American Journal of Forensic Medicine and Pathology, 2009
Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC) is a disease that affects young ... more Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC) is a disease that affects young adults and perhaps is the most common cause of sudden death in this age group. Many of these cases are faced by forensic pathologists, without a prior history, and unless suspected by the pathologist at the time of autopsy, the diagnosis is likely to be missed. Since some of these cases are hereditary, consequences of missing the diagnosis have a medicolegal implication that extends to involve other family members of the deceased. ARVC raises many controversial issues with regard to its existence, defining and diagnostic criteria, pathologic spectrum of changes, and pathogenesis. We reviewed the recent literature and included our experience to dictate a novel approach to the inherent problems faced by pathologists. In this review, we identified the most characteristic and distinct histopathologic features that are diagnostic or highly suggestive of ARVC, even in the absence of clinical history. We also highlighted the new insights on the disease pathogenesis. Hence, this review provides a better understanding of the disease and sheds light on many controversial issues regarding ARVC.
Papillary carcinoma of the thyroid (PTC) is the commonest thyroid cancer. In the recent decades a... more Papillary carcinoma of the thyroid (PTC) is the commonest thyroid cancer. In the recent decades an obvious increase in the incidence of PTC has occurred. The pathological diagnosis of PTC is usually an easy diagnosis in the majority of cases. However since the introduction of follicular variant of PTC and the wide threshold range in interpretation of the clearly set pathological criteria for diagnosis of PTC, between pathologists including experts, the diagnosis in some cases became quite difficult. Unfortunately some cases are unjustifiably over-called as follicular variant of PTC as a result of the wide inter observable variability between pathologists, including thyroid pathologists.
Sclerosing angiomatoid transformation of the spleen (SANT) is a relatively new, rare, and unique ... more Sclerosing angiomatoid transformation of the spleen (SANT) is a relatively new, rare, and unique lesion that involves the spleen. Less than 30 cases have been described to date. The lesion commonly affects middle-aged adults and shows a female predilection. It is often discovered incidentally through imaging. SANT is morphologically and immunohistochemically distinct. However, as it is a relatively new entity, misdiagnosis of SANT may lead to overtreatment of the patients. The pathogenesis of SANT is unknown. The lesion is entirely benign, and splenectomy is curative. We report a new case of SANT, with emphasis on the differential diagnosis and pathogenesis of SANT.
... amounts of sterols in their secretory cells as shown by the Schultz reaction. They do not exh... more ... amounts of sterols in their secretory cells as shown by the Schultz reaction. They do not exhibit any significant birefringence but this does not contra-dict the presence of sterols since the latter can be present in an isotropic form especially when it is dissolved in fats (Okey, 1944). ...
Page 1. CLINICAL TOXICOLOGY, 4(3), pp. 461-466, September, 1971 Ozone Poisoning in Man: Clinical ... more Page 1. CLINICAL TOXICOLOGY, 4(3), pp. 461-466, September, 1971 Ozone Poisoning in Man: Clinical Manifestations and Differential Diagnosis - A Review* Ahmed NM Nasr, MD; Ph.D. The University of Michigan Ann Arbor, Michigan ...
