Reduced fitness and physical functioning are long-term sequelae after curative treatment for esophageal cancer: a matched control study.

Reduced physical functioning is common following resections for esophageal cancer; however, objective data on physical performance outcomes in this cohort are rare. The aim of this study was to assess the physical performance and health related quality of life (HRQOL) of disease free survivors and compare findings in a case matched noncancer control group. Twenty-five males (mean (±SD) aged 63 (±6) years) who were over 6 months postesophagectomy and disease-free were compared with 25 controls (60 ± 6 years). Physical functioning was assessed through hand grip strength (dynamometry), exercise capacity (incremental shuttle walk test), physical activity levels (RT3 accelerometer), and body composition (bio-electrical impedance analysis). Health-related quality of life was measured using the EORTC QLQ-C30 questionnaire. Esophageal cancer survivors demonstrated significantly lower fitness (P < 0.001) and time spent in moderate (P < 0.001) and vigorous (P < 0.001) intensity physical activity compared with controls. Global health status and quality of life were similar in both groups (P = 0.245); however, physical and role functioning domains were lower in the cancer survivors (P < 0.001, and P = 0.001, respectively). These data show that disease-free survivors of curative esophageal cancer treatment demonstrate a significant compromise in physical functioning compared with controls, thus highlighting the multiple, complex rehabilitative needs of this cohort.

Open-access ultrasound referrals from general practice.

Direct access referral for radiological investigations from General Practice (GP) provides an indispensable diagnostic tool and avoids the inherently long waiting time that referral through a hospital based specialty would entail. Improving access to hospital based radiology services is one of Health Information and Quality Authority's key recommendations in its report on patient referrals from general practice. This study aimed to review all GP referrals for ultrasound investigations to a tertiary referral teaching hospital over a seven month period with respect to their demographics, waiting times and diagnostic outcomes. 1,090 ultrasounds originating in general practice were carried out during the study period. Positive findings were recorded in 332 (30.46%) examinations. The median waiting time from receipt of referral to the diagnostic investigation was 56 days (range 16 - 91 years). 71 (6.5%) patients had follow-up imaging investigations while recommendation for hospital based specialty referral was made in 35 cases (3.2%). Significant findings included abdominal aortic aneurysms, metastatic disease and lymphoma. Direct access to ultrasound for general practitioners allows the referring physician to make an informed decision with regard to the need for specialist referral. We believe these findings help support the case for national direct access to diagnostic ultrasound for general practitioners.

Leptin and adiponectin receptor expression in oesophageal cancer.

BACKGROUND: Oesophageal adenocarcinoma is an exemplar model of an obesity-associated adenocarcinoma. Altered secretion of adipokines by visceral fat is believed to play a key role in tumorigenesis. This study examined leptin receptor (ObR) and adiponectin receptor (AdipoR1 and AdipoR2) expression in oesophageal cancer, and its relationship with patient obesity status, clinicopathological data and patient survival. METHODS: Tissue microarrays were constructed from paraffin-embedded oesophagectomy specimens. ObR, AdipoR1 and AdipoR2 expression was quantified by immunohistochemistry. Anthropometric data were measured at the time of diagnosis, and obesity status was assessed using visceral fat area determined by computed tomography and body mass index. Receptor expression was correlated with various clinicopathological and anthropometric variables. Patient survival was estimated using the Kaplan-Meier method, and results compared between those with low versus high receptor expression. A Cox multivariable regression model was used to assess the relationship between survival and a number of co-variables. RESULTS: All 125 tumours analysed expressed AdipoR1 and AdipoR2, whereas 96·8 per cent expressed ObR. There was no significant difference in tumour pathological features or patient obesity status between tumours with low versus high ObR expression. A high level of AdipoR1 expression was significantly associated with increased patient age, obesity and less advanced tumour (T) category. Expression of AdipoR2 was inversely associated with T category (P = 0.043). Low AdipoR1 expression was an independent predictor of improved overall survival (hazard ratio 0.56, 95 per cent confidence interval 0.35 to 0.90; P = 0.017). CONCLUSION: The association between adiponectin receptor expression, obesity status and tumour category and survival suggests a potential mechanism linking obesity and oesophageal cancer.

Imaging features of extrapulmonary small cell carcinoma.

Small cell carcinoma accounts for approximately 20% of lung cancers; however, it rarely occurs at other sites. Extrapulmonary small cell carcinoma (EPSCC) is notoriously aggressive with a strong propensity for both regional and distant spread. The majority of the literature on these uncommon tumours is from a clinicopathological viewpoint with a relative paucity of detail regarding the radiological findings. This review will focus on the imaging features of EPSCC in its predominant sites of origin: the gastrointestinal tract, genitourinary tract, head, neck, and breast. We will also discuss the role of positron-emission tomography (PET)/computed tomography (CT) in the staging of EPSCC.

