Gregory A. Nuttall, MD

• Professor of Anesthesiology
• Mayo Clinic
• Rochester, Minnesota

Lymphoepithelial cyst Lymphoepithelial cyst is a rare benign squamous-lined cyst with subepithelial non-neoplastic lymphoid tissue symptoms at 4 weeks pregnant discount generic persantine canada. A pseudocyst is also in the differential diagnosis due to the necrotic appearance of the keratinous debris symptoms 6 days post embryo transfer buy persantine with mastercard. Diagnostic pitfalls: lymphoepithelial cyst Complicated pseudocyst Other squamous lined cysts in the region of the pancreas such as dermoid cysts and epidermoid cysts symptoms low blood pressure purchase persantine 25 mg with visa. Cytological findings: lymphoepithelial cyst Retention cysts Retention cysts are small cysts that form from cystically dilated segments of pancreatic ducts as a consequence of focal duct obstruction treatment degenerative disc disease buy line persantine. They are typically unilocular treatment zone tonbridge purchase persantine toronto, small (1 cm) medications known to cause seizures order persantine toronto, and are lined by ductal epithelium which is often denuded. They are unlikely to be confused with a mucinous neoplasm either clinically or on imaging studies. It is, however, conceivable that aspirates of these lesions, when focally lined by metaplastic mucinous epithelium, may show a few mucinous epithelial cells and muciphages. Cystic neoplasms Serous cystadenoma Serous cystadenoma (microcystic or glycogen-rich cystadenoma) is a benign, typically microcystic, neoplasm that produces serous fluid. Asymptomatic neoplasms less than 4 cm can be followed without resection making cytological confirmation of the diagnosis very important. The fluid aspirated from a serous cystadenoma is clear and thin and may be quite bloody, but is not mucoid as in most mucinous cysts. Smears are frequently very paucicellular and it is not uncommon for smears to be acellular. Tumour cells are uniform cuboidal cells in small clusters and flat sheets with round central to slightly eccentric nuclei and scant but visible cytoplasm that is homogenous to clear. The nuclei have smooth nuclear membranes, an even chromatin pattern, and inconspicuous to no nucleoli. Haemosiderin-laden macrophages may be a prominent component of the aspirate, and when identified in an aspirate without the typical proteinaceous debris expected of a pseudocyst, may serve as a surrogate marker and clue to the diagnosis of this neoplasm. The cytoplasm is delicate and may appear clear and finely vacuolated but is non-mucinous. Consideration of cyst location, organ traversed and other clinical and radiological features makes the distinction possible in many cases (Table 10. This is primarily due to hypocellularity of the mucinous contents aspirated and/or a lack of architectural specificity of the glandular epithelium, for example, absence of papillary fragments. In addition, the lining of the cysts is often heterogeneous, so it is important to emphasise that regardless of the cytological diagnosis, a higher-grade neoplasm cannot be excluded. Degenerate inflammatory cells and histiocytes within the mucin also help to distinguish cyst mucin from contaminating mucin. Thin, clear fluid may not be recognised at all if the fluid is processed by liquid-based methods. When processed as cytospin preparations, mucin stains (mucicarmine and/or Alcian blue pH 2. Background mucin that mimics proteinaceous debris may be confirmed with special stains for mucin (Mucicarmine stain). In fact, the typical heterogeneity of these neoplasms may produce aspirate specimens with a range of cellular atypia from adenoma to carcinoma making accurate cytological diagnosis a challenge. Hyperchromatic cells with irregular nuclear membranes and high nuclear to cytoplasmic ratios may be arranged in elongated to papillary clusters where the length is usually twice the width of the group. Even if very scant in amount, recognition of just one small group of such atypical epithelial cells is important for classifying the cyst as at least moderate dysplasia. Only necrosis appears to correlate with the presence of invasion, but this distinction cannot be made on aspirates of cyst contents alone. Oncocytic epithelium demonstrates round, regular nuclei, prominent nucleoli and abundant granular cytoplasm (H&E). Cytological findings: intraductal papillary mucinous neoplasm with moderate dysplasia and higher In addition to the above findings for lesions with low-grade dysplasia: mucinous glandular cells arranged in small clusters and flat to folded sheets with a honeycombed pattern. Clusters of columnar cells with round basal nuclei and mucinous cytoplasm are most often noted. Recognition of intraepithelial lymphocytes and sporadically placed goblet cells