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.

Clinical Immunology Review Series: an approach to the patient with recurrent orogenital ulceration, including Behçet's syndrome.

Patients presenting with recurrent orogenital ulcers may have complex aphthosis, Behçet's disease, secondary complex aphthosis (e.g. Reiter's syndrome, Crohn's disease, cyclical neutropenia) or non-aphthous disease (including bullous disorders, erythema multiforme, erosive lichen planus). Behçet's syndrome is a multi-system vasculitis of unknown aetiology for which there is no diagnostic test. Diagnosis is based on agreed clinical criteria that require recurrent oral ulcers and two of the following: recurrent genital ulcers, ocular inflammation, defined skin lesions and pathergy. The condition can present with a variety of symptoms, hence a high index of suspicion is necessary. The most common presentation is with recurrent mouth ulcers, often with genital ulcers; however, it may take some years before diagnostic criteria are met. All patients with idiopathic orogenital ulcers should be kept under review, with periodic focused assessment to detect evolution into Behçet's disease. There is often a delay of several years between patients fulfilling diagnostic criteria and a diagnosis being made, which may contribute to the morbidity of this condition. Despite considerable research effort, the aetiology and pathogenesis of this condition remains enigmatic.

Sweet's syndrome in association with common variable immunodeficiency.

Sweet's syndrome (SS), a rare reactive neutrophilic dermatosis, has been reported to occur in association with a variety of systemic disorders, categorized by von den Diesch into idiopathic, paraneoplastic, pregnancy and parainflammatory subgroups. The parainflammatory group has been well defined, and includes a wide spectrum of infectious triggers and disorders of immune dysregulation. To date, however, no cases of SS have been described in the context of common variable immunodeficiency (CVID). We report a case of paediatric-onset SS, previously reported as idiopathic, with a subsequent diagnosis of CVID.

Effects of single dose compared with three days' prednisolone treatment of healthy volunteers: contrasting effects on circulating lymphocyte subsets.

AIMS: To investigate the effects of longer term corticosteroid treatment on circulating lymphocyte subsets. METHODS: Prednisolone (20 mg daily) was given to 12 healthy volunteers in a single morning dose for three days. Circulating lymphocyte subsets were measured by flow cytometry after whole blood lysis. RESULTS: Seven hours after the first dose of prednisolone there was a significant fall in absolute numbers of lymphocytes, T cells, CD4+ and CD8+ cells, and B cells. The percentage of T cells fell significantly, due to a fall in percentage of CD4+ cells. In contrast to the seven hour findings, at 72 hours there was a significant rise in absolute numbers of lymphocytes, T cells, CD4+, CD8+, and B cells. This trend was already apparent by 24 hours. The percentage of CD4+ cells was significantly raised at 72 hours, while that of CD8+ cells had fallen significantly. The percentage of natural killer cells had fallen at 72 hours; that of B cells remained increased at 72 hours. CONCLUSIONS: These findings show that corticosteroid treatment causes significant changes in lymphocyte subsets, and that such changes must be considered when designing studies of lymphocyte subsets during illness.

Staging of pancreatic cancer before and after neoadjuvant chemoradiation.

Neoadjuvant chemoradiation therapy is used at many institutions for treatment of localized adenocarcinoma of the pancreas. Accurate staging before neoadjuvant therapy identifies patients with distant metastatic disease, and restaging after neoadjuvant therapy selects patients for laparotomy and attempted resection. The aims of this study were to (1) determine the utility of staging laparoscopy in candidates for neoadjuvant therapy and (2) evaluate the accuracy of restaging CT following chemoradiation. Staging laparoscopy was performed in 98 patients with radiographically potentially resectable (no evidence of arterial abutment or venous occlusion) or locally advanced (arterial abutment or venous occlusion) adenocarcinoma of the pancreas. Unsuspected distant metastasis was identified in 8 (18%) of 45 patients with potentially resectable tumors and 13 (24%) of 55 patients with locally advanced tumors by CT. Neoadjuvant chemoradiation therapy and restaging CT were completed in a total of 103 patients. Thirty-three patients with potentially resectable tumors by restaging CT underwent surgical exploration and resections were performed in 27 (82%). Eleven (22%) of 49 patients with locally advanced tumors by restaging CT were resected, with negative margins in 55%; the tumors in these 11 patients had been considered locally advanced because of arterial involvement on restaging CT. Staging laparoscopy is useful for the exclusion of patients with unsuspected metastatic disease from aggressive neoadjuvant chemoradiation protocols. Following neoadjuvant chemoradiation, restaging CT guides the selection of patients for laparotomy but may overestimate unresectability to a greater extent than does prechemoradiation CT.