Pectus excavatum is the most common chest wall deformity in children. Two procedures are widely a... more Pectus excavatum is the most common chest wall deformity in children. Two procedures are widely applied—the Nuss and the Ravitch. Several comparative studies are published evaluating both procedures with inconsistent results. Our objective was to compare the Nuss procedure to the Ravitch procedure using systematic review and meta-analysis methodology.All publications describing both interventions were sought through the Cochrane Central Register of Controlled Trials (CENTRAL) database, MEDLINE, and EMBASE. The statistical analysis was performed using RevMan 5 software. Odds ratios (OR) and weighted mean differences (WMDs) with 95% confidence intervals are presented.No randomized trials were identified. Nine prospective and retrospective studies were identified and were included in this study. There was no significant difference in overall complication rates between both techniques (OR, 1.75 (0.62-4.95); P = .30). Looking at specific complications, the rate of reoperation because of bar migration or persistent deformity was significantly higher in the Nuss group (OR, 5.68 (2.51-12.85); P = .0001). Also, postoperative pneumothorax and hemothorax were higher in the Nuss group (OR, 6.06 [1.57-23.48]; P = .009 and OR, 5.60 [1.00-31.33]; P = .05), respectively. Duration of surgery was longer with the Ravitch (WMD, 69.94 minutes (0.83-139.04); P = .05). There was no difference in length of hospital stay (WMD, 0.4 days (−2.05 to 2.86); P = .75) or time to ambulation after surgery (WMD, 0.33 days [−0.89 to 0.23]; P = .24). Among studies looking at patient satisfaction, there was no difference between both techniques.Our results suggest no differences between the Nuss procedure vs the Ravitch procedure with respect to overall complications, length of hospital stay, and time to ambulation. However, the rate of reoperation, postoperative hemothorax, and pneumothorax after the Nuss procedure were higher compared to the Ravitch procedure. No studies showed a difference in patient satisfaction.
Background: In children with Hodgkin's disease (HD), a significant residual mass may remain after... more Background: In children with Hodgkin's disease (HD), a significant residual mass may remain after definitive treatment. It may be composed of necrotic/fibrous tissue or resistant HD. Various imaging modalities are available to assess this mass, including chest x-ray (CXR), computed tomographic (CT) scan, and gallium scan. Our aim was to determine the sensitivity and specificity of each modality for residual HD. Methods: Two hundred fifty-six children with HD during 1985 to 2003 were retrospectively reviewed. Results: Twenty-six patients with HD had residual masses at end of therapy, deemed to be of concern for residual disease. These children had 16 abnormal CXRs, 18 abnormal CT scans, and 9 abnormal gallium scans; all patients underwent biopsy. Ten (38%) showed resistant HD and 16 (62%) had fibrotic and necrotic tissue. The sensitivity and specificity of each imaging modality were 60% and 38% for CXR, 67% and 8% for CT scan, and 71% and 71% for gallium scan, respectively. Conclusions: These imaging modalities were not sufficiently sensitive or specific to predict which residual masses may be harboring resistant HD. Hence, the need for surgical biopsy will remain important in the assessment of these masses. FDG-PET scan, which was not available to these children, is a modality that may improve this assessment. D
Infants with repaired esophageal atresia and distal tracheoesophageal fistula (EA/TEF) are at ris... more Infants with repaired esophageal atresia and distal tracheoesophageal fistula (EA/TEF) are at risk for severe respiratory distress, which is related to tracheomalacia (TM), gastroesophageal reflux, or both. This usually mandates an operation for TM and/or a fundoplication procedure (FP).We retrospectively performed a 26-year review of 288 patients with repaired EA/TEF. Research Ethic Board approval was obtained.Postoperatively, 22 (7.6%) infants with EA/TEF developed severe respiratory distress. Thirteen infants had an initial TM procedure and symptoms improved in 7 (54%). The 6 (46%) remaining patients with ongoing respiratory symptoms required an FP. Nine infants had an initial FP and the symptoms improved in 6 (67%). The remaining 3 (33%) patients with ongoing respiratory symptoms required a TM procedure. All patients improved with the second procedure. Several clinical parameters were assessed among the 4 patient groups (FP only, FP followed by TM procedure, TM procedure only, and TM procedure followed by FP); there were no significant differences noted.Whereas 54% to 67% of infants improved with a TM procedure or FP, 33% to 46% required both surgical procedures. No clinical parameters were identified that could predict which procedure should be performed first.