supports duodenal epithelium. Dense, oncocytic cytoplasm is consistent with intraductal oncocytic papillary neoplasm. Increased cellularity relative to adenoma Recognisable cytological atypia with increased cellularity and atypia correlating with increased grade: single intact cells, doublets and small cell clusters, cellular papillary groups, nuclear irregularity, increased nuclear: cytoplasmic ratio, decreased cytoplasmic mucin, irregular nuclear membranes and nucleoli Abundant background inflammation and necrosis support malignancy. Complete resection of thoroughly evaluated, non-invasive cysts is considered curative. The subepithelial ovarian-type stroma typically is not appreciated on cytology smears. This elongated group of epithelium twice as long as wide shows nuclear enlargement and crowding, open chromatin and nucleoli consistent with carcinoma. Low-grade epithelium displays small, round basal nuclei and cytoplasmic mucin that fills the cytoplasmic compartment in contrast to the apical mucin cup noted in foveolar cells that may contaminate the specimen as shown in. There is significant overlap in the clinical and radiological features of solid and cystic mass lesions of the pancreas precluding definitive management decisions based on clinical and radiological features alone in many cases. Diagnostic accuracy with sufficiently high sensitivity and specificity depends on a multimodal team approach that combines the clinical and radiological patient information with the cytological impression and the results of ancillary studies. The cyst lining cells may become attenuated from pressure decreasing the mucinous appearance of the cells. The initial diagnostic differential for the pathologist starts with the basic information from the radiological image: Is the lesion (A) solid or (B) cystic Pancreatic cancer and pancreaticoduodenectomy in elderly patient: morbidity and mortality are increased. Multidisciplinary approach to diagnosis and management of intraductal papillary mucinous neoplasms of the pancreas. Endoscopic ultrasound-guided tissue sampling by combined fine needle aspiration and Tru-Cut needle biopsy: a prospective study. Endoscopic ultrasound-guided pancreatic duct aspiration: diagnostic yield and safety. Pancreatic and bile duct brushing cytology in 1000 cases: review of findings and comparison of preparation methods. Providing on-site diagnosis of malignancy on endoscopic-ultrasound-guided fine-needle aspirates: should it be done Significance of peritoneal cytology in patients with potentially resectable adenocarcinoma of the pancreatic head. Endoscopic ultrasound-guided fine needle aspiration in the diagnosis and staging of pancreatic tumors. Endoscopic ultrasound-guided real-time fineneedle aspiration biopsy of the pancreas in cancer patients with pancreatic lesions. Endoscopic ultrasound-guided real-time fineneedle aspiration: clinicopathologic features of 60 patients. Endoscopic ultrasound and fine needle aspiration for the evaluation of pancreatic masses. Endoscopic ultrasound guided fine needle aspiration biopsy: a large single centre experience. Endoscopic ultrasound guided fine-needle aspiration cytology of pancreatic carcinoma: a 3-year experience and review of the literature. Yield of endoscopic ultrasound-guided fine-needle aspiration biopsy in patients with suspected pancreatic carcinoma. Performance of endosonography-guided fine needle aspiration and biopsy in the diagnosis of pancreatic cystic lesions. A prospective evaluation of an algorithm incorporating routine preoperative endoscopic ultrasound-guided fine needle aspiration in suspected pancreatic cancer. Endoscopic ultrasound-guided fine-needle aspiration biopsy: a powerful tool to obtain samples from small lesions. Analysis of false-negative diagnoses on endoscopic brush cytology of biliary and pancreatic duct strictures: the experience at 2 university hospitals. Reporting the presence of significant epithelial atypia in pancreaticobiliary brush cytology specimens lacking evidence of obvious carcinoma: impact on performance measures. Endoscopic ultrasound guided fine needle aspiration biopsy of autoimmune pancreatitis: diagnostic criteria and pitfalls. Cytologic diagnosis of pancreatic tuberculosis in immunocompetent and immunocompromised patients: a report of 2 cases. Cytologic criteria for welldifferentiated adenocarcinoma of the pancreas in fine-needle aspiration biopsy specimens. Preoperative gemcitabine-based chemoradiation for patients with resectable adenocarcinoma of the pancreatic head. Diagnostic utility of mucin profile in fine-needle aspiration specimens of the pancreas: an immunohistochemical study with surgical pathology correlation. Novel markers of pancreatic adenocarcinoma in fine-needle aspiration: mesothelin and prostate stem cell antigen