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Breast fine-needle aspiration biopsy (FNAB) has been increasingly accepted as an important triage tool for the evaluation of breast lumps. We examined the clinical utility and diagnostic accuracy of a negative breast FNAB result by studying 450 breast aspirates in 413 patients (average age 45 years) with a'negative' or benign cytologic interpretation performed at Massachusetts General Hospital over a 4-year period. Of these patients, 121 (29%) underwent subsequent biopsy and 17 (4%) were found to have malignancy (3% of total negative FNABs; 14% with histology). None of these 17 patients had a triple negative test. A cohort of 115 patients had documentation of negative physical, radiologic, and cytologic examinations (the triple negative), none of whom were found to have malignancy on histologic or at least 2-year clinical follow-up (negative predictive value[NPV] = 100% with a triple-negative test). Outside of the triple-negative test, the NPV of a negative breast FNAB is reduced with a false-negative rate of 7%. However, in the setting of a triple-negative test, the NPV in our patient population was 100%, reassuring the patient and clinician that clinical follow-up and not surgical intervention was sufficient for proper patient care. [ABSTRACT FROM AUTHOR]

Competing Interests: Conflicts of Interest: See Disclosures at the end of the article.

Purpose: This brief review provides an overview and, importantly, a context perspective of relevant current practical issues in perioperative patient safety., Principal Findings: The dramatic improvement in anesthesia patient safety over the last 30 years was not initiated by electronic monitors but, rather, largely by a set of behaviours known as "safety monitoring" that were then made decidedly more effective by extending the human senses through electronic monitoring, for example, capnography and pulse oximetry. In the highly developed world, this current success is threatened by complacency and production pressure. In some areas of the developing/underdeveloped world, the challenge is implementing the components of anesthesia practice that will bring safety improvements to parallel the overall current success, for instance, applying the World Federation of Societies of Anaesthesiologists (WFSA) "International Standards for A Safe Practice of Anaesthesia". Generally, expanding the current success in safety involves many practical issues. System issues involve research, effective reporting mechanisms and analysis/broadcasting of results, perioperative communication (including "speaking up to power"), and checklists. Monitoring issues involve enforcing existing published monitoring standards and also recognizing the risk of danger to the patient from hypoventilation during procedural sedation and from postoperative intravenous pain medications. Issues of clinical care include medication errors in the operating room, cerebral hypoperfusion (especially in the head-up position), dangers of airway management, postoperative residual weakness from muscle relaxants, operating room fires, and risks specific in obstetric anesthesia., Conclusions: Recognition of the issues outlined here and empowerment of all anesthesia professionals, from the most senior professors and administrators to the newest practitioners, should help maintain, solidify, and expand the improvements in anesthesia and perioperative patient safety.

The Anesthesia Patient Safety Foundation (APSF) was created in 1985. Its founders coined the term "patient safety" in its modern public usage and created the very first patient safety organization, igniting a movement that is now universal in all of health care. Driven by the vision "that no patient shall be harmed by anesthesia," the APSF has worked tirelessly for more than a quarter century to promote safety education and communication through its widely read Newsletter, its programs, and its presentations. The APSF's extensive research grant program has supported a great many projects leading to key safety improvements and, in particular, was central in the development of high-fidelity mannequin simulation as a research and teaching tool. With its pioneering collaboration, the APSF is unique in incorporating the talents and resources of anesthesia professionals of all types, safety scientists, pharmaceutical and equipment manufacturers, regulators, liability insurance companies, and also surgeons. Specific alerts, campaigns, discussions, and projects have targeted a host of safety issues and dangers over the years, starting with minimal intraoperative monitoring in 1986 and all the way up to beach-chair position cerebral perfusion pressure, operating room medication errors, and the extremely popular DVD on operating room fire safety in 2010; the list is long and expansive. The APSF has served as a model and inspiration for subsequent patient safety organizations and has been recognized nationally as having a dramatic positive impact on the safety of anesthesia care. Recognizing that the work is not over, that systems, organizations, and equipment still at times fail, that basic preventable human errors still do sometimes occur, and that "production pressure" in anesthesia practice threatens past safety gains, the APSF is firmly committed and continues to work hard both on established tenets and new patient safety principles.