An unusual case of Behçet's syndrome: triggered by typhoid vaccination?

A case of Behçet's syndrome in a 32-year-old woman occurring shortly after her third vaccination against typhoid fever is described. Scleritis and pyoderma gangrenosum were unusual manifestations of BS that occurred in this case. Treatment benefit was provided by mycophenolate mofetil and etanercept. As bacterial antigens have been proposed as potential triggers for the onset of BS, it is possible that the syndrome was precipitated by typhoid vaccination in this patient.

Skin reactivity to atypical mycobacteria in cystic fibrosis.

Atypical mycobacterial disease has been described in a small number of patients with cystic fibrosis. Apart from one uncontrolled study, there is little information regarding atypical mycobacterial skin reactivity in this group of patients. We evaluated delayed cutaneous hypersensitivity to purified extracts of Mycobacterium avium, Mycobacterium intracellular, Mycobacterium kansasii and Mycobacterium bovis in 23 healthy controls and 43 adult and adolescent patients with cystic fibrosis. Fifteen of the cystic fibrosis group were receiving regular corticosteroids. Additionally, direct smear examination and Lowenstein Jensen culture were performed on sputum from the cystic fibrosis group. The prevalence of positive skin reactions was similar in the group with cystic fibrosis (30%) and in the control group (57%). Subgroup analysis showed that those cystic fibrosis patients receiving corticosteroids had a markedly lower prevalence of positive reactions (7%) compared to controls (P less than 0.01). When this subgroup was excluded from analysis, the prevalence of positive skin reactions among patients with cystic fibrosis was 43%. In the prospective sputum bacteriology study, one of the 43 cases grew Mycobacterium avium-intracellulare and had clinical and radiological evidence of this disease. Of note, this patient showed positive skin tests to all four mycobacterial species tested. Our data show no difference in the prevalence rate of positive skin reactions to atypical mycobacterial antigens between a control population and an adult cystic fibrosis population. In addition, the predictive value of skin testing is low in cystic fibrosis due to the high prevalence of cross-reactivity between different mycobacterial species and the high prevalence of anergy among those patients with advanced disease receiving treatment with corticosteroids.

Computed tomography and magnetic resonance imaging in the assessment of pancreatic disease.

Significant technical advances have occurred in both computed tomography (CT) and magnetic resonance (MR) imaging that have resulted in improved visualization of the pancreas by both techniques. In this article we will consider the advances in both modalities and consider the relative roles of each in imaging the spectrum of pancreatic pathology.

Use of time during body computed tomography scanning in a tertiary care teaching hospital: focus on patient throughput.

RATIONALE AND OBJECTIVES: To control costs, it is increasingly important to make efficient use of imaging technology. We sought to determine and analyze the time required to complete each step of a body computed tomography (CT) scan, focusing on factors that influence patient throughput. METHODS: Over 4 weeks, we prospectively monitored the time required for each step of a body CT scan (i.e., image time, check time, and clear time). Covariate data were collected by patient status: outpatient, inpatient, emergency department (ED), and intensive care unit (ICU); work shift; and radiologist training level (junior resident, senior resident, fellow, and attending). Technologists also predicted whether repeat images would be requested by the radiologist. RESULTS: Three hundred eighty CT examinations were studied: 277 for outpatients, 90 for inpatients, 9 for ED patients, and 4 for ICU patients. The mean total examination time was 44.7 min (mean image time = 33.1 min, mean review time = 8.2 min, and mean clear time = 3.4 min), which did not differ significantly with patient status. A second opinion was sought from a consultant radiologist on the scans of 44 patients. Consultation was requested significantly more frequently (1) by junior residents than by senior residents or fellows and (2) for ED and ICU patients (22% and 50%, respectively) than in outpatients and inpatients (10% and 14%, respectively). Repeat images were obtained from 75 patients, and this was not significantly related to patient status, scan type, or radiologist training level. When the technologist predicted that no repeat images were needed, this prediction agreed with the radiologist in 86% of the cases. When the technologist predicted that repeat images were necessary, this prediction agreed with the radiologist in 56% of the cases. CONCLUSION: Reviewing scans before the patient leaves the CT suite adds considerably to the total time required to complete a scan, particularly if junior residents review scans. If technologists obtain repeat images at their discretion, time would be saved.

Vaccines for preventing infection with Pseudomonas aeruginosa in people with cystic fibrosis.