The transanal pull-through has become the standard operation for Hirschsprung's disease in many p... more The transanal pull-through has become the standard operation for Hirschsprung's disease in many pediatric surgical centers. Over the past 8 years, we have modified our technique by leaving a short—rather than a long—rectal cuff and by doing routine intraabdominal colonic biopsies through an umbilical incision before beginning the anal dissection. The aim of this study was to determine if these modifications have changed the outcome for children undergoing this operation.A retrospective cohort study of all patients who underwent transanal pull-through by a single surgeon between 1997 and 2005 was conducted.There were 23 children who had a long cuff (10-15 cm) and 22 who had a short cuff (<2 cm). The short cuff group tended to be younger (25 ± 23 vs 139 ± 67 days; P < .05) and smaller (3.5 ± 0.7 vs 6.0 ± 2.7 kg; P < .05) at the time of surgery. The operating time was shorter (167 vs 186 minutes; P = .05) in the short cuff group. Outcomes were improved in the short cuff group, as evidenced by decreased hospital stay (1.9 ± 0.6 vs 2.7 ± 0.9; P < .05), decreased incidence of enterocolitis (9% vs 30%; P = .1), and lower incidence of narrowing requiring daily dilatations (5% vs 30%; P < .05). Preliminary colonic biopsy was performed on 18 of the 45 patients. This had no significant effect on narcotic use (66% vs 70%; P = .8) and did not increase operating time (174 ± 31 vs 179 ± 34 minutes; P = .6). Hospital stay was shorter in the umbilical biopsy group (1.9 ± 0.6 vs 2.6 ± 0.9 days; P = .006).Results of the transanal pull-through have improved likely as a result of a combination of experience and use of a shorter rectal muscular cuff. The use of a preliminary colonic biopsy through an umbilical incision has not increased postoperative pain, prolonged operative time, or lengthened hospital stay.
We report the use of intravenous Methylene blue to treat the hypotension occurring following adre... more We report the use of intravenous Methylene blue to treat the hypotension occurring following adrenal vein ligation in a case of pheochromocytoma resection in a child. The potential benefits and problems, including correct dosage, are discussed.
American Journal of Forensic Medicine and Pathology, 2009
Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC) is a disease that affects young ... more Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC) is a disease that affects young adults and perhaps is the most common cause of sudden death in this age group. Many of these cases are faced by forensic pathologists, without a prior history, and unless suspected by the pathologist at the time of autopsy, the diagnosis is likely to be missed. Since some of these cases are hereditary, consequences of missing the diagnosis have a medicolegal implication that extends to involve other family members of the deceased. ARVC raises many controversial issues with regard to its existence, defining and diagnostic criteria, pathologic spectrum of changes, and pathogenesis. We reviewed the recent literature and included our experience to dictate a novel approach to the inherent problems faced by pathologists. In this review, we identified the most characteristic and distinct histopathologic features that are diagnostic or highly suggestive of ARVC, even in the absence of clinical history. We also highlighted the new insights on the disease pathogenesis. Hence, this review provides a better understanding of the disease and sheds light on many controversial issues regarding ARVC.
Papillary carcinoma of the thyroid (PTC) is the commonest thyroid cancer. In the recent decades a... more Papillary carcinoma of the thyroid (PTC) is the commonest thyroid cancer. In the recent decades an obvious increase in the incidence of PTC has occurred. The pathological diagnosis of PTC is usually an easy diagnosis in the majority of cases. However since the introduction of follicular variant of PTC and the wide threshold range in interpretation of the clearly set pathological criteria for diagnosis of PTC, between pathologists including experts, the diagnosis in some cases became quite difficult. Unfortunately some cases are unjustifiably over-called as follicular variant of PTC as a result of the wide inter observable variability between pathologists, including thyroid pathologists.