Purpose: To enhance patient safety through contemporaneous and comprehensive standards for a safe practice of anesthesia that augment, enhance, and support similar standards already published by various countries and that provide a resource for countries that have yet to formulate such standards., Standards Development: The Safe Anesthesia Working Group of the World Health Organization's "Safe Surgery Saves Lives" global initiative updated the 1992 International Standards for the Safe Practice of Anaesthesia (Standards) through an iterative process of literature review, consultation, debate, drafting, and refinement. These Standards address, in detail, the organization, support, practices, and infrastructure for anesthesia care. The Standards are grounded in the fundamental principle of safety in anesthesia, i.e., the continuous presence of an appropriately trained, vigilant anesthesia professional. In effect, the use of pulse oximetry during anesthesia is now considered mandatory, with acknowledgement that compromise may be unavoidable in emergencies. At the World Congress of Anaesthesiologists in 2008, drafts were presented for comment, further refinements were made, and the Revised Standards were adopted by the World Federation of Societies of Anaesthesiologists (WFSA). These Revised Standards were posted on the WFSA website for further feedback, and minor revisions followed. The International Standards for a Safe Practice of Anesthesia 2010 were endorsed by the Executive Committee of the WFSA in March 2010. Ongoing periodic revision is planned., Conclusion: While they are universally applicable, the 2010 Standards primarily target lesser-resourced areas. They are designed particularly for regions that have yet to formulate or adopt their own standards so as to promote optimum patient outcomes in every anesthetizing location in the world.

The following abstracts are compiled from Check Sample exercises published in 2008. These peer-reviewed case studies assist laboratory professionals with continuing medical education and are developed in the areas of clinical chemistry, cytopathology, forensic pathology, hematology, microbiology, surgical pathology, and transfusion medicine. Abstracts for all exercises published in the program will appear annually in AJCP.

A retrospective set of 191 gynecologic cytology slides with reference interpretations was run on an automated screening device that selects fields of view (FOVs) based on a hierarchical probability of abnormality being present. An interface was developed between the device and a remote server using customized image review software. FOVs were reviewed by 3 cytotechnologists and 3 cytopathologists, and binary triage (unsatisfactory for evaluation/negative for intraepithelial lesion or malignancy [NILM] vs "abnormal" [neither unsatisfactory nor NILM]) and specific interpretations were done. No morphologic training before FOV review was provided. Three or more reviewers agreed on the correct categorization of NILM/unsatisfactory in 89% (85/96) and abnormal in 83% (79/95). Three or more reviewers triaged cases to abnormal as follows: atypical squamous cells of uncertain significance, 83% (5/6); atypical squamous cells, cannot exclude high-grade lesion, 100% (3/3); low-grade squamous intraepithelial lesion (SIL), 83% (52/63); high-grade SIL, 94% (17/18); and atypical glandular cells, 40% (2/5). This procedure may have comparable sensitivity and specificity and possibly could provide effective initial triage to further evaluation. A review of individual cases suggests that further accuracy can be achieved with additional training and experience.

Background: Transmission over the Internet of low-resolution images acquired by automated screening of cervical cytology specimens has the potential to provide remote interpretation and, hence, centralization of a cytology workforce., Methods: Liquid-based cervical cytology slides were scanned using the FocalPoint(R) System. Ten black-and-white images that had the greatest probability of containing abnormality were acquired from each of 32 reference slides (16 negative samples, 3 samples of atypical squamous cells of uncertain significance, 5 samples of low-grade squamous intraepithelial lesions [LSIL], 5 samples of high-grade squamous intraepithelial lesions [HSIL], 1 adenocarcinoma in situ sample, and 2 carcinoma samples) and were transmitted as e-mail attachments in JPEG format to remote reading stations. The slides were interpreted independently by two pathologists and were assigned to either of two groups: 1) suspicious for >or=HSIL or 2)

Transitional cell carcinoma (TCC) of the ovary is a recently recognized subtype of ovarian surface epithelial-stromal cancer, and studies of its morphology are few. As a result, the criteria for its diagnosis and spectrum of its morphology are not clearly established. One hundred consecutive consultation cases of ovarian carcinoma with a pure or partial transitional cell pattern (excluding malignant Brenner tumor) diagnosed between 1989 and 2001 were evaluated for the frequency of various pathologic features and the relation of TCC to other surface epithelial-stromal carcinomas. The women were 33 to 94 years of age (mean, 56 years). A total of 47 tumors were stage I, 21 stage II, 31 stage III, and 1 stage IV; 13% of the stage I tumors and 41% of tumors of all stages were bilateral. The tumors ranged from 3.0 to 30 cm in greatest dimension (mean, 10 cm); 60% of them were solid and cystic, 24% solid, and 16% cystic. TCC was the exclusive or predominant component in 93% of the tumors and showed undulating (93%), diffuse (57%), insular (55%), and trabecular (43%) patterns. In four tumors with an insular growth, the pattern focally mimicked a Brenner tumor. Necrosis was present in 57% of the cases. Features that were seen in the tumors that in aggregate produced a relatively consistent appearance were "punched out" microspaces (87%), often the size of Call-Exner bodies, large cystic spaces (73%), and large blunt papillae (63%). Features that were sometimes seen, usually as a focal finding, included slit-like fenestrations (49%), bizarre giant cells (35%), small filiform papillae (18%), gland-like tubules (17%), squamous differentiation (13%), and psammoma bodies (4%). In 23 cases, TCC was a component of a mixed epithelial carcinoma, the additional components being serous adenocarcinoma in 16, endometrioid in 5, mucinous in 1, and clear cell carcinoma in 1. The tumor cells of the TCC component often were relatively monomorphic; 6% of the tumors were grade 1, 43% grade 2, and 51% grade 3. The nuclei were oblong or round and often had large single nucleoli (69%) or longitudinal grooves (48%). The cytoplasm was typically pale and granular but was rarely strikingly clear or oxyphilic. TCC of the ovary usually occurs in pure form but is also common as a component of a surface epithelial carcinoma of mixed cell type. In either situation, TCC has a constellation of architectural and cytologic features that readily distinguish it in most cases from other types of ovarian cancer. Recognition of these features will lead to a more consistent diagnosis of this tumor and aid in determining whether it has distinctive clinical features, particularly with regard to its behavior.

