Intra-observer agreements in multidisciplinary team assessments of pancreatic cancer patients.

BACKGROUND AND METHODS: Treatment strategies for pancreatic cancer patients are made by a multidisciplinary team (MDT) board. We aimed to assess intra-observer variance at MDT boards. Participating units staged, assessed resectability, and made treatment allocations for the same patients as they did two years earlier. We disseminated clinical information and CT images of pancreatic cancer patients judged by one MDT board to have nonmetastatic pancreatic cancer to the participating units. All units were asked to re-assess the TNM stage, resectability, and treatment allocation for each patient. To assess intra-observer variance, we computed %-agreements for each participating unit, defined as low (<50%), moderate (50%-75%), and high (>75%) agreement. RESULTS: Eighteen patients were re-assessed by six MDT boards. The overall agreement was moderate for TNM-stage (ranging from 50%-70%) and resectability assessment (53%) but low for treatment allocation (46%). Agreement on resectability assessments was low to moderate. Findings were similar but more pronounced for treatment allocation. We observed a shift in treatment strategy towards increasing use of neoadjuvant chemotherapy, particularly in patients with borderline resectable and locally advanced tumors. CONCLUSIONS: We found substantial intra-observer agreement variations across six different MDT boards of 18 pancreatic cancer patients with two years between the first and second assessment.

[Cardiac sarcoidosis]. / Kardial sarkoidose.

Sarcoidosis is characterised by granulomatous inflammation in one or more organs, including the heart. Cardiac sarcoidosis generally has non-specific symptoms, and the disease is often diagnosed at a late stage. The condition is associated with cardiomyopathy and arrhythmia and may be fatal.

Hepatoid adenocarcinoma of the stomach--proper identification and treatment remain a challenge.

OBJECTIVE: The term hepatoid adenocarcinoma (HAC) of the stomach was introduced three decades ago with the observation of high serum α-fetoprotein (AFP) levels in some gastric adenocarcinoma patients. This very rare gastric cancer patient subgroup is likely frequently misdiagnosed. MATERIAL: Two patients who were recently diagnosed with HAC of the stomach at our institution are presented. We also performed a structured literature search and reviewed pertinent articles to provide knowledge to improve the proper identification, diagnosis and management of patients with gastric HAC. RESULTS: HAC is a rare subgroup of gastric carcinoma with poor prognosis. Clinical management of this population may be challenging. The scientific literature is largely based on very small patient series or case reports, and the evidence for proper decision making and management is considered weak. CONCLUSION: All physicians involved in the diagnosis and treatment of patients with gastric cancer should pay attention to this rare subgroup to improve identification.

Estimating cardiac output from coronary CT angiography: an individualized compartment model in comparison to the Stewart-Hamilton method.

Background: Attenuation is correlated with the concentration of contrast medium (CM) in the arteries. The cardiac output (CO) affects the concentration of CM in the circulatory system; therefore, CO affects the time-density curve (TDC). Thus, estimating CO using TDC from test-bolus images acquired in computed tomography (CT) is possible. In this study, we compare two methods of estimating CO, namely, an individualized mathematical compartment model, integrating patient, contrast, and scanning factors with TDC, and the Stewart-Hamilton method based on the area under the curve of the TDC. Materials and methods: Attenuation in the aorta was measured during test-bolus in 40 consecutive patients with a clinical indication for coronary CT angiography (CCTA). Each participant underwent cardiac magnetic resonance imaging following CCTA to validate the estimated CO. The individual compartment model used TDC in conjunction with scanning and patient-specific parameters to estimate the concentration of CM and CO over time. This was compared to the CO calculated from the area under the curve using the Stewart-Hamilton method. Results: Both CO estimated with our individualized compartment model (r = 0.66, p < 0.01) and the Stewart-Hamilton method (r = 0.53, p < 0.01) were moderately correlated with CO measured with cardiac MRI. Body surface area (BSA) and time to peak (TTP) affected the accuracy of our model. Lower BSA resulted in overestimation, and lower TTP resulted in CO underestimation, respectively. We found no gender-specific difference in the accuracy of our model when correcting for BSA. The Stewart-Hamilton method performed better with a more complete TDC, whereas the compartment model performed better overall with a partial TDC. Conclusion: The TDC acquired in CCTA allows for CO estimation. Both the Stewart-Hamilton method and our mathematical compartment model show moderate correlation when applied to our data, although each method has its strengths and limitations. If the majority of the TDC is known, the Stewart-Hamilton method may be more reliable, but an individual compartment model is preferable when there are insufficient data points in the TDC. Regardless, both methods can potentially increase the diagnostic information acquired from a CCTA, which is increasingly recommended in clinical guidelines.

