Differentiation of Autoimmune Pancreatitis from Pancreatic Cancer Remains Challenging.

BACKGROUND: Autoimmune pancreatitis (AIP) is an uncommon form of chronic pancreatitis. Whilst being corticosteroid responsive, AIP often masquerades radiologically as pancreatic neoplasia. Our aim is to appraise demographic, radiological and histological features in our cohort in order to differentiate AIP from pancreatic malignancy. METHODS: Clinical, biochemical, histological and radiological details of all AIP patients 1997-2016 were analysed. The initial imaging was re-reviewed according to international guidelines by three blinded independent radiologists to evaluate features associated with autoimmune pancreatitis and pancreatic cancer. RESULTS: There were a total of 45 patients: 25 in type 1 (55.5%), 14 type 2 (31.1%) and 6 AIP otherwise not specified (13.3%). The median (IQR) age was 57 (51-70) years. Thirty patients (66.6%) were male. Twenty-six patients (57.8%) had resection for suspected malignancy and one for symptomatic chronic pancreatitis. Three had histologically proven malignancy with concurrent AIP. Two patients died from recurrent pancreatic cancer following resection. Multidisciplinary team review based on radiology and clinical history dictated management. Resected patients (vs. non-resected group) were older (64 vs. 53, p = 0.003) and more frequently had co-existing autoimmune pathologies (22.2 vs. 55.6%, p = 0.022). Resected patients also presented with less classical radiological features of AIP, which are halo sign (0/25 vs. 3/17, p = 0.029) and loss of pancreatic clefts (18/25 vs. 17/17, p = 0.017). There were no differences in demographic features other than age. CONCLUSION: Despite international guidelines for diagnosing AIP, differentiation from pancreatic cancer remains challenging. Resection remains an important treatment option in suspected cancer or where conservative treatment fails.

IRMER regulations: compliance rate of radiograph reporting by non-radiology clinicians.

AIM: To assess compliance with regulation 7(8) of Ionizing Radiation Medical Exposure Regulations (IRMER) 2000 legislation amongst non-radiologists reporting radiographs in a large district general hospital. MATERIALS AND METHODS: A prospective review of 100 consecutive radiography request cards from five different departments undertaking their specialty radiograph reporting were collected over 4 weeks. The requests were then traced to their respective case notes to assess documentation of radiographs. The five departments included chest, maxillo-facial, rheumatology, orthopaedics, and inpatients. Twenty-two case notes were gathered from chest clinics, 21 from maxillo-facial, 15 from rheumatology, 23 from orthopaedics fracture clinics, and 19 were taken from inpatients. RESULTS: Only 53% of radiographs undertaken by non-radiologists had a documented report. The specialty most compliant with IRMER was orthopaedics 17/23 (74%) and the specialty least compliant was maxilla-facial 8/21 (38%). Of the documented radiographs, the consultant grade was the largest group of doctors [36% (19/53)] that undertook documentation, and for the undocumented radiographs, they were also the largest group of clinicians that did not document radiographs [77% (36/47)]. All radiographs that were documented in the notes also had documented interpretation of the radiograph. CONCLUSION: Only 53% of plain radiographs were documented and reported by non-radiology clinicians even though IRMER legislation applies to all clinicians undertaking radiograph interpretation. All clinicians undertaking interpretation of radiographs should be made aware of this legislation and the responsibility to document their findings.

Cervical screening in under 25s: a high-risk young population.

OBJECTIVE: The changes to the UK NHS cervical screening programme launched in April 2004 recommend that the first cytological screening should be undertaken at the age of 25 years rather than at 20 years. This study analyses Papanicolaou smear diagnoses of women under 25 years in Lewisham Borough of London to determine the incidence of cervical intraepithelial neoplasia (CIN) in this age group. There are concerns that delaying the onset of cervical screening in this population may increase the risk of cervical cancer. STUDY DESIGN: Pap smear results of 2793 women (2617 between 20 and 24 years and 176 below 20 years) over a period of 1 year from 1 April 2003 to 31 March 2004 were analysed. Appropriate colposcopy referrals and the results of cervical biopsies performed were followed up. RESULTS: Of the 2793 cervical smears analysed: 1997 (71.5%) were normal; 375 (13.4%) inadequate; 144 (5.1%) borderline; 208 (7.4%) showed mild dyskaryosis and 69 (2.5%) showed high-grade lesions (moderate to severe dyskaryosis). One hundred and eighty-two women were referred to colposcopy: 34% showed histological evidence of high-grade precancerous lesions (CIN 2 or 3); 27% CIN 1 and 0.5% koilocytosis only. Thirteen percent had normal colposcopy while 22% did not attend. CONCLUSION: The Lewisham population of young women under the age of 25 years is vulnerable to potential precancerous cervical lesions. This may reflect a high level of sexual activity among the young girls. Absence of screening in this age group may miss these high-grade cervical lesions that could progress to cervical cancer in the near future. We reinforce the importance of cervical screening in the highly vulnerable sexually active population under 25.

Prevalence of anorectal dysfunction in women attending health care services.

