGM patients were parous, reproductive-aged Hispanic women who were born outside of the United States. Our findings further support the association of CNGM with corynebacteria and gram-positive bacilli. Furthermore, this study shows that Corynebacterium amycolatum, a nonlipophilic and multidrug-resistant corynebacterium can be associated with CNGM, hence the need for targeted antibiotic therapy. We propose identifying corynebacteria to the species level and performing antibiotic susceptibility testing in patients with CNGM because of the varied susceptibility testing profile that has been reported among different species of corynebacteria.

Effects of platelet glycoprotein IIb/IIIa inhibition with abciximab on thrombin generation and activity during percutaneous coronary intervention

BACKGROUND

Antagonists of the platelet glycoprotein IIb/IIIa decrease acute ischemic complications after percutaneous coronary interventions (PCI). Abciximab (c7E3 Fab, ReoPro) has been reported to decrease thrombin generation in vitro. We investigated in vivo the effect of abciximab therapy on thrombin generation, thrombin activity, and the activated clotting time (ACT) during PCI.

METHODS

We studied 32 consecutive patients who underwent PCI for unstable coronary syndromes. Group I (n = 11) was treated with heparin plus aspirin, and group II (n = 21) was treated with heparin plus aspirin plus standard-dose abciximab, administered 5 minutes after the initial heparin bolus. Patients received a standardized heparin bolus at time 0, and arterial blood specimens for prothrombin fragment F1.2, fibrinopeptide A (FPA), and ACT were obtained from the guiding catheter at 5 minutes, 10 minutes (ACT only), 20 minutes, and at the end of the PCI. Standard-dose abciximab was administered in group II only. Each patient served as his or her own control, and the changes against the baseline were compared between the 2 groups.

RESULTS

There were no significant differences between the 2 groups regarding baseline characteristics, hematocrit, and platelet count. Group I patients had higher ACT and lower F1.2 and FPA compared with group II at baseline. Subsequent measurements demonstrated a gradual decrease in FPA and F1.2 in group II; the end of procedure versus baseline changes that occurred in F1.2 were significantly different compared with group I (decrease of 0.59 +/- 0.22 nmol/L in group II vs increase of 0.22 +/- 0.3 nmol/L in group I, P =.04), and a trend in the same direction was evident for FPA changes (decrease of 1.46 +/- 1.16 ng/mL in group II vs increase of 2.25 +/- 1.58 ng/mL in group I, P =.07). The ACT response to abciximab was variable, but a 6.3% increase (+20 sec) in ACT was documented 5 minutes after abciximab bolus in group II compared with the 3.4% decrease (-10 sec) observed in group I at the same time point (P =.1).

CONCLUSION

Addition of abciximab to heparin plus aspirin during PCI was associated with a significant decrease in thrombin generation and a borderline decrease in thrombin activity.

Cell block alone as an ideal preparatory method for hemorrhagic thyroid nodule aspirates procured without onsite cytologists

OBJECTIVE

To study diagnostic efficacy of direct smears (DS) vs. cell block (CB) alone in hemorrhagic thyroid fine needle aspirations (FNAs) performed without a cytotechnologist or cytopathologist.

STUDY DESIGN

Ultrasound-guided thyroid FNAs from an offsite location were retrospectively searched during a 53-month period. Aspirates in the initial 13 months were submitted as air-dried DSs. Subsequent specimens were submitted as CBs. Each case was classified into 1 of 4 categories: (1) nondiagnostic, (2) nonneoplastic, (3) follicular lesions and (4) papillary thyroid carcinoma (PTC).

RESULTS

There were 77 aspirates: DS = 20 (26%) and CB = 57 (74%). Two cases had both DSs and CBs. Diagnoses of DS: nondiagnostic = 12 (60%); nonneoplastic = 7 (35%); follicular lesion = 1 (5%). Diagnoses of CB cases: nondiagnostic = 4 (7.0%); nonneoplastic = 43 (75.4%); follicular lesion, including 1 Hürthle cell neoplasm = 7 (12.3%), PTC = 3 (5.3%). Repeat FNAs on 4 nondiagnostic cases (3 DSs, 1 CB) utilizing the CB-only technique were diagnostic and included nodular goiter, follicular neoplasm, PTC, and reactive lymph node.