Neurofilament light in plasma is a potential biomarker of central nervous system involvement in systemic lupus erythematosus.

BACKGROUND: Neuropsychiatric manifestations (NP) are common in systemic lupus erythematosus (SLE). However, the pathophysiological mechanisms are not completely understood. Neurofilament light protein (NfL) is part of the neuronal cytoskeleton. Increased NfL concentrations, reflecting neurodegeneration, is observed in cerebrospinal fluid (CSF) in several neurodegenerative and neuroinflammatory conditions. We aimed to explore if plasma NfL could serve as a biomarker for central nervous system (CNS) involvement in SLE. METHODS: Sixty-seven patients with SLE underwent neurological examination; 52 underwent lumbar puncture, while 62 underwent cerebral magnetic resonance imaging (MRI). We measured selected auto-antibodies and other laboratory variables postulated to have roles in NP pathophysiology in the blood and/or CSF. We used SPM12 software for MRI voxel-based morphometry. RESULTS: Age-adjusted linear regression analyses revealed increased plasma NfL concentrations with increasing creatinine (ß = 0.01, p < 0.001) and Q-albumin (ß = 0.07, p = 0.008). We observed higher plasma NfL concentrations in patients with a history of seizures (ß = 0.57, p = 0.014), impaired motor function (ß = 0.36, p = 0.008), increasing disease activity (ß = 0.04, p = 0.008), and organ damage (ß = 0.10, p = 0.002). Voxel-based morphometry suggested an association between increasing plasma NfL concentrations and the loss of cerebral white matter in the corpus callosum and hippocampal gray matter. CONCLUSION: Increased plasma NfL concentrations were associated with some abnormal neurological, cognitive, and neuroimaging findings. However, plasma NfL was also influenced by other factors, such as damage accrual, creatinine, and Q-albumin, thereby obscuring the interpretation of how plasma NfL reflects CNS involvement. Taken together, NfL in CSF seems a better marker of neuronal injury than plasma NfL in patients with SLE.

Microvascular obstruction is a major determinant of infarct healing and subsequent left ventricular remodelling following primary percutaneous coronary intervention.

AIMS: We studied the time-dependent relationships between microvascular obstruction (MO), infarct size, and left ventricular (LV) remodelling after acute myocardial infarction (MI). METHODS AND RESULTS: Forty-two consecutive patients with first-time ST-elevation MI, single-vessel disease, successfully treated with primary percutaneous coronary intervention (PCI) were included. Microvascular obstruction, infarct size, and LV remodelling were assessed by cardiac magnetic resonance. Cardiac magnetic resonance was performed at: 2 days, 1 week, 2 months, and 1 year following PCI. Microvascular obstruction was assessed by first-pass perfusion. Patients were divided into three groups according to the presence or absence of MO at 2 days and 1 week: no detectable MO at any time point (11 patients), MO detectable only at 2 days (16 patients), and MO detectable both at 2 days and 1 week (15 patients). In multivariable analysis adjusting for infarct size at 2 days, detectable MO at 1 week was an independent predictor (P = 0.003) of infarct size at 1 year follow-up, associated with adverse infarct healing, adverse LV remodelling, increased LV volumes, and lower ejection fractions when compared with the rest of the cohort. CONCLUSION: Microvascular obstruction is an important determinant of infarct healing. The effect of MO on infarct size translated into distinct patterns of LV remodelling during long-term follow-up.

