Radiologist experience and CT examination quality determine metastasis detection in patients with esophageal or gastric cardia cancer.

We aimed to separate the influence of radiologist experience from that of CT quality in the evaluation of CT examinations of patients with esophageal or gastric cardia cancer. Two radiologists from referral centers ('expert radiologists') and six radiologists from regional non-referral centers ('non-expert radiologists') performed 240 evaluations of 72 CT examinations of patients diagnosed with esophageal or gastric cardia cancer between 1994 and 2003. We used conditional logistic regression analysis to calculate odds ratios (OR) for the likelihood of a correct diagnosis. Expert radiologists made a correct diagnosis of the presence or absence of distant metastases according to the gold standard almost three times more frequently (OR 2.9; 95% CI 1.4-6.3) than non-expert radiologists. For the subgroup of CT examinations showing distant metastases, a statistically significant correlation (OR 3.5; 95% CI 1.4-9.1) was found between CT quality as judged by the radiologists and a correct diagnosis. Both radiologist experience and quality of the CT examination play a role in the detection of distant metastases in esophageal or gastric cardia cancer patients. Therefore, we suggest that staging procedures for esophageal and gastric cardia cancer should preferably be performed in centers with technically advanced equipment and experienced radiologists.

Anterolateral rectopexy for correction of rectoceles leads to good anatomical but poor functional results.

BACKGROUND: Several different surgical repair procedures for symptomatic rectocele have been described with variable results. In our clinic, a modified anterolateral rectopexy is used. In this article we evaluate our results, with emphasis on patient satisfaction. METHODS: From 2001 until 2003, twenty patients with a symptomatic rectocele were treated by anterolateral rectopexy. The preoperative dynamic defecogram and anorectal complaints were analyzed and compared to postoperative outcome via a standardized questionnaire. RESULTS: After surgery, all rectoceles were restored as shown by postoperative defecogram. Anorectal symptoms (incomplete evacuation, continuous urge, prolapse, digital evacuation) were improved in 40%. As new-onset symptoms, dyspareunia (50%), digital support (55%) and incomplete evacuation (75%) were mentioned frequently. Most of the patients with larger rectoceles (>3.5 cm) had increased anorectal complaints after surgery. CONCLUSIONS: Anterolateral rectopexy for treatment of rectocele give limited improvement of anorectal complaints. Besides, many patients developed new complaints postoperatively and hence overall satisfaction was low.

Impact of intraoperative ultrasonography on treatment strategy for colorectal cancer.

The impact of intraoperative ultrasonography (IOUS) on treatment strategy was studied in 122 patients with primary colorectal cancer. All patients underwent preoperative liver imaging by ultrasonography and computed tomography (CT). After curative resection of the primary tumour patients were eligible for adjuvant chemotherapy. The findings on IOUS were assessed by ultrasonography 6 months after laparotomy. Of 34 patients with suspected liver metastases on ultrasonography or CT, the diagnosis was confirmed by IOUS in 21. In the remaining 13 patients the suspect lesions were shown to be benign. Of the 88 patients with normal preoperative imaging results, suspect lesions were detected in five; in four the lesion was found by IOUS only. One of these four also had an extrahepatic metastasis. At follow-up the diagnosis of metastasis proved to be wrong in two of the remaining three patients, so IOUS was helpful in only one patient. Surgical management was not markedly influenced by findings on IOUS in any patient. However, IOUS correctly changed the stage of the disease, and consequently postoperative treatment, in 14 patients (11 per cent). Two patients were erroneously excluded from the adjuvant protocol following an incorrect diagnosis based on IOUS.

Laparoscopic ultrasonography for hepatobiliary and pancreatic malignancy.

Despite the advances made since the introduction of ultrasonography, computed tomography and magnetic resonance imaging, a wide discrepancy may occur between preoperative and peroperative staging of gastrointestinal malignancy with liver and peritoneal metastases. Diagnostic laparoscopy performed immediately before a planned laparotomy can provide valuable information for the accurate assessment and appropriate management of some forms of gastrointestinal malignancy, especially that of the liver and pancreas. For evaluation of small liver and retroperitoneal malignancies, intraoperative ultrasonography performed by laparotomy is of proven value. It is now technically possible to perform ultrasonography through a laparoscopic cannula using high-resolution ultrasonographic transducers. This combination of laparoscopy and ultrasonography was studied in 25 patients with established liver lesions, carcinoma of the gallbladder or pancreatic cancer. Additional information leading to a change in surgical approach was obtained in 20 patients. Laparoscopic ultrasonography, although still in a preliminary phase of development, is a simple and reliable technique that will contribute to more accurate staging of intra-abdominal malignancy.