CONCLUSION

Without onsite assessment, CB alone is superior to DSs for hemorrhagic thyroid FNAs. It shows increased diagnostic efficacy and slide reduction and obviates repeat FNAs.

Directional coronary atherectomy in acute myocardial infarction

Balloon angioplasty (percutaneous transluminal coronary angioplasty, PTCA) is an established common strategy in the treatment of acute myocardial infarction (MI) with high success rates but a 5-10% incidence of reclosure/reinfarction due to thrombus and/or intimal flaps. Directional coronary atherectomy (DCA) by removing plaque/thrombus and achieving larger postprocedural luminal diameter may further decrease the incidence of reclosure/reinfarction, with a resultant better in-hospital outcome in this setting. We analyzed the clinical, procedural and in-hospital outcome of patients who underwent DCA or PTCA within 48 h of MI. Long lesions (>20 mm), large angiographic intracoronary thrombus, lesions in a bend, heavy calcification, and vessel diameter <3.0 mm were excluded from the study. Although slow flow occurred more frequently during DCA (17 vs. 9% during PTCA, p = 0.04), procedural success (<50% final diameter stenosis with TIMI-3 flow) was achieved in 96% of DCA and 92% of PTCA group (nonsignificant). Acute closure occurred in 9% of the PTCA group versus 2% of the DCA (p = 0.05), and the composite endpoint of in-hospital reinfarction, reintervention, bypass surgery or death was present in 9% of PTCA cases versus none of DCA cases (p = 0.03). There were no major peripheral vascular complications requiring surgery in either group. Therefore, DCA appears safe and effective in selected patients with recent MI, and is associated with a low incidence of major clinical complications.

Impact of multidisciplinary radiologic-pathologic correlation conference for benign image-guided breast biopsies on discordance rates and patient outcomes in a community teaching hospital

As the assessment for radiologic-pathologic concordance, particularly for benign image-guided breast biopsies, is crucial in the management of patients with imaging abnormalities, many health institutions now conduct multidisciplinary conferences to assess the imaging and pathology findings in patients who had image-guided needle biopsy. We aimed to identify the radiologic-pathologic discordance rates and changes in patient outcomes resulting from the implementation of radiologic-pathologic correlation conferences in a community teaching hospital. Twenty-two (5.6%) out of 393 cases presented were deemed discordant given that the imaging characteristics of the lesions were far too suspicious radiologically to correlate with the benign pathology. Six cases were recommended for further imaging (four had stable lesion on follow- up, one was lost to follow-up and one case eventually had surgical excision which showed atypia); 14 cases for repeat core needle/excisional biopsy (seven had surgical excision with benign histology, five did not have surgery but showed stable lesion on imaging, two were lost to follow-up); one case for close imaging follow-up (lesion ultimately disappeared); the remaining case for second opinion (no follow-up data). The rad-path correlation conference led to a higher level of patient care with significant change in practice across our hospital network.

Histopathological correlates of early arterial recoil following directional coronary atherectomy

Elastic recoil has been implicated in the pathophysiology of restenosis after conventional balloon angioplasty alone. Directional atherectomy may attenuate arterial recoil by removing the internal elastic lamina and medial smooth muscle cells and altering the vessel wall architecture. This study sought to evaluate early recoil after directional atherectomy and its relation with excision of deep arterial wall structures. We prospectively evaluated the correlation of the histopathologic evidence of media or adventitia as assessed in the atheroma retrieved during the procedure with the early changes in minimal lumen diameter after directional atherectomy followed by adjunct balloon dilatation in 50 consecutive cases. Recoil was assessed by routinely performed 1- and 15-min postprocedure angiograms, and patients were divided into two groups according to the absence (group I, n = 26) or presence (group II, n = 24) of recoil. The mean changes in minimal luminal diameter between 1 and 15 min was +0.22 mm in group I and -0.14 mm in group II. The absence of recoil was strongly associated with evidence of media tissue in the pathologic analysis as compared with cases with recoil (42 vs. 18%, respectively; p = 0.02). Similarly, retrieval of adventitia was seen exclusively in the group without recoil (15 vs. 0%; p = 0.06). Vessels that underwent recoil had significantly larger reference and immediate postprocedure minimal luminal diameters (3.62 +/- 0.57 and 3.02 +/- 0.45 mm, respectively) as compared with arteries with no recoil (3.28 +/- 0.35 and 2.75 +/- 0. 43 mm, respectively; p < 0.05 for both). Therefore, early luminal changes, likely related to elastic recoil, correlated with excision of deep wall structures during directional atherectomy. Arteries that showed recoil were larger, possibly due to thicker muscular layer and/or larger plaque burden as compared with arteries that did not recoil. Thus, optimal tissue debulking during directional atherectomy appears to attenuate recoil, providing an additional insight into the mechanism of action of this percutaneous revascularization device.

