Multicentre survey of radiologically inserted gastrostomy feeding tube (RIG) in the UK.

AIMS: To evaluate the variance in current UK clinical practice and clinical outcomes for direct percutaneous radiologically inserted gastrostomy (RIG). MATERIALS AND METHODS: A prospective UK multicentre survey of RIG performed between October 2008 and August 2010 was performed through the British Society of Gastrointestinal and Abdominal Radiology (BSGAR). RESULTS: Data from 684 patients were provided by 45 radiologists working at 17 UK centres. Two hundred and sixty-three cases (40%) were performed with loop-retained catheters, and 346 (53%) with balloon-retained devices. Sixty percent of all patients experienced pain in the first 24 h, but settled in the majority thereafter. Early complications, defined as occurring in the first 24 h, included minor bleeding (1%), wound infection (3%), peritonism (2%), and tube misplacement (1%). Late complications, defined as occurring between day 2 and day 30 post-procedure, included mild pain (30%), persisting peritonism (2%), and 30 day mortality of 1% (5/665). Pre-procedural antibiotics or anti-methicillin-resistant Staphylococcus aureus (MRSA) prophylaxis did not affect the rate of wound infection, peritonitis, post-procedural pain, or mortality. Ninety-three percent of cases were performed using gastropexy. Gastropexy decreased post-procedural pain (p < 0.001), but gastropexy-related complications occurred in 5% of patients. However, post-procedure pain increased with the number of gastropexy sutures used (p < 0.001). The use of gastropexy did not affect the overall complication rate or mortality. Post-procedure pain increased significantly as tube size increased (p < 0.001). The use of balloon-retention feeding tubes was associated with more pain than the deployment of loop-retention devices (p < 0.001). CONCLUSION: RIG is a relatively safe procedure with a mortality of 1%, with or without gastropexy. Pain is the commonest complication. The use of gastropexy, fixation dressing or skin sutures, smaller tube sizes, and loop-retention catheters significantly reduced the incidence of pain. There was a gastropexy-related complication rate in 5% of patients. Neither pre-procedural antibiotics nor anti-MRSA prophylaxis affected the rate of wound infection.

Audit of the introduction of CT colonography for detection of colorectal carcinoma in a non-academic environment and its implications for the national bowel cancer screening programme.

AIM: To compare the sensitivity of double-contrast barium enema (DCBE) with computed tomography colonography (CTC) to determine whether CTC is superior for the detection of colorectal cancer (CRC) locally, and to compare the results to those of a national barium enema audit. MATERIALS AND METHODS: All patients undergoing diagnostic DCBE or CTC between January 2003 and December 2005 were identified from the picture archiving communication system (PACS). Patients with a confirmed diagnosis of CRC were identified from the local cancer registry. Patients who were not diagnosed as having CRC on imaging were assumed true negatives if they were not listed in the cancer registry by December 2007, giving a minimum of 2 years follow-up. DCBE and CTC reports of all patients with CRC were analysed, and cancer detection was considered to have occurred (positive test result) if the report stated the definite presence of CRC or possible CRC requiring further investigation. RESULTS: 2520 DCBEs and 604 CTCs were included. Twenty-one of 33 patients with CRC were detected using DCBE (incidence 1.31%, sensitivity 63.7%). Thirty-two of 33 patients with CRC were -detected using CTC (incidence 5.46%, sensitivity 97.7%). CONCLUSION: CTC is more sensitive for the detection of CRC, and its introduction in a district general hospital is justified. However, there has been a consequent decline in DCBE sensitivity, which, if reflected nationally, suggests CTC is the preferential screening test for CRC.

CT colonography: interpretative performance in a non-academic environment.