The recent observation that studies of BRCA1-associated tumors contain a high proportion of medullary carcinomas and ductal carcinomas with medullary features has re-introduced pathologists to an old diagnostic problem. The term "medullary carcinoma" dates to the 19th century, but the modern entity was introduced in 1949 by Moore and Foote, who described a carcinoma with a lymphoid infiltrate, a favorable prognosis, and low frequency of metastasis. Almost three decades later, Ridolfi et al proposed specific criteria for diagnosis, resulting in an entity with an even more favorable prognosis and a lower incidence. The reproducibility and clinical relevance of the diagnosis have been questioned recently, and new criteria have been proposed and compared. The tumors typically express cytokeratin 7, often vimentin and S100-protein, but not cytokeratin 20. The usual ones are positive for p53 and negative for estrogen receptor, Her2/neu, and bcl-2. Medullary carcinomas express e-cadherin and beta-catenin more often than ordinary high-grade ductal carcinomas, and the former have genetic differences from the latter. The lymphoid infiltrate of medullary carcinomas is related to beta-actin fragments exposed by apoptotic cells. The present review discusses historical and recent developments and emphasizes diagnostic criteria.

Hyperbaric oxygenation (HBO) therapy has been reported to improve neurological recovery following spinal cord injury (SCI). In the present study, we examined whether multiple HBO expands the therapeutic window for acute SCI. Single HBO (2.8 ATA, 1 hour) treatment was used at 30 minutes, 3 hours, and 6 hours following SCI, and serial HBO treatment (once daily for 1 week) at 6 hours and 24 hours post-injury. Mild SCI was induced by adjusting the height for a weight drop insult (10 g) to 6.25 mm above the exposed spinal cord. The group of animals receiving a single HBO intervention beginning at 30 minutes and 3 hours, or serial HBO treatment starting at 6 hours following the injury had a significantly better neurological recovery than animals with SCI only. The results of this study demonstrate that multiple HBO expands the therapeutic window for acute SCI to 6 hours after injury, further that serial HBO administration is superior to single HBO therapy.

Forty cases of mesodermal adenosarcoma of the ovary occurred in women 30-84 years of age (mean 54 years). Abdominal discomfort and distension were the usual complaints. All the patients were treated with an oophorectomy, which was accompanied by a hysterectomy in 85%, a contralateral oophorectomy in 65%, and nonsurgical therapy in 28%. Tumor rupture occurred at or before the operation in 67% of the cases. Twenty-six tumors were stage I, 11 stage II, and 3 stage III. The tumors were unilateral in 97.5% of the cases and 5.5-50 cm (mean 14 cm) in greatest dimension; most of the tumors were predominantly solid but contained numerous small cysts. Microscopic examination revealed sarcomatous overgrowth in 12 tumors. Sex cord-like elements were present in six tumors (including four with sarcomatous overgrowth) and heterologous elements in five (including two with sarcomatous overgrowth). The highest mitotic index of the sarcomatous component was 1-25 (mean 6) mitotic figures per 10 high power fields. Only 6 of 26 women (23%) who were followed postoperatively for > or=5 years were free of tumor. In the other 20 patients recurrent tumor appeared at 0.4-6.6 years (mean 2.6 years) after operation as pure sarcoma (low grade or high grade) or adenosarcoma (with or without sarcomatous overgrowth). Eight women had additional recurrences, and four women had blood-borne metastases. One patient was alive at 15.7 years after the excision of pulmonary metastases. The 5-, 10-, and 15-year survival rates were 64%, 46%, and 30%, respectively. Age <53 years, tumor rupture, a high grade, and the presence of high-grade sarcomatous overgrowth appeared to be associated with recurrence or extraovarian spread. Ovarian adenosarcomas have a worse prognosis than uterine adenosarcomas, presumably because of the greater ease of peritoneal spread. Many of the tumors caused problems in differential diagnosis.