A case of Ménétriere´s disease treated with the monoclonal antibody cetuximab.

Ménétriere´s disease is a rare disorder of the body and fundus of the stomach, characterized by a massive proliferation of the foveolar cells and subsequent excess mucous secretion. This results in hypoproteinemia due to loss of serum proteins across the gastric mucosa. The cause of Ménétriere´s disease is unknown, and due to the irreversible and premalignant character of the disorder, the patients affected have been subdued to gastrectomy as the only curable treatment. Epidermial growth factor (EGF) has been implicated in the pathogenesis, a finding that makes the disorder receptive to monoclonal antibody treatment against the EGF receptor. In this case report, we present a 41-year-old woman referred to our emergency department due to dizziness, nausea, and vomiting. A thorough medical investigation, combining clinical history, laboratory investigations, an upper endoscopy with full-thickness snare biopsies, and a CT scan confirmed Ménétriere´s disease, and she was successfully treated with the monoclonal antibody cetuximab.

[Contrast-enhanced cardiac magnetic resonance in patients with acute myocarditis]. / Kontrastbasert MR-undersøkelse av hjerte ved akutt myokarditt.

BACKGROUND: Acute myocarditis is a serious condition that is challenging to diagnose. Recent developments in contrast-enhanced cardiac magnetic resonance imaging (ce-MRI) enable visualization of myocardial damage in patients with myocarditis. The objective of this study was to identify patients in whom ce-MRI could be useful to reach such a diagnosis. METHODS: We reviewed data from 37 patients referred to ce-MRI with suspected acute myocarditis at Stavanger University Hospital from July 2004 to May 2007. RESULT: 20 patients had epicardial contrast enhancement compatible with myocarditis. The contrast enhancement was focal and most frequently localized to the inferolateral wall (n = 12). No patient with Troponin T < 0.1 microg/L (n = 7) showed epicardial contrast enhancement. It was not possible to distinguish patients with acute myocarditis from the other patients on the basis of clinical signs, symptoms, C-reactive protein levels, ECG- or echocardiography. INTERPRETATION: Ce-cardiac MRI is important in the diagnosis of acute myocarditis. If troponin T levels are < 0.1 microg/L during the acute phase, it is unlikely that a contrast enhancement pattern will be compatible with myocarditis.

[A 90-year-old woman with acute abdomen]. / En 90 år gammel kvinne med akutt abdomen.

Bowel strangulation is defined as mechanical obstruction associated with compromised blood circulation of the bowel wall. Delayed diagnosis and treatment are the main causes of the high mortality. A 90-year-old woman was admitted to our hospital with acute abdominal pain. Plain abdominal x-ray studies were inconclusive. However, bowel strangulation was suggested by computer tomography and the diagnosis was confirmed under the laparotomy. In the case of bowel strangulation, abdominal CT is a fast, reliable and useful diagnostic tool when imaging is considered necessary before a laparotomy.

Relationship between orthostatic hypotension and white matter hyperintensity load in older patients with mild dementia.

BACKGROUND/OBJECTIVES: White matter hyperintensities (WMH) in magnetic resonance imaging (MRI) scans of the brain, and orthostatic hypotension (OH) are both common in older people. We tested the hypothesis that OH is associated with WMH. DESIGN: Cross-sectional study. SETTING: Secondary care outpatient clinics in geriatric medicine and old age psychiatry in western Norway. PARTICIPANTS: 160 older patients with mild dementia, diagnosed according to standardised criteria. MEASUREMENTS: OH was diagnosed according to the consensus definition, measuring blood pressure (BP) in the supine position and within 3 minutes in the standing position. MRI scans were performed according to a common protocol at three centres, and the volumes of WMH were quantified using an automated method (n=82), followed by manual editing. WMH were also quantified using the visual Scheltens scale (n=139). Multiple logistic regression analyses were applied, with highest vs. lowest WMH quartile as response. RESULTS: There were no significant correlations between WMH volumes and systolic or diastolic orthostatic BP drops, and no significant correlations between Scheltens scores of WMH and systolic or diastolic BP drops. In the multivariate analyses, only APOEε4 status remained a significant predictor for WMH using the automated method (p=0.037, OR 0.075 (0.007-0.851)), whereas only age remained a significant predictor for WMH scores (p=0.019, OR 1.119 (1.018-1.230)). CONCLUSION: We found no association between OH and WMH load in a sample of older patients with mild dementia.