AIM: To investigate interpretative accuracy and reporting time for radiologists performing computed tomography (CT) colonography in day-to-day non-academic clinical practice. MATERIALS AND METHODS: Thirteen radiologists from seven centres, who were reporting CT colonography in non-academic daily clinical practice, interpreted a dataset of 15 colonoscopically validated cases in a controlled environment. Ten cases had either a cancer or polyp >10mm; one case had a medium polyp and four were normal. Correct case categorization and interpretation times were compared using analysis of variance to aggregated results obtained from both experienced observers and observers recently trained using 50 cases, working in an academic environment. The effect of experience was determined using Spearman's rank correlation. RESULTS: Individual accuracy was highly variable, range 53% (95% CI 27-79%) to 93% (95% CI 68-100%). Mean accuracy overall was significantly inferior to experienced radiologists (mean 75 versus 88%, p=0.04) but not significantly different from recently trained radiologists (p=0.48). Interpretation time was not significantly different to experienced readers (mean 12.4 min versus 11.7, p=0.74), but shorter than recently trained radiologists (p=0.05). There was a significant, positive, linear correlation between prior experience and accuracy (p<0.001) with no plateau. CONCLUSION: Accuracy for sub-specialist radiologists working in a non-academic environment is, on average, equivalent to radiologists trained using 50 cases. However, there is wide variability in individual performance, which generally falls short of the average performance suggested by meta-analysis of published data. Experience improves accuracy, but alone is insufficient to determine competence.

A 4-year review of balloon dilation of ureteral strictures in renal allografts.

BACKGROUND: Ureteral obstruction necessitating intervention occurs in 2% to 7.5% of all renal allograft recipients. Conventional management includes open surgical repair, although more recently, percutaneous ureteral dilation has been performed. PATIENTS AND METHODS: The management and outcome of all seven allograft ureteral strictures treated with balloon dilation in our unit over a 4-year period were reviewed. Half (55%) of these strictures occurred in the proximal ureter. RESULTS: Four strictures were dilated successfully with a requirement for five dilations in total. These patients have stable graft function with no evidence of obstruction. Five strictures persisted despite 11 dilations. There were no significant complications from balloon dilation. CONCLUSION: Definitive surgical management should be considered if obstruction persists after one attempt at ureteral dilation, as multiple dilations have a low success rate (25%).

Dual phase helical CT versus portal venous phase CT for the detection of colorectal liver metastases: correlation with intra-operative sonography, surgical and pathological findings.

AIM: To assess whether dual phase helical computed tomography (DPCT) of the liver improves the detection of colorectal liver metastases compared with portal venous phase (PVP) imaging alone. MATERIALS AND METHODS: DPCT was performed in 33 consecutive patients before laparotomy for resection of colorectal liver metastases. CT comprised 8-mm slice collimation with a pitch of 1 to 1.25; imaging was commenced 20-25 and 65-70 s after the start of injection of 150 ml of contrast medium at 5 ml/s to coincide with hepatic arterial phase (HAP) and PVP contrast enhancement, respectively. Four blinded observers independently reviewed the HAP, PVP and DPCT images recording the site and size of all lesions. Alternative-free response receiver operating characteristic (AFROC) methodology was used to analyse the results, which were correlated with surgery, intra-operative ultrasound and histology. RESULTS: The mean observer sensitivities for malignant lesion detection were 75.3% for DPCT, 69.7% for PVP imaging and 66.7% for HAP imaging alone. There was a statistically significant improvement in malignant lesion detection using DPCT when compared with PVP imaging alone (P < 0.05). The mean areas under the AFROC curves were 0.84 for DPCT and 0.82 for PVP (P < 0.03) imaging alone. CONCLUSION: The detection of colorectal liver metastases was marginally better with DPCT than with PVP imaging alone, but the discovery of additional lesions did not affect the management of any of the patients in this study.

Ultrasound appearances of testicular epidermoid cysts.

Benign testicular tumours are uncommon but if recognized can enable a conservative approach to surgery to be recommended. This pictorial review demonstrates the variety of sonographic appearances of testicular epidermoid cysts correlating them with pathological findings in 19 lesions, the largest reported imaged series to date. Atchley, J. T. M., Dewbury, K. C. (2000). Clinical Radiology 55, 493-502.

Hepatocellular carcinoma in the cirrhotic liver: double-contrast MR imaging for diagnosis.