labeling increases accuracy in cytologically borderline cases. Immunocytochemical study of the expression of mesothelin in fine-needle aspiration biopsy specimens of pancreatic adenocarcinoma. Usefulness of S100P in diagnosis of adenocarcinoma of pancreas on fine-needle aspiration biopsy specimens. Undifferentiated carcinoma with osteoclast-like giant cells of the pancreas and periampullary region. Almost all infiltrating colloid carcinomas of the pancreas and periampullary region arise from in situ papillary neoplasms: a study of 39 cases. Evolving patterns in the detection and outcomes of pancreatic neuroendocrine neoplasms: the Massachusetts General Hospital experience from 1977 to 2005. Endoscopic ultrasound-guided fine needle aspirate microsatellite loss analysis and pancreatic endocrine tumor outcome. Cystic endocrine tumors of the pancreas: clinical, radiologic and histopathologic features in 13 cases. Islet cell tumour with vacuolated lipid-rich cytoplasm: a new histological variant of islet cell tumour. Cytological diagnosis of endocrine tumors of the pancreas by endoscopic ultrasound-guided fineneedle aspiration biopsy. Endoscopic ultrasound-guided fine needle aspiration cytology of pancreatic neuroendocrine tumours: cytomorphological and immunocytochemical evaluation. Pleomorphic pancreatic endocrine neoplasms: a variant commonly confused with adenocarcinoma. Misinterpretation of normal cellular elements in fine-needle aspiration biopsy specimens: observations from the College of American Pathologists Interlaboratory Comparison Program in Non-Gynecologic Cytopathology. Clinically aggressive solid pseudopapillary tumors of the pancreas: a report of two cases with components of undifferentiated carcinoma and a comparative clinicopathologic analysis of 34 conventional cases. Solid and cystic papillary neoplasm of the pancreas: a clinico-cytopathologic and immunocytochemical study of five new cases diagnosed by fine-needle aspiration cytology and a review of the literature. Endoscopic ultrasound-guided fine-needle aspiration cytology diagnosis of solid pseudopapillary tumor of the pancreas: a rare neoplasm of elusive origin but characteristic cytomorphologic features. Solid pseudopapillary tumor of the pancreas: a neoplasm with distinct and highly characteristic cytological features. Loss of E-cadherin and cytoplasmic-nuclear expression of beta-catenin are the most useful immunoprofiles in the diagnosis of solid pseudopapillary neoplasm of the pancreas. Primary pancreatic lymphoma evaluated by fine-needle aspiration: findings in 14 cases. Endoscopic ultrasound-guided fine needle aspiration biopsy of patients with suspected pancreatic cancer: diagnostic accuracy and acute and 30-day complications. Mucinous cystic neoplasm of the pancreas is not an aggressive entity: lessons from 163 resected patients. Asymptomatic pancreatic cysts: a decision analysis approach to observation versus resection. The role of pancreatic cyst fluid molecular analysis in predicting cyst pathology. The detection of telomerase activity in patients with adenocarcinoma of the pancreas by fine needle aspiration. Quantitative analysis of K-ras gene mutation in pancreatic tissue obtained by endoscopic ultrasonography-guided fine needle aspiration: clinical utility for diagnosis of pancreatic tumor. Molecular analysis of pancreatic cyst fluid: a comparative analysis with current practice of diagnosis. Impact of cytopathologist expert on diagnosis and treatment of pancreatic lesions in current clinical practice. Cyst fluid analysis in the differential diagnosis of pancreatic cystic lesions: a pooled analysis. Cyst-fluid analysis in the differential diagnosis of pancreatic cystic lesions: a meta-analysis. Cystic pancreatic lesions: a simple imaging-based classification system for guiding management. Neoplastic disorders of emerging importance-current state-of-the-art and unanswered questions. Fine needle aspiration of pancreatic cysts: Use of ancillary studies and difficulty in identifying surgical candidates. K-Ras and microsatellite marker analysis of fineneedle aspirates from intraductal papillary mucinous neoplasms of the pancreas. Lymphoepithelial cysts of the pancreas: a report of 12 cases and a review of the literature. Cyst fluid cytology and chemical features in a case of lymphoepithelial cyst of the pancreas: a rare and difficult preoperative diagnosis. Cytologic features of lymphoepithelial cyst of the pancreas: two preoperatively diagnosed cases based on fine-needle aspiration. Giant epidermoid cyst within an intrapancreatic accessory spleen mimicking a cystic neoplasm of the pancreas: case report and review of the literature. Histopathology and molecular genetics of multiple cysts and microcystic (serous) adenomas of the pancreas in von Hippel-Lindau patients.