Magnetic resonance image appearance of hamartoma of the breast.

The magnetic resonance imaging (MRI) features of a breast hamartoma are presented. The hamartoma was evaluated using several imaging techniques with and without gadolinium-DTPA. This case demonstrates that, in selected cases, MRI is of value as an adjunct to mammography and sonography.

Absorption kinetics and action profiles after sequential subcutaneous administration of human soluble and lente insulin through one needle.

The effects of sequential administration through one needle of human soluble and human lente insulin on plasma insulin levels and action profiles, assessed with glucose clamping, were studied in six healthy volunteers. Insulin kinetics after administration of human soluble insulin (0.22 IU/kg) alone were compared with those after sequential administration of 1) human soluble insulin followed by human lente insulin and 2) human lente insulin followed by human soluble insulin. Total insulin dose in both sequences was 0.55 IU/kg, 40% of which was short-acting insulin. Plasma insulin levels were not significantly different at any time point between 0 and 240 min after soluble insulin compared with either combination. Although insulin levels were slightly but significantly lower at 30 and 105 min after lente followed by soluble insulin compared with soluble followed by lente insulin, these differences probably reflect chance occurrences. Glucose requirements were not significantly different after either of the three administrations. We therefore conclude that the unwanted retarding effect after mixing of human soluble insulin with human lente insulin in the syringe on the onset of action of the soluble insulin can be prevented by sequential subcutaneous injection of these insulins with two syringes through one needle.

Absorption kinetics and action profiles of intermediate acting human insulins.

The effects of the currently available intermediate acting human insulins on plasma insulin levels and action profiles, assessed by the euglycaemic clamp technique for a period of 8 hr following the administration, were studied in 8 healthy volunteers. The amount of insulin administered was 0.33 IU/kg body wt., using the NPH-insulins Humulin NPH, Insulatard Human, and Protaphane HM and the zinc insulins Monotard-HM and Humulin Zinc. After administration of NPH-insulins an earlier rise of plasma insulin levels was observed, reaching a plateau after about 3 hr, whereas after injection of zinc insulins the plasma insulin levels only gradually increased during at least the first 5-6 hr after administration. Glucose requirements followed a more or less similar pattern, although within the NPH-insulins Protaphane-HM lagged slightly behind during the first 2 hr when compared to Humulin NPH. We conclude therefore, that human NPH-insulins show a faster action profile as compared to human zinc insulins. This difference should be taken into account when switching over from one insulin to another.

Delayed onset of action of soluble insulin after premixing with U100 lente insulin.

In previous studies we demonstrated that mixing lente with soluble insulin of U40 strength in the syringe delays the onset of action of soluble insulin. Lente insulin of U100 as compared to U40 strength, contains a proportionally smaller amount of excess of zinc. The purpose of our study was to investigate the effect of premixing lente and soluble insulin of U100 strength on plasma insulin levels and glucose requirements during glucose clamping for 8 h in eight healthy volunteers. Soluble (0.22 U/kg) and lente (0.33 U/kg) insulin were administered once separately and once immediately after mixing in the syringe. In both instances the insulins were injected into two depots in contralateral thighs. The initial rise of plasma insulin levels from 0 to 2 h was not significantly different for both studies: from 11 +/- 1 to 25 +/- 4 mU/l and from 10 +/- 1 to 31 +/- 5 mU/l after premixing and separate administrations, respectively. However, the areas under the curves of the glucose infusion rates were significantly greater from 0 to 2 h after the separate injections of soluble plus lente than after premixing 3.25 +/- 0.70 vs. 1.84 +/- 0.56 mmol/kg, respectively (P less than 0.05). Plasma insulin levels and glucose requirements were significantly higher after premixing, compared with separate injections of soluble plus lente, from 300 to 480 and from 405 to 480 min, respectively. We conclude that mixing soluble with lente insulin of U100 strength in the syringe delays the onset of action of soluble insulin.

Comparison of two commonly used insulin injection techniques.

In ten patients with insulin-dependent diabetes we compared postprandial blood glucose levels and plasma free insulin concentrations after the administration of insulin mixtures with two commonly used injection techniques. The morning dose of insulin was administered once using a 13 mm needle, inserted perpendicularly, and once with a 20 mm needle, inserted deep subcutaneously just above the muscle fascia at an angle dependent on the skinfold thickness. Plasma free insulin concentrations and postprandial blood glucose levels were virtually identical for either technique. We conclude, therefore, that the simpler perpendicular method is the technique of choice, saving the diabetics much unnecessary anxiety over a daily procedure.