Pulmonary Symptoms as the First Manifestation of Crohn's Disease

Crohn's disease is a granulomatous systemic illness with extra-intestinal manifestations. Of these extra-intestinal manifestations, lung involvement (0.4%) is the rare manifestation. Bronchopulmonary signs and symptoms are underrecognized, so suspicion should be high when granulomas are seen in lung biopsies. We report the case of a 27-year-old female who presented with bilateral pleuritic chest pain and shortness of breath. Chest X-ray showed left lung masses measuring up to 3.3 cm in the greatest dimension with right mid lung nodular opacity. Given the possibility of metastatic disease, positron emission tomography CT (PET-CT) scan was done, which showed activity in multiple liver lesions and multiple bilateral lung nodules. Both liver and lung biopsies were done, which showed multiple necrotizing and non-necrotizing granulomas. The patient was discharged home on antibiotics and antifungals. Few months later, she presented with loose stools and abdominal pain. CT scan of the abdomen and pelvis showed diffuse colonic wall thickening concerning for colitis. Colonoscopy showed ulcerated mucosa involving multiple parts of the colon. Biopsy of the colon showed mild to moderate acute colitis with submucosal non-necrotizing epithelioid granulomas, consistent with Crohn's disease.

Metachronous vulvar ectopic breast cancer, a case report and literature review

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When two or more primary tumors arise at the same time, they are considered synchronous.

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A metachronous tumor in a new primary that develops after an initial cancer diagnosis.

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The diagnosis of vulvar breast cancer is primarily histopathologic, based on morphology and immunostaining.

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Identifying a cancer as a metastasis versus as synchronous/metachronous significantly impacts staging and treatment.

Does Initial Imaging Modality Affect Breast Biopsy Upgrade Rates? A Single Institution Review

INTRODUCTION

Image-guided core needle biopsy (CNB) is the standard for diagnostic breast biopsy. However, the upgrade rate to a higher order lesion defined as identification of malignancy on final pathology from surgical excision remains problematic.

MATERIALS AND METHODS

A retrospective chart review of all core needle biopsies from 2008 to 2012 was performed. We identified lesions demonstrating atypia without associated malignancy on core needle biopsy and recorded multiple factors to evaluate predictors of upgrade.

RESULTS

Of 151 independent core needle biopsies recorded, 26.5% were upgraded to a higher order lesion. Concurrent mammogram and ultrasound (US) were associated with higher sampling error than any individual imaging modality (P = .021). MRI had a trend toward lower rate of upgrade rate but did not reach statistical significance.

DISCUSSION

Although MRI had a lower rate of upgrade rate due to sampling error, this did not reach significance possibly because of our small sample size.

Quality Assurance of the Gallbladder and Relationship Between Gallstones and Abdominal Panniculus Thickness in Adult Hospital Autopsies

Objectives

Inconsistency in the autopsy report can be a liability issue. We studied the discordance between the presence of the gallbladder and a corresponding abdominal scar and suggest how to improve this error. To our knowledge, the relationship between abdominal panniculus thickness in adult hospital autopsies and the presence of gallstones has not been reported in the literature. We report the correlation between age, sex, average panniculus thickness, and gallstones.

Methods

The laboratory information system was searched for autopsies performed between 1/1/09 and 12/21/18. Patients <18 years old and partial, nonabdominal autopsies were excluded. Autopsy reports were reviewed, and the following data were recorded: age, sex, presence or absence of gallbladder, abdominal scars, abdominal panniculus thickness, and gallbladder pathology.