Sclerosing angiomatoid transformation of the spleen (SANT) is a relatively new, rare, and unique ... more Sclerosing angiomatoid transformation of the spleen (SANT) is a relatively new, rare, and unique lesion that involves the spleen. Less than 30 cases have been described to date. The lesion commonly affects middle-aged adults and shows a female predilection. It is often discovered incidentally through imaging. SANT is morphologically and immunohistochemically distinct. However, as it is a relatively new entity, misdiagnosis of SANT may lead to overtreatment of the patients. The pathogenesis of SANT is unknown. The lesion is entirely benign, and splenectomy is curative. We report a new case of SANT, with emphasis on the differential diagnosis and pathogenesis of SANT.
... amounts of sterols in their secretory cells as shown by the Schultz reaction. They do not exh... more ... amounts of sterols in their secretory cells as shown by the Schultz reaction. They do not exhibit any significant birefringence but this does not contra-dict the presence of sterols since the latter can be present in an isotropic form especially when it is dissolved in fats (Okey, 1944). ...
Page 1. CLINICAL TOXICOLOGY, 4(3), pp. 461-466, September, 1971 Ozone Poisoning in Man: Clinical ... more Page 1. CLINICAL TOXICOLOGY, 4(3), pp. 461-466, September, 1971 Ozone Poisoning in Man: Clinical Manifestations and Differential Diagnosis - A Review* Ahmed NM Nasr, MD; Ph.D. The University of Michigan Ann Arbor, Michigan ...
Pectus excavatum is the most common chest wall deformity in children. Two procedures are widely a... more Pectus excavatum is the most common chest wall deformity in children. Two procedures are widely applied—the Nuss and the Ravitch. Several comparative studies are published evaluating both procedures with inconsistent results. Our objective was to compare the Nuss procedure to the Ravitch procedure using systematic review and meta-analysis methodology.All publications describing both interventions were sought through the Cochrane Central Register of Controlled Trials (CENTRAL) database, MEDLINE, and EMBASE. The statistical analysis was performed using RevMan 5 software. Odds ratios (OR) and weighted mean differences (WMDs) with 95% confidence intervals are presented.No randomized trials were identified. Nine prospective and retrospective studies were identified and were included in this study. There was no significant difference in overall complication rates between both techniques (OR, 1.75 (0.62-4.95); P = .30). Looking at specific complications, the rate of reoperation because of bar migration or persistent deformity was significantly higher in the Nuss group (OR, 5.68 (2.51-12.85); P = .0001). Also, postoperative pneumothorax and hemothorax were higher in the Nuss group (OR, 6.06 [1.57-23.48]; P = .009 and OR, 5.60 [1.00-31.33]; P = .05), respectively. Duration of surgery was longer with the Ravitch (WMD, 69.94 minutes (0.83-139.04); P = .05). There was no difference in length of hospital stay (WMD, 0.4 days (−2.05 to 2.86); P = .75) or time to ambulation after surgery (WMD, 0.33 days [−0.89 to 0.23]; P = .24). Among studies looking at patient satisfaction, there was no difference between both techniques.Our results suggest no differences between the Nuss procedure vs the Ravitch procedure with respect to overall complications, length of hospital stay, and time to ambulation. However, the rate of reoperation, postoperative hemothorax, and pneumothorax after the Nuss procedure were higher compared to the Ravitch procedure. No studies showed a difference in patient satisfaction.