OBJECTIVES: To assess the effectiveness of vaccination against Pseudomonas aeruginosa in patients with cystic fibrosis. SEARCH STRATEGY: The Cochrane Cystic Fibrosis and Genetic Disorders Group specialist trials register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and handsearching abstract books of conference proceedings. Date of the most recent search of the Group's specialised register: November 1999. SELECTION CRITERIA: All randomised or pseudorandomised trials (published or unpublished) comparing Pseudomonas aeruginosa vaccines (oral, parenteral or intranasal) with control vaccines or no intervention in patients with cystic fibrosis. DATA COLLECTION AND ANALYSIS: We planned to assess the following outcomes: time to infection with Pseudomonas aeruginosa, pulmonary function, body mass index, Schwachman score, frequency of pulmonary infective exacerbations, days of antibiotic usage, days unable to carry out normal daily activities, adverse events, mortality, antibody levels to Pseudomonas aeruginosa and T cell proliferation and cytokine production in response to Pseudomonas aeruginosa. MAIN RESULTS: One trial which included 17 vaccinated patients, with follow up reported to 10 years met the inclusion criteria. Finding only a single trial, and the lack of information on our predefined outcomes limited analysis. REVIEWER'S CONCLUSIONS: There is a paucity of randomised controlled trials assessing the effectiveness of vaccination against Pseudomonas aeruginosa in cystic fibrosis. Increased understanding of modulation of the immune response by vaccination has led to the development of alternative vaccines. We suggest that there is an urgent need for newer vaccines to be evaluated in adequately-powered, multicentre randomised controlled trials examining clinically relevant end-points in addition to immunological variables. Such a trial should assess effectiveness over several years, and include follow-up of vaccinees who become colonised with Pseudomonas aeruginosa.

Anti-neutrophil cytoplasm antibodies (ANCA) increase neutrophil adhesion to cultured human endothelium.

ANCA have been demonstrated to activate normal neutrophils in vitro. This study demonstrates that ANCA positive IgG and Fab2 fragments increase the adhesion of normal neutrophils to cultured human umbilical vein endothelium (HUVEC), and that preincubation of the endothelial monolayers with tumour necrosis factor (TNF) to activate the endothelium enhances this effect. Preincubation of neutrophils with anti-CD18 monoclonal antibodies inhibited adhesion, suggesting that the observed effect was integrin mediated.

Evaluation of the skull base by SPECT. A comparison with planar scintigraphy and computed tomography.

Computed tomography is currently the standard diagnostic tool for the evaluation of the skull base. The complex anatomy of this area is the primary reason why planar bone scintigraphy is often unsatisfactory; exact localization of abnormalities may be very difficult. These limitations may be overcome by SPECT. Seventeen patients with clinical features of basal skull involvement were assessed by CT, SPECT, and planar scintigraphy. Subsequent clinical diagnoses were malignancy in 15 patients, vasculitis in 1 patient, and osteomyelitis in 1 patient. Computed tomography with IV contrast was performed through the skull base at 5 mm intervals. Planar scintigraphy with Tc-99m MDP was followed by SPECT. Bony involvement compatible with the clinical findings was demonstrated by CT scans in 6 patients, by planar scintigraphy in 7 patients, and by SPECT in 9 patients. The abnormalities that were identified by CT were all identified by SPECT. This study suggests that, in imaging the skull base, SPECT is more sensitive and provides better anatomical localization than planar imaging and appears useful in patients with a negative CT study.

Cystic fibrosis in adolescents and adults.

A cystic fibrosis (CF) clinic for adults was established in 1977. We have reviewed the data on 164 patients who attended between 1977 and 1989. Twenty four patients had died, 11 being over 20 years of age at the time of death. Of the 140 patients still alive, 61% were male and 53% were aged over 20 years. Only 55% were diagnosed by one year and 88% by ten years. Almost all patients had respiratory symptoms and sputum culture yielded pseudomonas species in 69%. Other respiratory problems included major haemoptysis and pneumothorax, each in 10%. We found a wide range of respiratory impairment among older patients. Among 33 patients aged over 23 years, the mean (+/-S.D.) percent predicted FEV1 and FVC were 53.3% (+/- 18%) and 71.4 (+/- 20%) respectively. Mean weight in this group was 92.5% (+/- 14) of predicted. Malabsorption occurred in most patients and meconium ileus equivalent occurred in 34%. Other complications were clinical hepatomegaly (16%), diabetes mellitus (9%) and arthropathy (20%). Most patients were taking continuous antibiotics by mouth (89%) and by nebuliser (48%), beta-2 agonists by inhaler (57%) and oral steroids (29%). Almost all were taking multivitamins, pancreatic replacement therapy and multiple nutritional supplements. The number of CF "bed days" grew 12 fold since 1979 and the mean stay in hospital was double the hospital mean. The economic impact was such that over 1/4 of the annual hospital antibiotic budget was expended on CF patients.

