Gated MR imaging of left atrial myxomas

Two cases of left atrial myxoma were evaluated with magnetic resonance (MR) imaging. In both cases, the myxoma was clearly defined as to its location, origin, and size. In one case, the myxoma prolapsed through the mitral valve. Our study indicates that MR imaging is valuable in the diagnosis of myxomas.     

Fibroadenoma and the use of exogenous hormones. A case-control study

The association between fibroadenoma and the use of exogenous hormones in women aged 18-74 years was examined in a case-control study conducted in Connecticut during 1979-1981. The study population included 251 women with biopsy-confirmed fibroadenoma and 1,081 control women drawn from inpatient and outpatient general surgical services of five Connecticut hospitals. Among women under age 45 years, oral contraceptive use was negatively associated with the occurrence of fibroadenoma (age-adjusted odds ratio (OR) = 0.57, 95% confidence interval (CI) = 0.42-0.79). The odds ratio for women over age 45 years who had ever used oral contraceptives was 1.65 (95% CI = 0.58-4.68). Women over age 45 years who had ever used replacement estrogens had an elevated odds ratio for fibroadenoma (OR = 2.83, 95% CI = 1.21-6.60). The data suggest either that the effects of exogenous hormones may differ by age, or that the changing composition of exogenous hormones has brought about different associations depending upon the cohort of women.     

An epidemiologic study of fibrocystic breast disease with reference to ductal epithelial atypia

A case-control study of 255 women with fibrocystic breast lesions and 790 controls was conducted at two hospitals in New Haven, Connecticut during 1977-1979. Cases were found to weigh significantly less than controls, and were more likely than controls to have: a first-degree female relative with a history of breast cancer; a higher level of education; a recent history of regular gynecologic checkups; and (if under age 45 years) a later age at first pregnancy. They were less likely to have had a surgical menopause. The degree of ductal epithelial atypia in breast biopsy specimens was evaluated in order to see whether epidemiologic characteristics differed according to the degree of ductal atypia. The only variable to show a linear relationship with ductal atypia was a recent history of regular gynecologic checkups; those with no or minimal atypia were more likely to have had recent checkups than those with high atypia scores. This study thus gives no evidence that known risk factors for breast cancer are more strongly associated with fibrocystic breast disease with a high degree of atypia than with fibrocystic breast disease with a low degree of atypia. It also provides data to support the belief that women having frequent gynecologic checkups are more likely to be included as cases in case-control studies of fibrocystic breast disease, and particularly in the groups with no or minimal atypia, than those not having frequent checkups.     

Papillary Carcinoma Tall Cell Variant (TCV): A Review

Tall cell variant of papillary thyroid carcinoma is an aggressive form of thyroid cancer with a significant mortality. This review describes the pathology of this variant, compares it to its pathologic mimics and discusses its clinical pathologic features. The literature on this tumor is reviewed. A brief discussion of molecular pathologic correlates is included.     

National multicenter study of HIV testing and HIV seropositivity in patients with chronic hepatitis C virus infection

BACKGROUND: Although HIV testing is recommended for persons with hepatitis C virus (HCV) infection who are at risk for HIV, little is known about HIV testing in this population. METHODS: Data were prospectively collected in 4364 HCV-infected patients at 24 Veterans Affairs medical centers across the United States, including demographics, risk factors for HIV infection, and self-reported information on HIV testing. RESULTS: Overall, 76.8% had been tested for HIV at least once, 14.8% were never tested, 6.6% did not know if they were tested, and 1.8% declined to answer. Multivariable analysis identified injection drug use, needlestick injury, sex with a same-sex partner, a greater number of lifetime sexual partners, and sex with an injection drug user as factors that were independently associated with HIV testing. At least one risk factor for HIV infection was present in 84.5% of the 646 patients who were never HIV tested. Among the 3350 subjects who were tested for HIV, 8.4% were positive, 88.3% were negative, 2.4% did not know the results of their test, and 0.9% declined to answer. Multivariable analysis identified African American and Hispanic race/ethnicity, income < or = 10,000 dollars, sex with a same-sex partner, and sex with an injection drug user as the only variables that were independently associated with HIV seropositivity. CONCLUSIONS: Although a substantial proportion of HCV-infected patients have been tested for HIV, missed opportunities for early diagnosis of HIV infection exist. Public health strategies to improve HIV testing among patients with chronic HCV infection are needed.     