Results

Out of 385 autopsies reviewed, 48 (12.5%) had cholecystectomies. Of these 48 patients, 6 (12.5%) abdominal scars were not documented. The presence of the gallbladder was not mentioned in 6 (1.6%) reports. The most common pathology was gallstones, 78 (20.3%); cholesterolosis, 9 (2.3%); and cholecystitis, 6 (1.6%). The average age of females and males with gallstones was 68.9 and 66.4 years, respectively. The average abdominal panniculus thickness in males with and without gallstones and in females without gallstones was 3.3 cm. In contrast, the average abdominal panniculus thickness in females with gallstones was 4.0 cm.

Conclusion

Our study demonstrated that 12.5% of our autopsy reports failed to document the presence of abdominal scars in patients who surgically lacked a gallbladder. There is a need to improve documentation of abdominal scars and the presence or absence of the gallbladder. This can be achieved by creating mandatory fields (eg, gallbladder present/surgically absent) in the autopsy report template. Also, our study found that females with gallstones have a thicker abdominal panniculus than females without gallstones and males with or without gallstones.

Rad-Path Correlate: Concordance and Discordance Rates in Danbury Hospital Patient Population

Objectives

Imaging-guided needle biopsy is a reliable alternative to surgical biopsy in the diagnosis of breast pathologies. However, false-positive results are common. Rad-Path correlation is crucial in identifying such results, thus allowing appropriate diagnosis and follow-up. We report our experience of Rad-Path correlation results in a community teaching hospital.

Methods

The tumor board data at Danbury Hospital were searched for Rad-Path conferences held from 2013 to 2018. Benign breast biopsies obtained from SNOMED, a monthly pathology list of imaging-guided needle biopsies performed at Danbury Hospital, were presented at these conferences. Data from the list were used for this research. Fibroadenoma cases were excluded in the analysis. The total number of cases presented and proportion of concordant and discordant cases were reviewed. Data on discordant cases were further reviewed to determine the reasons for discordance and follow-up outcomes.

Results

In the last 6 years, 64 Rad-Path meetings were held. A total of 393 benign breast biopsies were presented. Of the 393 cases, 24 (6.1%) were discordant. The radiologic findings for the discordant cases were as follows: mass/nodule, 15; calcifications, 7; linear nonmass enhancement, 1; and duct debris, 1. All the suspicious radiologic findings received a benign pathologic diagnosis. These discrepancies in Rad-Path findings were discussed in detail during the multidisciplinary tumor board. Out of 24 discordant cases, 5 (20.8%) were reviewed by the sign-out radiologist and their BI-RADS updated accordingly, another 5 (20.8%) cases had excisional biopsies, 9 (37.5%) cases were recommended for 6- or 12-month radiology follow-up, and the remaining 5 (20.8%) cases were lost to follow-up.

Conclusion

Rad-Path correlation is a key component of imaging-guided breast biopsy reporting. It facilitates detection of discordant radiologic and pathologic findings, and it prevents misdiagnosis and unnecessary repeat interventional procedures. This practice ultimately results in improved patient management.

The Gallbladder and Vermiform Appendix as Quality Assurance Indicators in Autopsy Pathology

OBJECTIVES

We investigate the number of autopsy reports that did or did not document the presence or absence of the gallbladder or appendix or document abdominal scars in patients following cholecystectomy or appendectomy. We also report gallbladder and appendix pathology at autopsy.

METHODS

Autopsy reports from patients 18 years or older autopsied at a community teaching hospital between January 1, 2009, and December 31, 2018 were reviewed. Nonabdominal autopsies were excluded. Histopathologic examination of the gallbladder and appendix was only performed if gross pathology was seen.

RESULTS

Of the 385 autopsies studied, 48 (12.5%) had cholecystectomies, of which 6 (12.5%) did not document abdominal scars. Sixty-two (16.1%) had appendectomies, of which 12 (19.4%) did not document abdominal scars. The presence or absence of the gallbladder and appendix was not documented in 6 (1.6%) and 16 (4.2%) of reports, respectively. Pathology was seen in 87 (25.8%) gallbladders and 4 (1.2%) appendixes.

CONCLUSIONS

Absence of the gallbladder or appendix is a relatively common autopsy finding. Auditing autopsy reports for documentation of their presence or absence, along with associated abdominal scars, are potential quality assurance indicators of autopsy reports. Documentation of these elements could be improved by changing the autopsy template or using synoptic reporting.