Role of endoscopic ultrasound fine-needle aspiration evaluating adrenal gland enlargement or mass

AIM: To report the clinical impact of adrenal endoscopic ultrasound fine-needle aspiration (EUS-FNA) in the evaluation of patients with adrenal gland enlargement or mass. METHODS: In a retrospective single-center case-series, patients undergoing EUS-FNA of either adrenal gland from 1997-2011 in our tertiary care center were included. Medical records were reviewed and results of EUS, cytology, adrenal size change on follow-up imaging ≥ 6 mo after EUS and any repeat EUS or surgery were abstracted. A lesion was considered benign if: (1) EUS-FNA cytology was benign and the lesion remained < 1 cm from its original size on follow-up computed tomography (CT), magnetic resonance imaging or repeat EUS ≥ 6 mo after EUS-FNA; or (2) subsequent adrenalectomy and surgical pathology was benign. RESULTS: Ninety-four patients had left (n = 90) and/or right (n = 5) adrenal EUS-FNA without adverse events. EUS indications included: cancer staging or suspected recurrence (n = 31), pancreatic (n = 20), mediastinal (n = 10), adrenal (n = 7), lung (n = 7) mass or other indication (n = 19). Diagnoses after adrenal EUS-FNA included metastatic lung (n = 10), esophageal (n= 5), colon (n = 2), or other cancer (n = 8); benign primary adrenal mass or benign tissue (n = 60); or was non-diagnostic (n = 9). Available follow-up confirmed a benign lesion in 5/9 non-diagnostic aspirates and 32/60 benign aspirates. Four of the 60 benign aspirates were later confirmed as malignant by repeat biopsy, follow-up CT, or adrenalectomy. Adrenal EUS-FNA diagnosed metastatic cancer in 24, and ruled out metastasis in 10 patients. For the diagnosis of malignancy, EUS-FNA of either adrenal had sensitivity, specificity, positive predictive value and negative predictive value of 86%, 97%, 96% and 89%, respectively. CONCLUSION: Adrenal gland EUS-FNA is safe, minimally invasive and a sensitive technique with significant impact in the management of adrenal gland mass or enlargement

EUS-guided celiac plexus interventions in pancreatic cancer pain: An update and controversies for the endosonographer

Patients with pancreatic cancer (pancreatic ductal adenocarcinoma [PDAC]) can develop abdominal pain that can be debilitating. Celiac plexus neurolysis (CPN) is a chemical ablation of the celiac plexus that can be used to treat pain caused by pancreatic malignancy. It can be performed by an anterior or posterior approach, and also can be done percutaneously or under guidance of transabdominal ultrasound, computed tomography, intra-operatively or most recently under linear endoscopic ultrasound (EUS) guidance (EUS-CPN). EUS is well-suited for identification of the celiac plexus due to the close proximity of the gastric wall to the origin of the celiac artery. EUS-CPN is now widely practiced, and different EUS approaches have been developed in order to improve the efficacy of this technique. Our objective is to review the use of EUS-CPN in PDAC, including a description of different techniques, review of its efficacy, predictors of pain response, and describe its limitations and safety, as well as new developments

Pancreatic hydatid cyst diagnosed on EUS-guided FNA

A 22-year-old woman presented with abdominal pain. Abdominal CT scan demonstrated a mass lesion in the pancreatic body (Fig. 1A). There was no lesion in the liver on CT scan (Fig. 1B). EUS showed a 50- × 35-mm cystic mass lesion containing numerous floating serpentine-like linear structures (Fig. 2; Video 1, available online at www.VideoGIE.org). EUS-guided FNA was performed with a 22-gauge needle

Digital audio and speech watermarking based on the multiple discrete wavelets transform and singular value decomposition

The ever-increasing illegal manipulation of genuine audio products has been a dilemma for the music industry. This situation calls for immediate, yet effective, solutions to avoid further financial losses and intellectual property violations. Audio and speech watermarking has been proposed as a possible solution, since this technology embeds copyright information into audio files as a proof of their ownership. In this paper, we propose an effective, robust, and an inaudible audio and speech watermarking algorithm. The effectiveness of the algorithm has been brought by virtue of applying a cascade of two powerful mathematical transforms; the discrete wavelets transform (DWT) and the singular value decomposition (SVD). Experimental results will be presented in this paper to demonstrate the effectiveness of the proposed algorithm

Endoscopic ultrasound characteristics of pancreatic lymphoepithelial cysts: A case series from a large referral center.