Neuroendocrine tumors are more common in the female than male genital tract; most are uterine small cell carcinomas or ovarian carcinoids. Primary ovarian carcinoids are divided into insular, trabecular, strumal, and mucinous types; most are benign. Carcinoids metastatic to the ovary are more aggressive; most arise in the gastrointestinal tract. Scattered neuroendocrine cells are seen in a variety of ovarian surface epithelial tumors; sporadic mucinous cystic tumors with neuroendocrine cells have been associated with Zollinger-Ellison syndrome. Frank neuroendocrine carcinomas in the ovary include small cell carcinoma and large cell neuroendocrine carcinoma, each with a poor prognosis and often associated with a conventional surface epithelial tumor Such carcinomas also occur in the endometrium and cervix. Uterine carcinoids are rare if strict criteria are applied. Small cell neuroendocrine carcinomas also occur rarely in the vagina and vulva. Most male genital tract neuroendocrine tumors are prostatic small cell carcinomas or testicular carcinoids. Extragonadal carcinoids of the male genital tract are rare. Testicular carcinoids should be distinguishedfrom metastatic tumors. It is important to distinguish prostatic small cell carcinoma from poorly differentiated adenocarcinoma with small cells. Small cell neuroendocrine carcinomas also occur rarely in the scrotum, penis, and penile urethra.

Study Objective: To determine in vitro whether hyperbaric oxygen has any effect on the morphology of sickle cells., Design: Prospective, in vitro, study, with each patient sample serving as its own control., Setting: University medical center., Patients: 10 children known to be homozygous for hemoglobin S., Interventions: Blood samples were obtained from 10 children during routine visits to the University sickle cell clinic. Blood samples were exposed to room air to achieve maximal sickling. Each sample was divided into control and study aliquots, and the study portions placed in a research hyperbaric chamber with 100% oxygen at 3 atmospheres absolute pressure for 15 min. Then smears were prepared from all samples at regular intervals and examined by technicians in the sickle cell clinic who were blinded as to the details of this study., Measurements: Percentages of normal cells, sickle cells and sickle forms were reported. Data were interpreted using t-tests., Main Results: Hyperbaric oxygen appeared to have no effect on sickle cell morphology. Percentages of each cell type were unaffected by hyperbaric oxygen exposure., Conclusions: Hyperbaric oxygen appears to have no effect on the morphology of sickle cells in vitro. Other mechanisms may account for the beneficial clinical effects of hyperbaric oxygen in sickle cell crisis, although in vivo studies are warranted.

A 2-month-old infant underwent repair of a ventricular septal defect under deep hypothermic circulatory arrest. Bispectral index and EEG suppression ratio were evaluated using an Aspect BIS monitor. Erroneous readings from the monitor could have led to a potentially dangerous alteration in surgical and anaesthetic management.

Purpose: In this study the authors reviewed the medical records of a random sample of patients undergoing coronary artery bypass grafting (CABG) during the preceding ten years at University Medical Center. The purpose of this study was to evaluate the impact of exposure to calcium channel blockers (CCB's) on blood product use following cardiopulmonary bypass (CPB)., Design: Retrospective medical record review., Setting: University hospital., Participants: 527 patients undergoing CABG or re-do CABG., Interventions: The medical records of approximately 50% of patients undergoing CABG or re-do CABG at University Medical Center between 1988 and 1998 were randomly selected by the medical records librarian for review. Preoperative medications, bypass time and temperature, and blood product use were recorded., Results: Of the 527 patients studied, 309 (59%) had no exposure to CCB's. 218 (41%) were on CCB's at the time of admission. Patients who were on CCB's had an average 12.5 (+/- 1.0) blood product units transfused following bypass whereas those not on CCB's had an average 8.7 (+/- 0.6) units transfused (p < 0.001). Use of packed red blood cells (p < 0.001), fresh frozen plasma (p = 0.018) and platelets (p = 0.023) were each individually significantly increased., Conclusions: In this study, it appeared that patients exposed to CCB's before cardiac revascularization received significantly more blood products than those who were not exposed to CCB's. Because of the limitations imposed by retrospective studies, further prospective studies are warranted to define the clinical significance of CCB use in the perioperative period.

We report an interaction of a transesophageal atrial pacemaker (TAP) with a permanently implanted pacemaker in a cardiac patient who had undergone ablative therapy for atrial tachyarrhythmia 5 years earlier. The patient's permanent A-V pacemaker was completely inhibited by the TAP, and there was loss of ventricular contractions and blood pressure. The patient required epicardial A-V pacing to overcome the programmed heart rate of 76 bpm. We describe alternative methods to epicardial pacing. We also recommend close inspection of the chest radiograph, which often can reveal the serial numbers of the implanted pacemaker, as a means of identifying the device's functions and programming.