It is inactivated by 2% glutaraldehyde disinfectants symptoms 8 days past ovulation discount 100mg persantine, autoclaving medications related to the female reproductive system discount persantine 100 mg visa, and many disinfectants treatment 5th metatarsal fracture cheap generic persantine uk, such as alcohol and hypochlorite (household bleach) treatment 0f gout cheap persantine 100 mg. During the first phase medications given for bipolar disorder buy persantine 25mg with mastercard, a few weeks after exposure medicine gif cheap persantine online american express, viral replication is rapid and there may be mild, generalized flulike symptoms such as low fever, fatigue, arthralgia, and sore throat. In the prolonged second, or latent, phase, many patients demonstrate no clinical signs, whereas some have a generalized lymphadenopathy or enlarged lymph nodes. The final acute stage, when immune deficiency is evident, is marked by numerous serious complications. Each patient may demonstrate more effects in one or two categories as well as minor changes in the other systems. Gastrointestinal effects seem to be related primarily to opportunistic infections, including parasitic infections. The signs include chronic severe diarrhea, vomiting, and ulcers on the mucous membranes. Necrotizing periodontal disease is common, with inflammation, necrosis, and infection around the teeth in the oral cavity. This is often aggravated by malignant tumors, particularly lymphomas, and by opportunistic infections such as herpesvirus, various fungi, and toxoplasmosis in the brain. Encephalopathy is reflected by confusion, progressive cognitive impairment, including memory loss, loss of coordination and balance, and depression. In the lungs, Pneumocystis carinii, now considered a fungus, is a common cause of severe pneumonia (see chapter 19) and is frequently the cause of death. A positive result is followed by the more sensitive Western blot test, which is used for confirmation. It is essential for testing blood donations and to monitor the viral load in the blood as the disease progresses. A new rapid, non-invasive test (20 minutes) using saliva is now available, but the more complex testing is necessary to confirm a positive result. The centers for Disease control and Prevention (cDc) has established case definition criteria using the indicator diseases, opportunistic infections and unusual cancers, and has provided a classification for the phases of the infection. The life and health care of an infected child are frequently complicated by the illness and perhaps death of the parents. Pneumocystis carinii pneumonia is often the cause of death in children and prophylactic antimicrobial drugs are often prescribed. Treatment Antiviral drugs can reduce the replication of viruses, but they do not kill the virus, and thus are not a cure (see chapter 4). The virus mutates as well, becoming resistant to the drug, particularly when single drugs are administered. For example, two viral reverse transcriptase inhibitors, such as zidovudine and lamivudine, plus a protease inhibitor such as indinavir form one such combination. This approach reduces drug-resistant mutations of the virus and the drugs are chosen to attack the virus from several points. A "one pill daily" combination of three drugs (Atripla) is available to improve patient adherence to their drug protocol. A primary focus of treatment is on minimizing the effects of complications, such as infections or malignancy, by prophylactic medications and immediate treatment. Even though safer and more effective drugs are available in many parts of the world, there continues to be an uneven distribution of such drugs. The patient has a history of skin rashes, both eczema and contact dermatitis, since infancy. He jumped in the swimming pool to cool off, but immediately felt exhausted and climbed out. Finally one paramedic could detect a mark on his leg, but no swelling at the site. He was given an epinephrine injection and oxygen then was transported to hospital. Explain the rationale for: (i) pruritus (itchy skin), (ii) difficulty talking and breathing, and (iii) feeling faint. Explain how epinephrine and glucocorticoids would help reduce the manifestations of anaphylaxis. This continued to spread over his entire body and his neck was swollen, therefore he remained in the hospital. Intravenous glucocorticoids were continued as well as the antihistamine diphenhydramine (Benadryl). By the third day, the area where the stings occurred on the leg had turned a dark purple color. He also carries an EpiPen and Benadryl with him at all times, as well as