Background: In children with Hodgkin's disease (HD), a significant residual mass may remain after... more Background: In children with Hodgkin's disease (HD), a significant residual mass may remain after definitive treatment. It may be composed of necrotic/fibrous tissue or resistant HD. Various imaging modalities are available to assess this mass, including chest x-ray (CXR), computed tomographic (CT) scan, and gallium scan. Our aim was to determine the sensitivity and specificity of each modality for residual HD. Methods: Two hundred fifty-six children with HD during 1985 to 2003 were retrospectively reviewed. Results: Twenty-six patients with HD had residual masses at end of therapy, deemed to be of concern for residual disease. These children had 16 abnormal CXRs, 18 abnormal CT scans, and 9 abnormal gallium scans; all patients underwent biopsy. Ten (38%) showed resistant HD and 16 (62%) had fibrotic and necrotic tissue. The sensitivity and specificity of each imaging modality were 60% and 38% for CXR, 67% and 8% for CT scan, and 71% and 71% for gallium scan, respectively. Conclusions: These imaging modalities were not sufficiently sensitive or specific to predict which residual masses may be harboring resistant HD. Hence, the need for surgical biopsy will remain important in the assessment of these masses. FDG-PET scan, which was not available to these children, is a modality that may improve this assessment. D
Infants with repaired esophageal atresia and distal tracheoesophageal fistula (EA/TEF) are at ris... more Infants with repaired esophageal atresia and distal tracheoesophageal fistula (EA/TEF) are at risk for severe respiratory distress, which is related to tracheomalacia (TM), gastroesophageal reflux, or both. This usually mandates an operation for TM and/or a fundoplication procedure (FP).We retrospectively performed a 26-year review of 288 patients with repaired EA/TEF. Research Ethic Board approval was obtained.Postoperatively, 22 (7.6%) infants with EA/TEF developed severe respiratory distress. Thirteen infants had an initial TM procedure and symptoms improved in 7 (54%). The 6 (46%) remaining patients with ongoing respiratory symptoms required an FP. Nine infants had an initial FP and the symptoms improved in 6 (67%). The remaining 3 (33%) patients with ongoing respiratory symptoms required a TM procedure. All patients improved with the second procedure. Several clinical parameters were assessed among the 4 patient groups (FP only, FP followed by TM procedure, TM procedure only, and TM procedure followed by FP); there were no significant differences noted.Whereas 54% to 67% of infants improved with a TM procedure or FP, 33% to 46% required both surgical procedures. No clinical parameters were identified that could predict which procedure should be performed first.
The transanal pull-through has become the standard operation for Hirschsprung's disease in many p... more The transanal pull-through has become the standard operation for Hirschsprung's disease in many pediatric surgical centers. Over the past 8 years, we have modified our technique by leaving a short—rather than a long—rectal cuff and by doing routine intraabdominal colonic biopsies through an umbilical incision before beginning the anal dissection. The aim of this study was to determine if these modifications have changed the outcome for children undergoing this operation.A retrospective cohort study of all patients who underwent transanal pull-through by a single surgeon between 1997 and 2005 was conducted.There were 23 children who had a long cuff (10-15 cm) and 22 who had a short cuff (<2 cm). The short cuff group tended to be younger (25 ± 23 vs 139 ± 67 days; P < .05) and smaller (3.5 ± 0.7 vs 6.0 ± 2.7 kg; P < .05) at the time of surgery. The operating time was shorter (167 vs 186 minutes; P = .05) in the short cuff group. Outcomes were improved in the short cuff group, as evidenced by decreased hospital stay (1.9 ± 0.6 vs 2.7 ± 0.9; P < .05), decreased incidence of enterocolitis (9% vs 30%; P = .1), and lower incidence of narrowing requiring daily dilatations (5% vs 30%; P < .05). Preliminary colonic biopsy was performed on 18 of the 45 patients. This had no significant effect on narcotic use (66% vs 70%; P = .8) and did not increase operating time (174 ± 31 vs 179 ± 34 minutes; P = .6). Hospital stay was shorter in the umbilical biopsy group (1.9 ± 0.6 vs 2.6 ± 0.9 days; P = .006).Results of the transanal pull-through have improved likely as a result of a combination of experience and use of a shorter rectal muscular cuff. The use of a preliminary colonic biopsy through an umbilical incision has not increased postoperative pain, prolonged operative time, or lengthened hospital stay.
We report the use of intravenous Methylene blue to treat the hypotension occurring following adre... more We report the use of intravenous Methylene blue to treat the hypotension occurring following adrenal vein ligation in a case of pheochromocytoma resection in a child. The potential benefits and problems, including correct dosage, are discussed.
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