The aim of this study was to assess the prevalence of different bowel symptoms (constipation, faecal incontinence and faecal evacuation dysfunction) and associated urinary symptoms in women attending health care services. All women attending colposcopy clinics and general gynaecology clinics in a district general hospital in the southwest of England were invited to participate in the study. In addition, women attending the local family planning clinic were also recruited. Women attending these clinics routinely completed a history sheet and were asked to complete the Birmingham Bowel and Urinary Symptoms Questionnaire. Two hundred women participated in the study: 116 (64.4%) had at least one bowel symptom from the list in the questionnaire and 57 (31.6%) of women thought they had a bowel problem but only 26 (14.4%) consulted their family doctor regarding the problem while four (2.2%) were referred for specialist opinion. Six were unsure about their bowel symptoms. There were 46 (25.5%) of women who had constipation, 99 (55%) had faecal incontinence and 97 (53.8%) complained of faecal evacuation dysfunction. Only 48 (26.6%) of women were free of any bowel complaint. One patient with faecal incontinence discussed her problem with her midwife but no further action was taken as she was too embarrassed to discuss it with her doctor. Seventy-eight (43.3%) of patients had urinary symptoms. Fifty-five (30.5%) thought they had a urinary problem but only 29 (16.1%) consulted their doctor and 17 (9.4%) were referred for specialist opinion. Sixty-one (33.8%) of those who admitted to have urinary incontinence also had faecal incontinence. Forty-nine (27.2%) of the patients were free of all symptoms. The mode of delivery as well as previous surgery did not have any influence on urinary incontinence nor on anal incontinence. This study has demonstrated a high prevalence of bowel symptoms in women attending health care services.

Bladder augmentation using Pelvicol implant for intractable overactive bladder syndrome.

The objective of the study was to evaluate the effectiveness of an implant of porcine dermis to augment the bladder in women with refractory overactive bladder syndrome (OAB). Twelve women underwent a Pelvicol bladder augmentation. A visual analogue score for severity of incontinence and a quality of life questionnaire was carried out pre-operatively and at 12 months post-operatively. Follow up cystoscopy was carried out in three women in addition. Three women were dry and cured; five women were significantly improved; two women were slightly improved and the procedure was unsuccessful in the remaining two women. There were no significant complications and voiding was spontaneous in every case. A bladder augmentation using porcine dermis may have a role in the surgical management of non-neuropathic women with OAB that has failed to respond to conservative therapy.

Are dyspepsia management guidelines coherent with primary care practice?

BACKGROUND: Spontaneous physician behaviour can affect guideline applicability, implementation strategies and application costs, particularly in relation to widespread pathologies chiefly managed by general practitioners (GPs). Of the array of dyspepsia management guidelines, the closest to general practice, partly owing to proposing committee composition, are the European Society for Primary Care Gastroenterology (ESPCG) guidelines. METHODS: To evaluate variability in dyspepsia management among GPs in Padua and divergence in spontaneous prescriptive behaviour from the ESPCG dyspepsia guideline, we prospectively studied the behaviour of 39 GPs over a 3-month period of outpatient activity, through questionnaires on each consultation. Test-group representativeness was preliminarily defined in terms of antisecretory drug expenditure. RESULTS: 1790 forms on dyspepsia-related consultations were studied in a population of 51,193 registered patients; 1264 patients with a history of dyspeptic pathology consulted their GP (19% duodenal ulcer (DU), 9% gastric ulcer (GU), 54% gastro-oesophageal reflux disease (GERD), 32% non-ulcer dyspepsia (NUD), 1% cholelithiasis), while 526 patients presented with symptoms of dyspepsia with no previous gastroscopy (EGDS) (42% were aged <45 years), of whom 42% had twice consulted their GP. Empirical management by prescription of symptomatic drugs was the most common procedure in DU (33%), GU (73%) and NUD (74%) relapses. Helicobacter pylori eradication therapy was prescribed in only 2% of patients with a history of organic or functional dyspepsia. 145 patients with uninvestigated dyspepsia were referred for second-level endoscopy and 43 for H. pylori testing. Forty-four percent of endoscopies prescribed for uninvestigated patients did not comply with the ESPCG guideline; full compliance would have determined a 105% rise in endoscopies. Prescriptive variability between GPs was high (based on the Goodman-Kruskal (0.41, P < 0.001) and Cramer tests (V = 0.51, P < 0.005)) and agreement between observed and expected prescriptions according to ESPCG criteria was as low as V = 0.11. On the basis of the most frequently observed behaviours, we developed three options of the ESPCG guideline and compared them to spontaneous prescriptions. CONCLUSIONS: Highest compliance emerged where the clinical approach for all patients with uninvestigated dyspepsia was symptomatic therapy at first presentation followed by a different attitude at second presentation, setting a higher cut-off age than in the guideline (which in our case proved, on mathematical calculation, to be 55 years).

[Interferon-alpha. Results of a pharmaco-epidemiologic study]. / Interferone alfa. Risultati di uno studio farmaco-epidemiologico.

In the present study we evaluated the use of alpha-IFN in the ULSS 21 of Veneto Region. All outpatients treated with interferon during the period June-July 1992 (114 subjects) were interviewed using a standard questionnaire which was meant to collect information about therapy, side effects and quality of life. Alpha-IFN was mostly prescribed for chronic non-A non-B hepatitis (as approved by the FDA in the USA and by the Ministero della Sanità in Italy), while 35% of the patients were suffering from diseases for which interferon use is approved by Ministero della Sanità but not by FDA. In most cases, independently of the specific disease, a standard dose of 9 MU/week was used, which often resulted to be below the recommended doses reported in the literature. Adverse effects were frequently reported. The most common include fever, chills, headache, fatigue, myalgia. Mild mental disturbances (irritability and/or depression) and thyroid dysfunction were also reported but were less frequent. Finally, a negative influence of alpha-IFN therapy on the quality of life was reported by about half of the interviewed patients.