Background: Mucinous adenocarcinoma rarely arises as a primary tumor within the parotid gland, and only the histologic features of this tumor have been described., Case: A 4-cm, firm mass arose in the right parotid gland of a 72-year-old male over a six-week period. Cystic on computed tomography, the mass, on fine needle aspiration biopsy, yielded monomorphic, moderately atypical cells, both single and clustered, associated with abundant mucoid material and focal necrosis. Tumor cells had eccentric nuclei, prominent nucleoli and occasional cytoplasmic vacuolization. A few binucleated and multinucleated tumor cells were present. Histologic sections of the resected gland showed mucinous adenocarcinoma. A metastatic workup was negative. The differential diagnoses on cytology included other primary tumors of the parotid gland producing mucin or a mucoid matrix and metastatic mucinous adenocarcinomas., Conclusion: To our knowledge, this is the first cytologic description of mucinous adenocarcinoma, primary in the parotid gland.

A group of investigators have proposed that the presence of micropapillary or cribriform patterns within ovarian serous tumors diagnosed as borderline according to World Health Organization (WHO) criteria identifies a subset of these neoplasms that are apt to be associated with invasive peritoneal implants and therefore should be designated as "micropapillary carcinoma." The authors of the current article identified 40 serous borderline tumors that showed one or both of these patterns, using the earlier investigators' published criteria for so-called micropapillary carcinoma, and compared them with 44 tumors that lacked these patterns (controls). Twenty-six patients with micropapillary tumors were aged 21 to 76 years (mean 38); 11 with cribriform tumors were aged 34 to 79 years (mean 60); and 3 with tumors having both patterns were aged 21 to 58 years (mean 38); the control patients were aged 22 to 83 years (mean 54). An advanced stage, bilaterality, and ovarian surface growth were features of the "micropapillary" tumors more often than of the control tumors. Except for a postoperative death related to sepsis, all 11 patients with Stage I tumors with either or both patterns who were followed until their death, or for at least 5 years (mean 7.9 years), survived without evidence of disease; a twelfth patient had a recent removal of recurrent pelvic tumor at 2.8 years and was alive at 3.3 years. Six of the eight patients with Stage II or III tumors with either or both patterns who were followed for at least 5 years (mean 7.5 years) survived disease-free. No deaths from tumor or progressive recurrences occurred in 27 control cases with 5-14 (mean 7.9) years of follow-up data. The two tumor-related deaths in the entire series, one from a micropapillary tumor and one from a cribriform tumor, occurred in patients who had Stage III tumors with invasive peritoneal implants. No patient with "micropapillary" tumors and noninvasive implants had progressive disease. Two women with "micropapillary" tumors and two control subjects had stable recurrent tumor or a newly developed tumor in a contralateral ovary that had been spared during the initial operation. Our findings confirm those of previous investigators that noninvasive serous tumors with a micropapillary or cribriform pattern or both patterns may be accompanied by invasive peritoneal implants more often than tumors without such patterns and that in such cases the disease is likely to be progressive and fatal. Since so-called micropapillary carcinomas lack obvious stromal invasion within the ovary, and their prognosis when they spread to the peritoneum is much closer to that associated with typical Stage II and III serous borderline tumors than to that associated with similarly staged serous carcinomas, the authors believe that this newly described category of tumors should remain as a subset within the borderline category, with a notation that their prognosis is poor if they are associated with invasive peritoneal implants.

Purpose: Recent experimental data suggest that intrathecal (it) kappa-opioid agonists produce profound visceral analgesia. This study investigated the development of visceral analgesic tolerance to it butorphanol, a potent kappa-agonist that has fewer side effects than commonly used it opioids. Understanding of this tolerance could make it butorphanol more effective in treating chronic visceral pain., Methods: This was a randomized, controlled animal study involving 80 Sprague-Dawley rats. Rats implanted with lumbar it catheters were infused either with it saline or butorphanol (52 nmol.hr-1) for 96 hr. Six hours afterwards, each rat was challenged once with one of the differing it butorphanol doses to construct dose-response curves. Visceral analgesia was evaluated by the abdominal writhing responses to the acetic acid injected intraperitoneally. The time of the first writhe and the total number of writhes were recorded., Results: For both the saline- and butorphanol-infused groups, a higher challenge dose of it butorphanol produced longer time for the first writhe to occur (P < 0.01, one-way ANOVA), and fewer writhes occurring within 30 min (P < 0.01, one-way ANOVA). However, the dose response curves of the butorphanol-infused groups were shifted rightward (P < 0.001, partial F test)., Conclusion: The challenge doses of it butorphanol produced dose-dependent visceral analgesia in both the saline- and butorphanol-infused groups, confirming its efficacy. The butorphanol-infused groups showed dose-response shifts, demonstrating the development of tolerance to this visceral analgesia.