Metabolic syndrome and leptin are associated with adverse pathological features in male colorectal cancer patients.

AIM: Metabolic syndrome (MetS) describes a clustering of factors including central obesity, hypertension and raised plasma glucose, triglycerides and high-density lipoprotein (HDL) cholesterol. Central obesity is associated with a risk for colorectal cancer, but the impact of MetS on colorectal cancer biology and outcomes is unclear. METHOD: A prospective observational study of colorectal cancer patients was carried out in an Irish population. Patients underwent metabolic and anthropometric assessment before treatment, including measurement of serum hormones and adipokines and CT measurement of visceral fat. MetS was defined according to the International Diabetes Federation definition(3) . RESULTS: One-hundred and thirty consecutive colorectal cancer patients (66 men and 64 women) were recruited. MetS was diagnosed in 38% patients compared with the population norms reported at 21%(21) . Male patients had a significantly greater visceral fat area compared with female patients. MetS was associated with node-positive disease (P = 0.026), percentage nodal involvement (P = 0.033) and extramural vascular invasion (P = 0.049) in male patients but no significant association was observed in female patients. HDL cholesterol was also significantly associated with a more advanced pathological stage (P = 0.014) and node-positive disease (P = 0.028). Leptin was associated with nodal status (P = 0.036), microvascular invasion (P = 0.054), advanced pathological stage (P = 0.046) and more advanced Dukes stage (P = 0.042). CONCLUSION: We report a high prevalence of MetS and visceral obesity in a colorectal cancer population. MetS and plasma leptin are associated with a more aggressive tumour phenotype in male patients only.

Magnetic resonance elastography: feasibility of liver stiffness measurements in healthy volunteers at 3T.

AIM: To demonstrate the feasibility of obtaining liver stiffness measurements with magnetic resonance elastography (MRE) at 3T in normal healthy volunteers using the same technique that has been successfully applied at 1.5 T. METHODS AND MATERIALS: The study was approved by the local ethics committee and written informed consent was obtained from all volunteers. Eleven volunteers (mean age 35 ± 9 years) with no history of gastrointestinal, hepatobiliary, or cardiovascular disease were recruited. The magnetic resonance imaging (MRI) protocol included a gradient echo-based MRE sequence using a 60 Hz pneumatic excitation. The MRE images were processed using a local frequency estimation inversion algorithm to provide quantitative stiffness maps. Adequate image quality was assessed subjectively by demonstrating the presence of visible propagating waves within the liver parenchyma underlying the driver location. Liver stiffness values were obtained using manually placed regions of interest (ROI) outlining the liver margins on the gradient echo wave images, which were then mapped onto the corresponding stiffness image. The mean stiffness values from two adjacent sections were recorded. RESULTS: Eleven volunteers underwent MRE. The quality of the MRE images was adequate in all the volunteers. The mean liver stiffness for the group was 2.3 ± 0.38 kPa (ranging from 1.7-2.8 kPa). CONCLUSIONS: This preliminary work using MRE at 3T in healthy volunteers demonstrates the feasibility of liver stiffness evaluation at 3T without modification of the approach used at 1.5 T. Adequate image quality and normal MRE values were obtained in all volunteers. The obtained stiffness values were in the range of those reported for healthy volunteers in previous studies at 1.5 T. There was good interobserver reproducibility in the stiffness measurements.

MRI assessment of changes in liver iron deposition post-venesection.

OBJECTIVE: The aim of this study was to determine if changes in hepatic iron content in patients with hemochromatosis pre- and post-venesection could be detected by changes in liver signal intensity with MRI. MATERIALS AND METHODS: The study was performed with institutional ethics approval and with informed consent. Gradient echo images were performed on 20 patients with hemochromatosis pre- and post-venesection and 10 control subjects: gradient echo T1-weighted in- and out-phases (4.54 (in)/2.27 (out), 167 [TE/TR], Flip 70°) and gradient echo T2* (5/18 [TE/TR], Flip 10°). The liver to muscle signal ratio was compared pre- and post-venesection. RESULTS: All MRI sequences showed significant correlation between the liver to muscle signal intensity ratio and the serum ferritin pre-venesection [r=-0.70, -0.65, -0.74, -0.72, in/out/T2*r/T2*, respectively]. There was a significant increase on all sequences in the liver to muscle signal intensity ratio post-venesection (p<0.001). The control group and patients post-venesection had almost identical liver to muscle signal intensity ratios. CONCLUSION: The reduction in liver signal intensity caused by iron excess in hemochromatosis returns to normal post-venesection. Measurement of liver to muscle signal intensity ratios may be a useful tool in assessing treatment response in iron overload states.