Magnetic resonance portal venography: use of fast-acquisition true FISP imaging in the detection of portal vein thrombosis.

AIM: To determine the accuracy of true fast imaging with steady-state precession (true FISP) in the diagnosis of portal vein thrombosis in patients with cirrhosis and compare it to contrast-enhanced three-dimensional (3D) magnetic resonance (MR) angiography, the reference standard. MATERIALS AND METHODS: Twenty-four consecutive patients with suspected portal venous thrombosis underwent contrast-enhanced 3D MR angiography and true FISP imaging of the portal vein. All patients had undergone at least one other imaging study, either computed tomography, (CT) or ultrasound. Both sets of MR images were evaluated for patency of the portal venous system and for image quality. RESULTS: Portal vein thrombosis was diagnosed in six of the 24 patients. Four patients with portal vein thrombosis were accurately diagnosed on the true FISP sequence. This sequence also accurately diagnosed the patency of the portal vein in 17 patients. However, the results were inconclusive in three patients. The image quality of the true FISP sequence of the three inconclusive patients was graded as either poor or fair. Of these three patients, contrast-enhanced 3D MR angiography confirmed portal vein thrombosis in two patients and portal vein stenosis in one patient. True FISP imaging had a sensitivity of 67% and a specificity of 100% for the diagnosis of portal vein thrombosis. CONCLUSION: The results of the present study show that the true FISP sequence is useful in diagnosing portal vein thrombosis. It could be employed as an adjunct to contrast-enhanced MR angiography in the severely debilitated patient where respiratory motion may degrade the images or in patients where the use of intravenous contrast medium is not possible due to poor venous access.

Radiology of urinary diversions.

Radiologic evaluation of urinary diversion has three objectives: to monitor upper tract distention, to detect new urothelial tumors and to detect metastasis. The type of imaging procedure and the frequency of imaging is dictated by the urologist preference. As many surgical procedures are available for noncontinent and continent diversion, interpretation of radiographic studies requires a detailed knowledge of the type of surgical procedure that has been performed.

Technologic advances in abdominal MR imaging.

Magnetic resonance (MR) imaging is finding an ever-growing role in the evaluation of a wide range of conditions in the abdomen. No longer confined to problem solving regarding abnormalities in solid organs, such as the liver and kidneys, MR imaging is increasingly being applied to the evaluation of the pancreatic and biliary ductal systems and even the bowel. Recent technical advances in hardware and software have allowed the acquisition of MR images that are largely free of artifact secondary to bowel peristalsis or respiratory motion; images providing excellent anatomic detail can now be obtained routinely. Faster sequences have reduced image acquisition time, thereby improving patient acceptance and allowing more efficient utilization of machine time. New three-dimensional sequences allow rapid image acquisition, reducing section misregistration and motion artifact while improving multiplanar reformations. The potential of MR imaging to provide functional and anatomic information is intriguing, and new techniques, including diffusion and perfusion imaging, are being evaluated. This review considers the advances in imaging hardware and pulse sequence design that underlie the increasing role of MR imaging in evaluation of the abdomen and discusses evolving clinical applications.

Chest radiography for general practitioners: scope for change?

In order to derive guidelines for general practitioners on the value of chest radiography we prospectively reviewed all chest radiographs over a 10 month period. Radiographic chest examinations (frontal with or without a lateral view) were performed on 2017 patients in the radiology department or at the chest clinic. Patient details were noted, referring practice and waiting times monitored. The adequacy of the referral letter was assessed, and specific predetermined clinical findings were correlated with the radiographic findings. Results were divided into three groups (normal, abnormal with a clinically unrelated or chronic abnormality, and abnormal with a clinically related abnormality). Of these patients, 1245 (62%) had normal examinations and 460 (23%) had clinically related abnormalities. Abnormalities were rare in the 10-29 year age group, and when reassurance was sought for patients with symptoms of non-specific chest pain or general ill health. Patients presenting with haemoptysis or with symptoms of lower respiratory infection, or of chronic airways disease often had an abnormal radiograph. A clinical diagnosis was indicated or implied in 1664 (82%) and confirmed in 876 (53%). The most frequent reason for referral was for reassurance (618 patients). Guidelines based on age and symptoms should rationalize the use of chest radiography by general practitioners.