Naltrexone and disulfiram in patients with alcohol dependence and current depression

OBJECTIVE: Although disulfiram and naltrexone have been approved by the Food and Drug Administration for the treatment of alcoholism, no medications have been approved for individuals with alcohol dependence and comorbid psychiatric disorders. In particular, the effect of these medications on alcohol use outcomes and on specific psychiatric symptoms is still unknown in patients with the most common co-occurring disorder, major depression. METHOD: Two hundred fifty-four patients with a major Axis I psychiatric disorder and comorbid alcohol dependence were treated for 12 weeks in an outpatient medication study conducted at 3 Veterans Administration outpatient clinics. Randomization included (1) open randomization to disulfiram or no disulfiram, and (2) double-blind randomization to naltrexone or placebo. This resulted in 4 groups: (1) naltrexone alone, (2) placebo alone, (3) disulfiram and naltrexone, and (4) disulfiram and placebo. Primary outcomes were measures of alcohol use. Secondary outcomes included psychiatric symptoms assessed by the Hamilton Depression Rating Scale, alcohol craving, gamma-glutamyltransferase levels, and adverse events. RESULTS: One hundred thirty-nine subjects (54.7%) met the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for major depression. There was no relationship between the diagnosis of depression and medication treatment on alcohol use outcomes, psychiatric symptoms, or the reporting of side effects for these medications. There was a significant interaction between diagnosis, medication group, and craving, where subjects with depression on disulfram reported lower craving over time than subjects with depression on naltrexone. CONCLUSIONS: The results suggest that disulfiram and naltrexone are safe pharmacotherapeutic agents for dually diagnosed individuals with depression for the treatment of alcohol use disorders.     

Is fine-needle aspiration (FNA) of multiple thyroid nodules justified?

Background: The clinical management of patients with solitary thyroid nodule is well established; however, the evaluation of patients with multiple thyroid nodules is controversial. The aim of this study was to assess if there is a correlation between the risk of malignancy and number of thyroid nodules. Design: The study cohort included 2884 patients (2410 females and 474 males) with 3274 thyroid nodules that underwent FNA under ultrasound guidance between November 1997 and April 2004. Multiple thyroid nodules were aspirated in 360 patients; 2 in 332 (291 females, 41 males), 3 nodules in 26 (23 females, 3 males), and 4 nodules in 2 patients (1 female, 1 male). Subsequent information regarding the histological diagnosis was obtained in the cases that underwent surgical excision. Results: The average age for patients with single or multiple nodules was the same (51 yr). The FNA specimens were diagnosed as benign (n=1663, 51%), neoplasm (n=880, 27%), suspicious for neoplasm or papillary carcinoma (n=234, 7%), malignant (n=187, 6%), and non-diagnostic (n=310, 9%). Surgical excision was performed in 1135 patients: 993 patients with single nodules and 142 patients with multiple nodules. The surgical pathology diagnosis was benign in 656 nodules (52%) and malignant in 596 nodules (48%). In the malignant category 153 tumors were papillary microcarcinoma (<1 cm). Excluding these cases, the malignancy rate was 39% in patients with single nodules, 41% with two nodules, and 21% with three nodules. Conclusions: The cancer risk is similar for patients with one or two nodules over 1 cm and decreases with three or more thyroid nodules.     

Microcarcinoma of the thyroid

Thyroid microcarcinoma, defined as a thyroid tumor measuring 1 cm or less, is an extremely indolent tumor. Papillary microcarcinoma, the most common subtype, is often identified incidentally in a thyroid removed for benign clinical nodules or diffuse processes (eg, thyroiditis). In this clinical situation, over 99% are cured by simple lobectomy. In the less common scenario, the microcarcinoma is the primary lesion to a lymph node metastasis presenting clinically as a neck mass; in this situation, the tumor should be treated as a clinical cancer. Other rare microcarcinomas can occur and, of these, the most recently described is micromedullary carcinoma. In the familial setting, these lesions are identified in prophylactic thyroidectomies and are not unexpected findings. However, when found as sporadic tumors, their implications are still unknown. The histologic features, pathologic mimics, and molecular facets of these microscopic neoplasms are discussed in this review.