Hypoxemia has long been recognized as a risk to patients in the operating room and postanesthesia care unit, and hemoglobin oxygen saturation (HbO2) monitoring with pulse oximetry has become a standard of care in these areas. There is growing evidence, however, suggesting that later postoperative hypoxemia also may play a role in organ dysfunction leading to morbidity and mortality. Economic pressures to move patients earlier from expensive postanesthesia recovery and intensive care areas to the general care floor -- where nurse-to-patient ratios are lower and lines of sight and sound may be impaired by walls and curtains -- may lead to inadequate surveillance of at-risk patients. These patient-management trends underscore the importance of improved monitoring of respiratory status on the general care floor. In this environment, telemetric pulse oximetry monitoring may represent a cost-effective approach to maximizing quality of care while enhancing risk management. This review discusses late postoperative hypoxemia and identifies areas for further investigation.

Objective: To compare directly measured pressures at the cuff/trachea interface that are associated with two different bronchial cuff designs and four different methods of bronchial cuff inflation suggested for use with one-lung ventilation., Design: In vitro study., Setting: Experimental laboratory in a university-affiliated hospital., Interventions: The bronchial cuffs of two different endotracheal tubes were inflated using one of four different methods of determining the cuff volume and pressure necessary to "just seal" the bronchus and obtain lung separation; positive-pressure test, negative-pressure test, CO2 analysis, and a new test using an anesthesia ventilator. When each method predicted the "just-seal" state, the pressure at the cuff/bronchus interface as well as cuff inflation pressure and volume were recorded., Measurements and Main Results: Although the new test was incompatible with the bronchial blocker, the other three tests all accurately predicted lung separation with the Univent, with no significant differences in pressures exerted on the trachea. However, when used with the double-lumen tube, the new test produced significantly lower measured parameters than the other inflation methods. CO2 analysis did not reliably predict bronchial seal with the double-lumen tube., Conclusions: To achieve lung separation with the lowest pressure on the trachea, the new test is the most appropriate method for use with the double-lumen tube; however, the negative-pressure test appeared to be the easiest and fastest method for use with the bronchial blocker. Although the bronchial blocker was associated with lower pressures transmitted from the cuff to the trachea, the in vitro model cannot predict which bronchial cuff design would be superior in vivo.

We compared the standard PE10 catheter to a smaller microspinal catheter for intrathecal (IT) catheterization in rats. The PE10 or microspinal catheter was implanted in the lumbar subarachnoid space through the atlantooccipital membrane in rats (21 each group). Surviving rats without paralysis were tested on a rota-rod treadmill for motor function on Postoperative Days (POD) 3-6. Different doses of IT butorphanol were injected to demonstrate the functionality of the catheters by measuring tail-flick antinociception. Methylene blue was injected IT immediately before the spinal necropsy in each rat to identify the catheter tip location. For PE10 and microspinal catheters, the immediate death rate after the catheter implantation was 4 of 21 and 3 of 21 (no significant difference); paralysis rate was 8 of 21 and 2 of 21 (P < 0.05), and motor coordination recovery on POD6 was 67% and 91% (P < 0.01), respectively. Rats in both groups showed a dose-dependent response to IT butorphanol. Intrathecal methylene blue stained the lumbar spinal cord but not the surrounding tissue in both groups. Therefore, the microspinal catheter is better than the PE10 for IT catheterization in rats because it causes less paralysis and provides faster recovery of motor function.