Associations between leptin and adiponectin receptor upregulation, visceral obesity and tumour stage in oesophageal and junctional adenocarcinoma.

BACKGROUND: Obesity is associated with oesophageal adenocarcinoma, but mechanisms linking fat and carcinogenesis remain poorly understood. Altered circulating adipocytokines may be important. This study aimed to identify pathways through which visceral fat impacts on tumour biology. METHODS: Seventy-five patients with oesophageal adenocarcinoma underwent anthropometric and radiological assessment of obesity. Expression of leptin receptor (ObR) and adiponectin receptors 1 and 2 (AdipR1, AdipR2) was quantified by real-time reverse transcriptase-polymerase chain reaction. The human oesophageal adenocarcinoma cell line OE33 was used as the calibrator sample. RESULTS: Ninety-one per cent of tumours expressed ObR, 95 per cent expressed AdipR1 and 100 per cent expressed AdipR2. Relative expression of ObR was upregulated in 67 per cent, and AdipR1 and AdipR2 were downregulated in 55 and 68 per cent respectively, relative to the calibrator sample. Upregulated ObR and AdipR2 expression was significantly associated with anthropometric and radiological measures of obesity. Upregulated ObR was associated with advanced tumour and node category (P = 0.036 and P = 0.025 respectively), and upregulated AdipR2 with nodal involvement (P = 0.037). CONCLUSION: Obesity is associated with upregulated ObR and AdipR2 expression in oesophageal adenocarcinoma. The association of ObR and AdipR2 with tumour stage suggest that pathways involving adipocytokines affect tumour biology.

Association of visceral adiposity with oesophageal and junctional adenocarcinomas.

BACKGROUND: Obesity is associated with an increased incidence of oesophageal and oesophagogastric junction adenocarcinoma, in particular Siewert types I and II. This study compared abdominal fat composition in patients with oesophageal/junctional adenocarcinoma with that in patients with oesophageal squamous cell carcinoma and gastric adenocarcinoma, and in controls. METHOD: In total, 194 patients (110 with oesophageal/junctional adenocarcinoma, 38 with gastric adenocarcinoma and 46 with oesophageal squamous cell carcinoma) and 90 matched control subjects were recruited. The abdominal fat area was assessed using computed tomography (CT), and the total fat area (TFA), visceral fat area (VFA) and subcutaneous fat area (SFA) were calculated. RESULTS: Patients with oesophageal/junctional adenocarcinoma had significantly higher TFA and VFA values compared with controls (both P < 0.001), patients with gastric adenocarcinoma (P = 0.013 and P = 0.006 respectively) and patients with oesophageal squamous cell carcinoma (both P < 0.001). For junctional tumours, the highest TFA and VFA values were seen in patients with Siewert type I tumours (respectively P = 0.041 and P = 0.033 versus type III; P = 0.332 and P = 0.152 versus type II). CONCLUSION: Patients with oesophageal/junctional adenocarcinoma, in particular oesophageal and Siewert type I junctional tumours, have greater CT-defined visceral adiposity than patients with gastric adenocarcinoma or oesophageal squamous cell carcinoma, or controls.

Survey of medical students and junior house doctors on the effects of medical radiation: is medical education deficient?

BACKGROUND: We investigated the knowledge of ionising radiation among medical students and junior doctors in Ireland and assessed whether this knowledge improved with clinical experience. METHODS: A total of 269 subjects completed a questionnaire on the fundamentals of diagnostic imaging and patient doses. RESULTS: Overall knowledge was poor, 99% of subjects underestimated the dose of radiation involved in a barium enema, plain film of abdomen, lumbar spine X-ray and a PET scan. Almost 90% underestimated the dose of a CT abdomen/pelvis. 42% of subjects knew that PET involved ionising radiation while 27% thought that MRI did. There was a significant improvement in understanding after transition to a clinical environment, however, no further development. 1% had attended formal radiation protection courses. CONCLUSION: The knowledge of basic radiological procedures and patient doses was extremely limited. Current undergraduate teaching needs to be expanded and continued post-qualification to improve core understanding and facilitate safe practice.

Non-seminomatous testicular metastasis mimicking acute appendicitis.

This is the first report in the literature of a non-seminomatous metastasis from an occult testicular primary that presented as an acute appendicitis. The report highlights the necessity of testicular re-imaging in cases of occult malignancy and reviews the association of chromosome 12 with embryonal germ cell tumours.