BACKGROUND AND OBJECTIVES: Lymphoepithelial cysts (LECs) of the pancreas are benign lesions that can mimic cystic neoplasms on imaging. Endoscopic ultrasound (EUS) features have not been well described. We aimed to describe the clinical and EUS characteristics of LECs and the present outcomes of management at a high-volume referral center. MATERIALS AND METHODS: We identified patients who underwent EUS and were found to have LECs based on fine-needle aspiration (FNA) cytology or surgical pathology from existing databases. EUS features, imaging characteristics, and pathology results were described. RESULTS: Sixteen patients were found to have 17 LECs. The mean size was 33 mm ± 15 mm. Locations within the pancreas included 10 lesions in the tail, 3 in the body, 1 in the uncinate process; the remaining 3 were exophytic. Six lesions were anechoic, 6 were hypoechoic, and 5 had mixed echogenicity. Nine lesions had mixed solid/cystic components, 7 were purely cystic, and 1 was solid. Cyst fluid was thick or viscous in six cases and thin in three. Eleven patients had diagnostic cytopathology. Six patients ultimately underwent surgery due to symptoms, nondiagnostic FNA, or other clinical concerns for malignancy. CONCLUSIONS: Pancreatic LECs have variable morphology and echogenicity on EUS, but the appearance of a cyst with variable solid and cystic components combined with the appearance of thick, turbid, and viscous aspirate should raise suspicion for an LEC. The majority of patients with LECs at our center avoided surgery for LECs on the basis of diagnostic EUS-FNA

Economic, Social And Clinical Evaluations Of Diabetes Self Management Program At Universiti Sains Malaysia Health Center : Comparison Between Structured And Less Structured Educational Programs [RC660. H126 2008 f rb].

Kes-kes penyakit diabetes mellitus (DM) di dunia meningkat dengan banyaknya masa kini. Tambahan lagi, banyak komplikasi yang serius boleh berlaku akibat penyakit DM dan ini boleh memberi kesan negatif ke atas kualiti hidup individu serta meningkatkan beban ekonomi negara. Diabetes mellitus is increasing tremendously in the world. In addition, many serious complications could result from diabetes which would affect on the quality of life and would increase the economical burden in the country

Acoustic echo cancellation using adaptive filtering algorithms for quranic accents (Qiraat) identification

Echoed parts of Quranic accent (Qiraat) signals are exposed to reverberation of signals especially if they are listened to in a conference room or the Quranic recordings found in different media such as the web. Quranic verse rules identification/Tajweed are prone to additive noise and may reduce classification results. This research work aims to present our work towards Quranic accents (Qiraat) identification, which emphasizes on acoustic echo cancellation (AEC) of all echoed Quranic signals during the preprocessing phase of the system development. In order to conduct the AEC, three adaptive algorithms known as affine projection (AP), least mean square (LMS), and recursive least squares (RLS) are used during the preprocessing phase. Once clean Quranic signals are produced, they undergo feature extraction and pattern classification phases. The Mel Frequency Cepstral Coefficients is the most widely used technique for feature extraction and is adopted in this research work, whereas probabilities principal component analysis (PPCA), K-nearest neighbor (KNN) and gaussian mixture model (GMM) are used for pattern classification. In order to verify our methodology, audio files have been collected for Surat Ad-Duhaa for five different Quranic accents (Qiraat), namely: (1) Ad-Duri, (2) Al-Kisaie, (3) Hafs an A’asem, (4) IbnWardan, and (5) Warsh. Based on our experimental results, the AP algorithm achieved 93.9 % accuracy rate against all pattern classification techniques including PPCA, KNN, and GMM. For LMS and RLS, the achieved accuracy rates are different for PPCA, KNN, and GMM, whereby LMS with PPCA and GMM achieved the same accuracy rate of 96.9 %; however, LMS with KNN achieved 84.8 %. In addition, RLS with PPCA and GMM achieved the same accuracy rate of 90.9 %; however, RLS with KNN achieved 78.8 %. Therefore, the AP adaptive algorithm is able to reduce the echo of Quranic accents (Qiraat) signals in a consistent manner against all pattern classification techniques

Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis in Pancreatic Cancer: A Prospective Pilot Study of Safety Using 10 mL versus 20 mL Alcohol

Background. The dose of alcohol used in EUS-CPN is not standardized. The objective was to compare the safety of 20 mL alcohol versus 10 mL alcohol during EUS-CPN for patients with pancreatic cancer-related pain. Methods. 20 patients were selected to receive 10 mL or 20 mL of alcohol during EUS-CPN. Followup was done at baseline, 24 hours, and weekly. Health-related quality of life (HRQoL) was assessed at baseline, week 2, week 4, and every 4 weeks thereafter until pain returned. Results. There were no major complications in both groups. Minor self-limited adverse effects were seen in 6 (30%) subjects and included lightheadedness in 1 (5%), transient diarrhea in 2 (10%), and transient nausea and vomiting in 3. Pain relief was similar in both groups: 80% in the 10 mL group and 100% in the 20 mL group (P = 0.21). The mean (± SD) duration of pain relief in the 10 mL and 20 mL groups was 7.9 ± 10.8 and 8.4 ± 9.2 weeks, respectively. 30% of patients in each group had complete pain relief. Conclusions. EUS-CPN using 20 mL of alcohol is safe. Similar clinical outcomes were seen in both groups. Further investigations to confirm these findings are warranted