avoiding situations in which a sting could occur. Why is it important for this patient to carry an EpiPen with him and wear a Medic-Alert bracelet At this time she is having an exacerbation, which includes a facial rash, joint pains, and chest pain. She is in a relationship with a fellow classmate who says that he has not had many relationships before theirs. After a party, they engage in unprotected sex, although they usually use a condom. She immediately seeks advice and testing from the campus health center and is told that three tests over several months will be done. How can the risk of infection be reduced before birth, during delivery, and after birth When a foreign antigen enters the body, specific matching antibodies (humoral immunity) or sensitized T-lymphocytes (cell-mediated immunity) form, which then can destroy the matching foreign antigen. Specialized memory cells ensure immediate recognition and destruction of that antigen during future exposures. It also may be transmitted by infected mothers to infants before, during, or after birth. Compare active natural immunity and passive artificial immunity, describing the causative mechanism and giving an example. Define an autoimmune disease, and explain how the causative mechanism differs from a normal defense. Describe the respiratory infection influenza, including the cause, transmission, immunization, incidence, manifestations, and possible complications. Describe the basic characteristics of bacteria, viruses, chlamydiae, rickettsiae, mycoplasmas, fungi, prions, and helminths. Detailed classifications of organisms with their proper names are available in microbiology references. Bacteria are classified as prokaryotic cells because they are very simple in structure-lacking even a nuclear membrane-but they function metabolically and reproduce. By comparison, eukaryotic cells are nucleated cells found in higher plants and animals, including humans. In the 18th and 19th centuries, scientists experimented on fermentation and spoilage of foods. This resulted in the concept of the "germ theory of disease" as well as explanations of how wine and other foods became unfit for consumption. The transmission of pathogens and infection through hands, surfaces, water, and the air was documented, and the practices of asepsis were begun. Microorganisms vary widely in their growth needs, and their specific requirements often form the basis for identification tests. Many microbes can be grown in a laboratory using an appropriate environment and a suitable culture medium in a Petri dish. The need for oxygen, carbohydrates, a specific pH or temperature, or a living host depends on the needs of the particular microbe. Those microbes that require living cells in which to survive are particularly difficult to identify without specialized laboratory techniques such as cell culture, immunoassays, or electron microscopy. The specific growth factors play a role in determining the site of infection in the human body. For example, the organism causing tetanus is an anaerobic bacterium that thrives in the absence of oxygen and therefore can easily cause infection deep in the tissue. The major groups of bacteria are: Bacilli, or rod-shaped organisms, for example, Clostridium tetani, the microbe causing tetanus or "lockjaw. A toxin from the bacterium causes seizures and muscle spasms and, eventually, respiratory failure. A bacterium has one of two types of cell walls, gram-positive or gramnegative, which differ in their chemical composition. This difference can be quickly determined in the laboratory using a Gram stain and provides a means of identification and classification for bacteria. Targeting cell wall structure and function is important because human cells do not have cell walls. A drug such as penicillin thus does not damage human cells but is effective against gram-positive bacteria. This semi-permeable membrane selectively controls movement of nutrients and other materials in and out of the cell. This layer is found outside the cell wall and offers additional protection to the organism. Pili or fimbriae are tiny hairlike structures found on some bacteria, usually in the gram-negative class. Plasmids commonly contain genetic information conveying drug resistance; thus such resistance can be shared with many other types of bacteria. The cellular components provide for the metabolism, growth, reproduction, and unique characteristics of the bacterium. They have a variety of effects, often interfering with nerve conduction, such as the neurotoxin from the tetanus bacillus. Exotoxins stimulate antibody or antitoxin production, which