Evaluating QUANTEC Small Bowel Dose-Volume Guidelines for Rectal Cancer Patients Treated Using a Couch Top Inclined Belly Board.

PURPOSE: The goal of this work was to analyse small bowel (SB) dose-volume following the Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) guidelines for rectal cancer patients treated using a couch top inclined belly board (iBB). As part of this, the consistency in SB displacement was evaluated using on-treatment cone-beam computed tomographic (CBCT) imaging. METHODS: Twenty-four patients with rectal cancer were treated on a commercially available iBB. All patients went through the standard radiochemotherapy protocol in either a pre- or postoperative setup. All patients underwent weekly CBCT imaging during the course of radiation treatment. The planning computed tomographic data sets were used to analyze the quality of SB displacement, and the CBCT data sets were used to assess the reproducibility in SB displacement during treatment. The SB dose volume was evaluated and compared with QUANTEC-recommended dose limitations. Similarly, the impact of body mass index on dose volume and SB displacement was evaluated. RESULTS: The SB displacement was assessed respectively as "good" and "very good" by both independent evaluating radiation oncologists. The consistency of SB displacement through the course of radiation treatment was scored as "excellent" for 22 of 24 and 23 of 24 patients by both radiation oncologists, respectively. The QUANTEC recommendation was met for all patients without bowel adhesions; however, the most benefit was observed for patients with body mass index > 23 kg/m2. CONCLUSIONS: Our study has shown that QUANTEC recommendations for SB dose during rectal cancer treatment can easily be met by treating patients on a couch top iBB. This technique is robust and produces consistent SB displacement.

Catheter fracture and embolization associated with arm implantation of the cook vital port.

PURPOSE: To determine the frequency of arm port catheter fracture and embolization related to the Cook Vital Port Mini Titanium. MATERIALS AND METHODS: A retrospective audit of our Cerner Radiology Information System was performed between June 1, 2006, and June 30, 2011, to determine the number of Cook arm venous ports implanted and the frequency of foreign body retrievals related to catheter fracture for these arm ports. RESULTS: A total of 691 arm implantations of the Cook Vital Port during the 5-year time frame were analysed. Eleven of these patients (1.6%) required intravenous foreign body retrieval in the interventional radiology suite related to catheter fracture and embolization. Three of these fractured catheters were retrieved from the peripheral venous system upstream of the pulmonary circulation, whereas 8 embolized to the pulmonary arteries. All were successfully extracted with an intravenous snare by interventional radiology. CONCLUSION: We discovered a 1.6% frequency of catheter fracture and embolization associated with arm implantation of the Cook Vital Port. All the catheters fractured at the vein entry site and did not detach from the port housing. The cause for catheter fracture and embolization is uncertain. Pulmonary embolization of the fractured catheters puts the patients at risk for possible further complications. No patients had ancillary complications related to catheter embolization or to catheter extraction procedures. Further investigation is required in an attempt to determine the circumstances that may result in catheter fracture and embolization related to this venous access device.

Intrapancreatic accessory spleen: A case report and review of the literature.

We present the case of a 26 year old male who was found to have a mass in the tail of the pancreas on an ultrasound scan. The lesion was suspicious for a non-functioning pancreatic neuroendocrine tumour (PNET) and so he underwent distal pancreatectomy. Pathology revealed this to be an intrapancreatic accessory spleen (IPAS). This is a rare entity, and the literature on this subject is reviewed. A lesion in the pancreas that enhances in a manner similar to the spleen, whether the contrast is used in the setting of a Contrast Enhanced Ultrasound, a contrast enhanced CT scan, or a gadolinium enhanced MRI scan, is suggestive of IPAS. Nonetheless, the majority of these rare lesions are likely to be surgically excised rather than observed due to the similar appearance to PNET.

Epidural loss-of-resistance biomechanics: an open pilot cadaver study.

PURPOSE: We measured dynamic biomechanics of loss-of-resistance (LOR) epidural placement in prone cadavers, focussing on the period immediately following LOR, to estimate forces acting on the tissue of the epidural space. METHODS: An epidural syringe with 17G Hustead needle was instrumented to track force on the plunger, pressure in the chamber, and movement of barrel and plunger. Insertions were attempted in five formalin-preserved cadavers from T2-3 to L4-5, using LOR with saline or air, and confirmed with X-ray. RESULTS: Sixteen insertions were successful. Soft tissues in formalin-preserved cadavers are much harder than in living humans. With continuous pressure on the plunger, fluid thrust through the needle at the point of LOR was significantly greater (P = 0.005) with saline (mean ± standard deviation [95% confidence intervals]: 19.3 ± 14.9 [8.3 to 30.3] N); than with air (0.17 ± 0.25 [0 to 0.39] N). Stress exerted on epidural tissue was similar (air = 7792 ± 920 [6986 to 8598] Pa; saline = 7378 ± 3019 [5141 to 9614] Pa); and in both cases was greater than the stress exerted by cerebrospinal fluid pushing outwardly on the dura (4800 Pa). CONCLUSION: Formalin-preserved cadavers are too stiff to make them an experimental model from which we can generalize to live humans, although we were successful in entering the epidural space and testing the instrumentation for further studies on live animals or humans. Continuous pressure on the plunger while advancing the epidural needle may "blow" the dura away from the needle tip and help prevent dural puncture. Better results are seen with saline rather than air.

Emphysematous pancreatitis: a less aggressive form of infected pancreatic necrosis?