Management of Branch‐duct Intraductal Papillary Mucinous Neoplasms: A Large Single Center Study to Assess Predictors of Malignancy and Long Term Outcomes

Background and Aims Management of branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) remains challenging. We determined factors associated with malignancy in BD-IPMNs and long-term outcomes. Methods This retrospective cohort study included all patients with established BD-IPMNs by the International Consensus Guidelines (ICG) 2012 and/or pathologically confirmed BD-IPMNs in a tertiary care referral center between 2001 and 2013. Main outcome measures were the association between high-risk stigmata (HRS)/worrisome features (WFs) of the ICG 2012 and malignant BD-IPMNs, performance characteristics of EUS-FNA for the diagnosis of malignant BD-IPMNs, and recurrence and long-term outcomes of BD-IPMN patients undergoing surgery or imaging surveillance. Results Of 364 BD-IPMN patients, 229 underwent imaging surveillance and 135 underwent surgery. Among the 135 resected BD-IPMNs, HRS/WFs on CT/magnetic resonance imaging (MRI) were similar between the benign and malignant groups, but main pancreatic duct (MPD) dilation (5-9 mm) was more frequently identified in malignant lesions. On EUS-FNA, mural nodules, MPD features suspicious for involvement, and suspicious/positive malignant cytology were more frequently detected in the malignant group with a sensitivity, specificity, and accuracy of 33%, 94%, and 86%; 42%, 91%, and 83%; and 33% 91%, and 82%, respectively. Mural nodules identified by EUS were missed by CT/MRI in 28% in the malignant group. Patients with malignant lesions had a higher risk of any IPMN recurrence during a mean follow-up period of 131 months (P = .01). Conclusions Among HRS and WFs of the ICG 2012, an MPD size of 5 to 9 mm on CT/MRI was associated with malignant BD-IPMNs. EUS features including mural nodules, MPD features suspicious for involvement, and suspicious/malignant cytology were accurate and highly specific for malignant BD-IPMNs. Our study highlights the incremental value of EUS-FNA over imaging in identifying malignant BD-IPMNs, particularly in patients without WFs and those with smaller cysts. Benign IPMN recurrence was observed in some patients up to 8 years after resection

Using Botulinum Toxin for the Treatment of Gastroparesis (GP) for the selection of Patients with Higher Clinical Success, Improved Quality of Life (QOL), and Improved Social Functioning Post Gastric Peroral Endoscopic Myotomy (GPOEM)

Background/Objective:While G-POEM remains an effective and exciting treatment for GP patients, predictors of clinical success remain poorly characterized. Botox injection of the pylorus prior to committing to GPOEM can help differentiate those who might have a favorable clinical response to this procedure in patients with GP. Methods:To evaluate the utility of Botox injection prior to G-POEM, 124 patients with clinically diagnosed GP who underwent a GPOEM were assessed in this retrospective cohort study. All G-POEM procedures were conducted at a single center and were completed between February 2018 and May 2023. Patients who had received intrapyloric Botox injection (n=79) had QoL and clinical success rates compared to patients who received other treatment options (n=45). Results were assessed at 1-, 3-, 6-, 12-, 24-, 36-, 48-months post G-POEM. Results:When assessing symptom severity, the difference between the change in GCSI values for Botox patients and patients receiving other prior therapy was statistically significant at 6 months post-GPOEM; +1.27 for Botox patients vs +0.55 for other treatments (p-value of 0.03). At this 6-month checkpoint, 64% of the Botox group achieved clinical success compared to 37.5% for the other treatment group. When comparing QoL, intrapyloric Botox injection has statistically significant improvements in SF-36 total score at 1, 3-, 6-, 12-, and 36-months post G-POEM, while patients receiving other treatments had no statistically significant improvements in their SF-36 total scores. Conclusion:We hypothesize that clinical improvement on pre GPOEM Botox selects patients with a higher component of pyloric spasm who end up responding more favorably to G-POEM. Scientific/Clinical/Policy Impact and Implications:Intrapyloric Botox injection is technically feasible in almost all patients with GP and does not require special expertise, training, or equipment; therefore, this should be strongly considered prior to referring a patient for G-POEM