Five primary ovarian carcinomas composed of a high-grade neuroendocrine tumor of non-small-cell type and a surface-epithelial-stromal tumor are reported. The five tumors presented in women aged 36 to 77 (mean, 57) years with abdominal distension or a palpable mass in three cases, right lower quadrant pain with tenderness and fever in one case, and a cervicovaginal smear showing a high estrogen effect in one postmenopausal patient. The tumors were unilateral, 9 to 30 (mean, 16) cm in greatest dimension, and had solid and cystic components. Three tumors were stage I; one, stage II; and one, stage III. Two patients who received chemotherapy died of tumor 8 and 36 months postoperatively, another who refused chemotherapy but later received radiation died of tumor after 19 months, a fourth was lost to follow-up, and a fifth was treated recently. Microscopically, the neuroendocrine components of all the tumors were composed predominantly of sheets, closely packed islands, cords, and trabeculae of epithelial cells with little intervening stroma. The tumor cells in the neuroendocrine areas were medium-sized to large compared with the cells of small cell carcinoma, and they contained scanty to moderate amounts of cytoplasm and hyperchromatic nuclei with coarse chromatin clumping in three cases and abundant cytoplasm and vesicular nuclei with single, large eosinophilic nucleoli in the other two. In all the cases, areas of necrosis and single-cell necrosis were extensive, and mitotic figures were abundant. Positive argyrophil and argentaffin reactions were observed in occasional to many cells in all cases. The glandular components of the tumors were grade 1/3 endometrioid adenocarcinoma (one case), grade 2/3 mucinous adenocarcinoma (2 cases), and mucinous borderline tumor with small foci of mucinous adenocarcinoma (two cases). Numerous enterochromaffin cells were identified in hematoxylin and eosin sections of the borderline mucinous components of two tumors; occasional nonargentaffin argyrophilic cells were present in the endometrioid and mucinous carcinoma components. Luteinized stromal cells were present focally in two cases, including the case in which there was evidence of a high estrogen level. Immunohistochemical studies in five cases showed staining of most cells in the solid components for cytokeratin and chromogranin A and some to most cells for serotonin and neuron-specific enolase. Neuropeptides that were detected in the solid component of one or more of the cases included vasoactive intestinal peptide, somatostatin, gastrin, and glucagon; negative results were obtained for pancreatic polypeptide and insulin. Flow cytometry in four tumors revealed that the neuroendocrine component was aneuploid in two, suspicious for aneuploidy in one, and diploid in one. Tumors of the type described are distinct pathologically from primary ovarian carcinoid tumors and small cell carcinoma of pulmonary type. Although experience with this type of tumor is limited, the prognosis appears to be poor.

Five patients with ovarian endometrioid tumors composed predominantly of ciliated cells are reported; two patients had bilateral neoplasms. Two unilateral, predominantly cystic ciliated-cell tumors from women in their 40s were associated with endometriosis: one was borderline and arose in an endometriotic cyst; the other was borderline with foci of carcinoma and was associated with ipsilateral ovarian and peritoneal endometriosis. Five predominantly adenofibromatous tumors in the three other women, all postmenopausal, were not associated with endometriosis. One woman with a borderline ciliated-cell adenofibroma had had a prior contralateral adnexectomy, another with a borderline ciliated-cell adenofibroma had a contralateral ciliated-cell adenofibroma, and the third woman had a ciliated-cell adenocarcinoma and a contralateral borderline ciliated-cell adenofibroma. In two of the latter three patients the fallopian tubes contained foci of ciliated-cell hyperplasia. All five ciliated-cell malignant tumors were stage I, were treated by operation alone, and had not recurred 21 to 64 (mean 39) months postoperatively. Ciliated-cell tumors of the ovary should be distinguished from serous and mixed serous and endometrioid cancers because of different pathological and possibly different clinical features. Criteria for separating endometrioid ciliated-cell tumors into benign, borderline, and malignant categories are presented; whether any of these neoplasms behaves in a clinically aggressive fashion has yet to be determined.

We studied four endometrial carcinomas with a conspicuous component that resembled patterns in Sertoli cell tumors. The patients presented at age 44-83 years (mean 65 years), with abnormal or postmenopausal vaginal bleeding in three and abnormal cervical cytology in one. All were multiparous, moderately to markedly obese, and hypertensive, and three patients had non-insulin-dependent diabetes mellitus. One tumor was suspected to be an endometrial stromal sarcoma with sex-cord-like differentiation on biopsy. Gross examination of the hysterectomy and bilateral salpingo-oophorectomy specimens showed solid polypoid endometrial tumors in each case. Light microscopic examination showed three to be superficially invasive of the myometrium and one to be confined to the endometrium; none of the tumors showed the tongue-like pattern of myoinvasion or the angiolymphatic invasion characteristic of low-grade endometrial stromal sarcomas. The sertoliform component, which predominated in one case and was only focal in the three others, was composed of uniform small hollow tubules lined by columnar cells with apical cytoplasm and of compact slender cords. The tubules and cords were often present between benign-appearing or carcinomatous glands. In the case with predominate sertoliform areas, the lesional cells had clear cytoplasm suggesting a lipid-rich variant; special stains of this case demonstrated cytoplasmic glycogen but no fat. In none of the cases was cytoplasmic mucin, argyrophil granules, or argentaffinity demonstrated. The nonsertoliform areas of the tumors consisted of typical endometrioid adenocarcinoma; concurrent endometrial hyperplasia was also present in each case. Squamous differentiation and minor foci of anaplastic carcinoma with bizarre tumor giant cells were present in three tumors. Immunoperoxidase stains showed staining for two or more markers of epithelial or glandular differentiation in the sertoliform areas in all cases (keratin, epithelial membrane antigen, carcinoembryonic antigen, CA125, Tag72), with focal expression of vimentin in all cases. In none of the cases was desmin or actin staining observed. The evidence indicates that tumors in this series are variants of endometrioid adenocarcinoma and are distinct from uterine tumors resembling ovarian sex-cord tumors and stromal sarcomas with sex-cord-like differentiation.