White matter hyperintensities and the course of depressive symptoms in elderly people with mild dementia.

OBJECTIVES: To explore the relationship between white matter hyperintensities (WMH) and the prevalence and course of depressive symptoms in mild Alzheimer's disease (AD) and Lewy body dementia. DESIGN: This is a prospective cohort study conducted in secondary care outpatient clinics in western Norway. SUBJECTS: The study population consisted of 77 elderly people with mild dementia diagnosed according to standardised criteria. METHODS: Structured clinical interviews and physical, neurological, psychiatric, and neuropsychological examinations were performed and routine blood tests were taken. Depression was assessed using the depression subitem of the Neuropsychiatric Inventory and the Montgomery-Åsberg Depression Rating Scale (MADRS). A standardised protocol for magnetic resonance imaging scan was used, and the volumes of WMH were quantified using an automated method, followed by manual editing. RESULTS: The volumes of total and frontal deep WMH were significantly and positively correlated with baseline severity of depressive symptoms, and depressed patients had significantly higher volumes of total and frontal deep WMH than non-depressed patients. Higher volumes of WMH were also associated with having a high MADRS score and incident and persistent depression at follow-up. After adjustment for potential confounders, frontal deep WMH, in addition to prior depression and non-AD dementia, were still significantly associated with baseline depressive symptoms (p = 0.015, OR 3.703, 95% CI 1.294-10.593). Similar results emerged for total WMH. CONCLUSION: In elderly people with mild dementia, volumes of WMH, in particular frontal deep WMH, were positively correlated with baseline severity of depressive symptoms, and seemed to be associated with persistent and incident depression at follow-up. Further studies of the mechanisms that determine the course of depression in mild dementia are needed.

Visual rating of white matter hyperintensities in Parkinson's disease.

Dementia is a common complication of Parkinson's disease (PD), but the cause is incompletely understood. In previous studies, dementia has been associated with an increase in hyperintense lesions in the cerebral white matter. The aim of this study was to explore whether white matter hyperintensities (WMH) on cerebral magnetic resonance imaging (MRI) are associated with dementia in PD. For this study, 35 patients with PD, 16 with dementia (PDD) and 19 without (PDND), and 20 control subjects were recruited. MRI scans of patients and controls were rated for WMH, blind to diagnosis, using the Scheltens visual rating scale. Both bivariate and multivariate statistical analyses were carried out. Cerebrovascular risk factors, education, gender, or age were similar across groups. Compared with the PDND group, the PDD group had significantly higher level of WMH in the deep white matter and in the periventricular areas. WMH in the deep white matter was the only variable that was associated significantly with Mini-Mental State Examination score and explained 38% of the variance in the multivariate linear regression analysis. Our findings suggest that WMH in the deep white matter may contribute to dementia in PD.

Benign peritoneal cystic mesothelioma.

BACKGROUND: Benign peritoneal cystic mesothelioma (BPCM) is a rare tumor of unknown origin, most frequently encountered in women of reproductive age. Etiology is unknown; definitions and terminology are confusing, and preoperative diagnosis is difficult. Several differential diagnoses must be considered. METHODS: Based on our own clinical experience and a review of the relevant literature, we address clinical challenges and controversies of importance. RESULTS: Current literature on BPCM is mostly based on small case reports. Complete surgical resection is recommended if possible. Nevertheless, recurrent disease is not uncommon. Clinical positive effects of various adjuvant medical treatments remain to be shown. CONCLUSIONS: Lack of consistent definitions, various treatment approaches, and mostly short follow-up times make it difficult to draw any firm conclusions from published reports. The natural history of this rare disease is less than well clarified. When possible, in an individual patient, surgical resection with curative intent seems to be the treatment of choice.