after being processed to reduce the toxic effect, can be used as toxoids to induce an immune response (see chapter 3). Endotoxins may cause fever and general weakness, or they may have serious effects on the circulatory system, causing increased capillary permeability, loss of vascular fluid, and endotoxic shock. For example, collagenase breaks down collagen, and streptokinase dissolves blood clots. These bacteria can survive long periods in the spore state, but they cannot reproduce when in spore form. Later, when conditions improve, the bacteria resume a vegetative state and reproduce. Tetanus and botulism are two examples of dangerous infections caused by spores in the soil entering the body, where they return to the vegetative state and reproduce. The generation time or rate of replication varies from a few minutes to many hours, depending on the particular microbe. If binary fission occurs rapidly, a large colony of bacteria can develop very quickly, and this leads to the rapid onset of infection. The limiting factors to bacterial growth include insufficient nutrients and oxygen, the effects of increased metabolic wastes in the area, and changes in pH or temperature, all of which cause microbes to die faster than they can divide. Thus the colony eventually self-destructs, but pathogenic bacteria may cause life-threatening damage to tissues before self-destruction. Describe three similarities and three differences between bacteria and human cells. How is each of these differences important in the development of antibacterial medications Viruses There are several types of viruses, many of which include numerous subtypes. Table 4-1 lists some types of viruses and common pathogens causing disease in humans. The need of viruses for living tissue complicates any laboratory procedure to grow or test viruses. The protein coat comes in many shapes and sizes and undergoes change relatively quickly in the evolution of the virions. The nucleic acid content and its form provide methods of classification of viruses. When a virus infects a person, it attaches to a host cell, and the viral genetic material enters the cell. The new viruses are assembled, then released by lysis of the host cell or by budding from the host cell membrane. Some viruses remain in a latent stage; they enter host cells and replicate very slowly or not at all until some time later. Frequently one type of virus exists in many similar forms or strains, and viruses tend to mutate, or change slightly, during replication. Some viruses such as the influenza virus are composed of nucleic acids from differing viral strains in animals and humans. Influenza H1N1 has components from both swine influenza and human influenza; these A. They are transmitted by insect vectors, such as lice or ticks, and cause diseases such as typhus fever and Rocky Mountain spotted fever. These microbes lack cell walls-therefore are not affected by many antimicrobial drugs-and they can appear in many shapes. These factors make it difficult for a host to develop adequate immunity to a virus, either by effective antibodies or vaccines. They can hide inside human cells, and they lack their own metabolic processes or structures that might be attacked by drugs. A vaccine is now available for this common cancer and is approved for use in females entering puberty to prevent later cancer. Growth of various types of fungi can be observed easily on cheese, fruit, or bread. Fungal or mycotic infection results from single-celled yeasts or multicellular molds. These organisms are classified as eukaryotic and consist of single cells or chains of cells, which can form a variety of structures. Fungi are frequently considered beneficial because they are important in the production of yogurt, beer, and other foods, as well as serving as a source of antibiotic drugs. The long filaments or strands of a fungus are hyphae, which intertwine to form a mass called the mycelium, the visible mass. Fungi reproduce by budding, extension of the hyphae, or producing various types of spores.

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Syndromes

• Stroke recovery
• Cranial arteritis (sometimes called temporal arteritis)
• Have you passed blood clots?
• Low blood oxygen levels (hypoxia)
• Lead to problems with feeding and speech
• Because of nerve damage, you could have problems digesting the food you eat. You could feel weakness or have trouble going to the bathroom. Nerve damage can also make it harder for men to have an erection.
• Schizophrenia
• Cerebral angiogram
• Arteriosclerosis of the extremities
• Stool occult blood test to test for blood in your stool