OBJECTIVE: Emphysematous pancreatitis is characterized by the presence of intraparenchymal pancreatic air in the setting of necrotizing pancreatitis. Mortality and morbidity rates approach approximately 40% and 100%, respectively. Traditionally, emphysematous pancreatitis was an indication for surgical intervention. The purpose of this review was to discuss our experience with nonoperative management of emphysematous pancreatitis. METHODS: Between July 2005 and August 2007, 5 patients with emphysematous pancreatitis were admitted to Royal University Hospital (Saskatoon, Saskatchewan, Canada). The cases are described in the context of the current literature. RESULTS: The 5 male patients ranged in age from 50 to 77 years. Four required at least 1 week in the intensive care unit. All 5 cases of emphysematous pancreatitis went on to be treated successfully with nonoperative management. Furthermore, after a minimum of 1-year follow-up, they remain out of hospital and continue to do well. CONCLUSIONS: Our data suggest that emphysematous pancreatitis may be a favorable subtype of severe pancreatitis. In well-selected patients, nonoperative management with aggressive antibiotic treatment and nutritional support may suffice.

Improving inter-observer variability in the evaluation of ultrasonographic features of polycystic ovaries.

BACKGROUND: We recently reported poor inter-observer agreement in identifying and quantifying individual ultrasonographic features of polycystic ovaries. Our objective was to determine the effect of a training workshop on reducing inter-observer variation in the ultrasonographic evaluation of polycystic ovaries. METHODS: Transvaginal ultrasound recordings from thirty women with polycystic ovary syndrome (PCOS) were evaluated by three radiologists and three reproductive endocrinologists both before and after an ultrasound workshop. The following endpoints were assessed: 1) follicle number per ovary (FNPO), 2) follicle number per single cross-section (FNPS), 3) largest follicle diameter, 4) ovarian volume, 5) follicle distribution pattern and 6) presence of a corpus luteum (CL). Lin's concordance correlation coefficients (rho) and kappa statistics for multiple raters (kappa) were used to assess level of inter-observer agreement (>0.80 good, 0.60 - 0.80 moderate/fair, <0.60 poor). RESULTS: Following the workshop, inter-observer agreement improved for the evaluation of FNPS (rho = 0.70, delta rho = +0.11), largest follicle diameter (rho = 0.77, delta rho = +0.10), ovarian volume (rho = 0.84, delta rho = +0.12), follicle distribution pattern (kappa = 0.80, delta kappa = +0.21) and presence of a CL (kappa = 0.87, delta kappa = +0.05). No improvement was evident for FNPO (rho = 0.54, delta rho = -0.01). Both radiologists and reproductive endocrinologists demonstrated improvement in scores (p < 0.001). CONCLUSION: Reliability in evaluating ultrasonographic features of polycystic ovaries can be significantly improved following participation in a training workshop. If ultrasonographic evidence of polycystic ovaries is to be used as an objective measure in the diagnosis of PCOS, then standardized training modules should be implemented to unify the approach to evaluating polycystic ovarian morphology.

Reactive hyperemia increases forearm vein area.

PURPOSE: To determine the effect of reactive hyperemia on human forearm vein area. METHODS: After obtaining ethics approval and informed consent, an automatic tourniquet was applied to the forearms of 20 healthy subjects for one, two, and three minutes, at pressures of 25 mmHg, 200 mmHg, then 25 mmHg. A blinded radiographer measured the cross-sectional area of the cephalic vein at the wrist using ultrasonography. Measurements were recorded prior to tourniquet application and every minute thereafter for ten minutes, at each pressure setting and each time interval. RESULTS: The mean vein cross-sectional area (mm2) increased from 8.22 +/- 3.09 to 10.77 +/- 3.50 after one minute of ischemia, from 8.31 +/- 2.78 to 10.61 +/- 2.77 after two minutes of ischemia, and from 8.39 +/- 3.34 to 10.94 +/- 3.46 after three minutes of ischemia (P < 0.05 for all). A tourniquet inflated to 25 mmHg for 13 min produced a mean vein cross-sectional area of 10.71 +/- 3.25 mm2. CONCLUSIONS: Reactive hyperemia causes human forearm vein cross-sectional area to increase. A low pressure tourniquet will also increase forearm vein area, but veins dilate more quickly during reactive hyperemia. This may have important clinical implications for attempting venous cannulation in patients with difficult venous access.

Chest X-ray ordering related to varied clinical scenarios: a survey of Saskatchewan physicians.

INTRODUCTION: The chest X-ray (CXR) is one of the most commonly requested diagnostic imaging examinations. It is estimated that over 250,000 CXRs are ordered in Saskatchewan annually. Judicious use of the CXR is valuable in patient care, while unnecessary use increases costs, adds to patient irradiation, and may be in conflict with standards of patient care. In 1993, the Saskatchewan Health Services Utilization and Research Commission (HSURC) developed clinical practice guidelines (CPGs) for the CXR. These guidelines were based on a metaanalysis of validated literature. We were uncertain about whether Saskatchewan physicians were ordering CXRs based on the HSURC CXR CPGs. MATERIALS AND METHODS: A survey, based on recommendations from the HSURC CXR CPGs, was developed and distributed to 363 physicians in Saskatchewan by mail (30/363) and by email (333/363). The survey asked physicians if they would order, or not order, a CXR for 5 basic clinical scenarios. The question of whether to order a CXR was then repeated when the basic scenario was altered one variable at a time, to determine if the physicians would change their CXR orders. RESULTS: According to our assessment of physician responses to the initial clinical scenarios, the surveyed physicians correctly followed the HSURC CXR CPGs in the following frequencies: 100% scenario 1, 91.9% scenario 2, 35.4% scenario 3, 100% scenario 4, and 61.2% scenario 5. Alteration of the basic clinical scenarios resulted in very unpredictable ordering of CXRs by the survey participants. CONCLUSION: The Saskatchewan physicians we surveyed are not ordering CXRs on the basis of HSURC CXR CPGs. They order too many nonindicated CXRs. Further communication with, and education of, the physician population about the HSRUC CXR CPGs may be warranted.