PURPOSE: To measure the sensitivity and accuracy of double-contrast magnetic resonance (MR) imaging for the diagnosis of hepatocellular carcinoma (HCC) in the cirrhotic liver. MATERIALS AND METHODS: Twenty-seven patients with MR features of dysplastic nodules and/or HCC were examined. T2-weighted spin-echo and T1-weighted gradient-echo imaging was performed before and after superparamagnetic iron oxide (SPIO) administration and immediately followed by T1-weighted gradient-echo imaging at 10, 40, and 120 seconds after bolus injection of a gadolinium-based contrast material. Nonenhanced, nonenhanced plus SPIO-enhanced, and nonenhanced plus SPIO-enhanced plus gadolinium-enhanced images were reviewed. Alternative-free response receiver operating characteristic (ROC) methodology was used to analyze the results, which were correlated with histopathologic findings after transplantation in 15 patients and at biopsy in 12. Lesions visualized with all three techniques were characterized as a dysplastic nodule or HCC, and ROC analysis was performed. RESULTS: For all observers, SPIO-enhanced MR imaging (mean accuracy, 0.76) was more accurate than nonenhanced MR imaging (mean accuracy, 0.64) (P <.04), and double-contrast MR imaging (mean accuracy, 0.86) was more accurate than SPIO-enhanced imaging (P <.05). Both types of lesions were correctly characterized with all three techniques, although observer confidence for lesion characterization was greatest with double-contrast MR imaging. CONCLUSION: Double-contrast MR imaging significantly improves the diagnosis of HCC compared with SPIO-enhanced and nonenhanced imaging (P <.01).

Colonic wall thickening is related to age and not dose of high strength pancreatin microspheres in children with cystic fibrosis.

OBJECTIVE: Colonic fibrosis causing stricture is a recently described complication in cystic fibrosis (CF). Studies have suggested that ultrasound evidence of bowel thickening predicts this complication and that it is prevalent among children receiving large doses of high-strength pancreatin preparations. We performed ultrasound studies on our patients to look for evidence of bowel wall thickening or early stricture. METHOD: Detailed colonic ultrasounds were carried out in 33 children with CF including 25 who had been receiving high-strength pancreatin (Creon 25,000) continuously for 3 years at the time of study. RESULTS: Median lipase intake was 19 330 U/kg/day (range 0-59 880 U/kg/day) and median protease intake was 387 U/kg/day (range 0-1170 U/kg/day). The combined thickness of mucosa, sub-mucosa and muscle layers was measured in ascending, transverse and descending colon using a 7.5 MHz transducer. Measurements were also made in nine healthy controls. There was no relationship between enzyme dosage and colon thickness but simple regression identified a significant relationship (P < 0.001) between age and maximum colon thickness in all three areas. The colon of CF children was up to 50% thicker than in controls. CONCLUSIONS: Thickening of the order described elsewhere did not occur among any of the children studied. The results suggest that the most important factor determining the thickness of the CF colon is age.

An epidemiological study of the ocular and visual profiles of Oklahoma Cherokees and Minnesota Chippewas.

Over the last three decades some American Indian tribes in North America have received attention in the literature as a minority group with unique visual characteristics. Studies on the refractive status of Indians have shown an increase of refractive errors and particularly an abnormally high prevalence, and amount of, with-the-rule astigmatism. These changes appear to have taken place over the last 40 years. Eskimos, on the other hand, have recently showed an astoundingly high incidence of myopia. Other Native American tribes do not show dramatic changes in myopia or astigmatism. The Public Health Service-Indian Health Service, as an ongoing aspect of their responsibilities to Native Americans, perform screenings on children. This study reports the results of visual screenings primarily of Oklahoma Cherokee and Minnesota Chippewa children.

Anorexia nervosa: let's get going.

A psychiatrist and President of the American Anorexia Nervosa Association presents a personal account of the development of his interest in this disorder. Progress in understanding the etiology of anorexia nervosa has been slow. For the benefit of patients and families, there is a need to organize information on treatment of anorexia nervosa and on the practitioners who are qualified to provide such treatment.