Between 1975 and 1990, 79 patients with Stage I epithelial ovarian cancer were treated at Massachusetts General Hospital. Patients were identified from the tumor registry and medical records were retrospectively reviewed. Pathological slides were evaluated for the presence of endometriosis, specifically looking for malignancy arising in endometriosis. Evidence of endometriosis was found in 22 of the 79 cases (28%). In the 23 cases of endometrioid histology, 9 cases (39%) were associated with endometriosis and, in the 17 cases of clear cell tumors, 7 (41%) were associated with endometriosis. All 8 cases of mixed histology had clear cell and/or endometrioid components and 4 cases (50%) were associated with endometriosis. Endometrioid adenocarcinoma accounted for 41% of the tumors associated with endometriosis, clear cell carcinoma 31%, mixed (endometrioid and/or clear cell types) 18%, and other types 9%. Among the 22 patients with associated endometriosis, we found 7 carcinomas (32%) arising in endometriosis. In these 7 cases a spectrum of benign and atypical endometriosis with a transition to clear cell or endometrioid adenocarcinoma were identified. These premalignant changes were characterized by cytologic atypia and architectural proliferation. Endometriosis was frequently encountered among patients with Stage I epithelial ovarian cancer of endometrioid and clear cell histologies. Endometriosis may play a role in the pathogenesis of some early stage malignant ovarian epithelial neoplasms.

Twelve ovarian neoplasms resembling salivary gland carcinomas and cutaneous basal cell carcinomas were studied and assigned to two groups: six with an exclusive or conspicuous component resembling adenoid cystic carcinoma and six with an exclusive or predominant component resembling basal cell carcinoma. The patients whose tumors simulated an adenoid cystic carcinoma presented at 60 to 78 (mean, 67) years of age. The adenoid cystic-like pattern was present in the primary ovarian tumor in five cases and four of these tumors had an additional surface epithelial-stromal component (serous adenocarcinoma in two, endometrioid adenocarcinoma in one, and mixed clear cell/endometrioid adenocarcinoma in one). The one patient with a Stage Ia tumor was free of disease at 37 months. Of the four patients whose tumors were Stage IIIc, two died of tumor at 13 and 123 months, respectively; another was alive with tumor at 27 months; and one was lost to follow-up. In the sixth case, an adenoid cystic-like pattern was present in a recurrent tumor in a patient from whom an ovarian endometrioid adenocarcinoma had been excised 11 years earlier. The patients whose carcinomas were predominantly or entirely basaloid presented at 19 to 65 (mean, 49) years of age. Three of these tumors had prominent squamous differentiation and gland formation, suggesting a relation to endometrioid carcinoma; three other tumors had an ameloblastoma-like pattern, with focal squamous differentiation in one, and a minor component of endometrioid adenocarcinoma adjacent to another. The four patients in the basaloid carcinoma group with Stage Ia tumors were alive without tumor at 16 to 71 (mean, 35) months.(ABSTRACT TRUNCATED AT 250 WORDS)

The importance of cooperation and understanding between the obstetrician and anesthesiologist in the management of obstetric emergencies cannot be overemphasized. Indications for cesarean section and choice of anesthetic are significant considerations. Algorithms for the management of special treatment problems such as malignant hyperthermia, postdural headache, and epidural abscess and hematoma are presented. Posting of protocols for the management of particular crises in both delivery and postanesthesia care units is strongly recommended.

The increasing use of sedation to enhance patient comfort during diagnostic and therapeutic procedures has been noted by the Joint Commission of Accredited Healthcare Organizations, specialty societies, and the public. Although anesthesiologists, by virtue of training and experience, possess unique qualifications to provide such sedation services, their availability remains somewhat limited by primary commitments to the operating room, intensive care unit, or pain service. The Risk Management Committee of the Department of Anaesthesia of Harvard Medical School has made specific recommendations to the Harvard-affiliated hospitals for anesthesiologists who participate in institutional-level committees in setting guidelines for such services when they are provided by nonanesthesiologists. Specific consideration is given to facilities, backup emergency services, equipment, education and training, issues of informed consent, documentation, and release of patients from medical care. These recommendations emphasize the collaboration of the department of anesthesia and other departments that provide sedation services in formulating policies and procedures that reflect values intrinsic to the practice of anesthesiology.