Valsalva and gravitational variability of the internal jugular vein and common femoral vein: ultrasound assessment.

PURPOSE: Central venous cannulation via the common femoral vein is an important starting point for many interventions. The purpose of this study was to determine the optimum conditions for cannulation of the femoral vein and to compare these with the relative changes in the internal jugular vein. METHODS: High-resolution 2D ultrasound was utilised to determine variability of the calibre of the femoral and internal jugular veins in 10 healthy subjects. Venous diameter was assessed during the Valsalva manoeuvre and in different degrees of the Trendelenburg position. RESULTS: The Valsalva manoeuvre significantly increased the size of the femoral and internal jugular veins. There was a relatively greater increase in femoral vein diameter when compared with the internal jugular vein of 40 and 29%, respectively. Changes in body inclination (Trendelenburg position) did not significantly alter the luminal diameter of the femoral vein. However, it significantly increased internal jugular vein diameter. CONCLUSIONS: Femoral vein cannulation is augmented by the Valsalva manoeuvre but not significantly altered by the gravitational position of the subject.

Antibiotic prophylaxis in interventional radiology--anything new?

Every interventional procedure can result in infective complications. Generally the incidence is low; however, with newer and more aggressive techniques the infection risk is more prevalent and can result in serious adverse outcomes to our patients. Antibiotic prophylaxis has become commonplace; however, there is little controlled data to underpin our regimens and most choices are based on surgical practice and anecdotal evidence. The rise of antibiotic resistance and treatment of many immunocompromised patients further compounds the difficulties faced. The purpose of this article was to examine the evidence that is presented regarding antibiotic prophylaxis in interventional radiology and highlight how we integrate this into our daily practice. In particular we will focus on evolving procedures and techniques that are associated with a high incidence of infection.

Testicular varicoceles.

A testicular varicocele represents an abnormal degree of venous dilatation of the pampiniform plexus. It is a relatively common condition and may present at scrotal pain and swelling. An association with male subfertility is an area of debate. This article describes the present day radiological criteria and imaging techniques to aid accurate diagnosis of varicoceles. In addition, the role of the interventional radiologist in treating this condition is discussed.

A critical appraisal of the out-patient fracture clinic: is communication really the key?

The most common factor in an adversarial doctor-patient relationship is failed communication. We audited our communication skills, patient satisfaction and assessed patients' capacity for retaining information. 120 consecutive first time patients with one of 5 fracture types were assessed. Patients scored (a) the doctor's communication skills and (b) their overall fracture clinic experience. Patient satisfaction was high, mean 8.2 (range 2-10, SD 1.76) points. There was a statistically significant difference in a patient's knowledge pre and post consultation. Forty-three patients (36%) could recall a specific consequence of the fracture (p<0.005). Forty (31%) and twenty six (22%) patients could recall the name of the Registrar and Consultant respectively. Doctors scored 9.2 (range 7-10, SD 1.23) points for communication skills. Patients are concerned with a fracture's impact on daily activities, often failing to register who treats them and any serious consequences. With doctors being scored so highly, the dilemma remains of how better to deliver the message.

Reduced inflammation in genetically hypertensive rat airways is associated with reduced tachykinin NK(1) receptor numbers.

The airways of the genetically hypertensive rat (GH) are hyperinnervated by substance P-containing sensory nerves and exhibit reduced inflammatory responsiveness to substance P and to capsaicin. The present study measured tracheal inflammation to resiniferatoxin (1.0 microgram/kg i.v.), a capsaicin analogue, which lacks the hypotensive action of capsaicin itself, alone or after the neuronal nitric oxide synthase inhibitor 1-(2-trifluoromethylphenyl)imidazole (TRIM) (50 mg/kg i.p.). The inflammatory response to resiniferatoxin alone was 50% lower in untreated GH than in control rats, a similar strain difference to that seen previously with capsaicin. Pre-treatment with TRIM had no effect on inflammation in either strain. Binding kinetics of the tachykinin NK(1) receptor antagonist [3H](S)-1-(2-[3-(3, 4-dichlorophenyl)-1-(3-isopropoxyphenylacetyl)piperidin-3-yl]ethyl)-4- phenyl-l-azoniabicyclo[2,2,2,]octane chloride ([3H]SR140333)(0.125-16.0 nM) showed 50% reduction of B(max) in GH versus control tracheae (74+/-13 cf.165+/-26 fmol/mg protein). Our results indicate that the reduced neurogenic inflammatory responsiveness in GH rats can be attributed entirely to reduced tachykinin NK(1) receptor numbers.