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.

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.

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.

Multiphase contrast-enhanced helical CT of liver metastases from renal cell carcinoma.

The aim of this study was to evaluate whether in patients with metastatic renal cell carcinoma (RCC) multiphase liver studies would improve detection of metastatic liver disease. Forty-six consecutive patients with known metastatic RCC underwent standardized non-contrast and triphasic contrast enhanced hepatic CT examinations as part of their routine imaging studies. Once a liver abnormality was detected, it was characterized as metastatic by a panel of three radiologists who followed pre-set criteria. These criteria included change in size, biopsy results and lack of benign features. Presence and conspicuity of liver metastases were graded using a five-point scale by consensus of a panel of three radiologists. The highest number of lesions evaluated per patient was limited to ten. Seventy-two liver metastases were detected in 16 patients. Of these, 54 were seen on unenhanced scans; 47 in the hepatic arterial (HA) phase, at 25 s; 65 in the portal-venous (PV) phase, at 60 s; and 49 in delayed images, at 90 s. Scanning only during the PV phase would have missed seven lesions (10%), six of which were seen on unenhanced images and six were seen in HA phase. All patients with metastatic liver disease would have been identified by combination of unenhanced and PV phase or by HA and PV phase scanning. Forty-two lesions were graded more conspicuous on the PV phase, whereas 18 (25%) were more conspicuous on the HA phase. The combination of unenhanced, HA and PV scanning should be considered in the initial evaluation of patients with metastatic RCC for improved lesion detection and characterization. Subsequently, the combination of unenhanced and PV phase imaging is preferred.

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.

Two-dimensional multiplanar and three-dimensional volume-rendered vascular CT in pancreatic carcinoma: interobserver agreement and comparison with standard helical techniques.

OBJECTIVE: The purpose of this study was to compare two-dimensional curved multiplanar and three-dimensional reconstructions, routine axial presentations, and combined techniques in the assessment of vascular involvement by pancreatic malignancy. MATERIALS AND METHODS: For 44 patients with known pancreatic malignancy a total of 56 arterial phase helical CT scans were obtained. Targeted pancreatic imaging was performed, and reformatted images were generated. Axial source images, reformatted images, and the combination of axial and reformatted images were interpreted independently by three observers. The observers graded the celiac axis, common and proper hepatic, splenic, gastroduodenal, and superior mesenteric arteries for tumor involvement. Grades of vascular involvement were compared by intra- and interobserver variability analyses. RESULTS: Intraobserver agreement averaged over five vessels was good between the axial and combined techniques for each individual observer (0.64 < or kappa < or = 0.66), but intraobserver agreement was poor between the axial and reformatted (kappa = 0.17 and kappa = 0.31, respectively) and the reformatted and combined techniques (kappa = 0.31 and kappa = 0.38, respectively) for two observers. For grading of vascular involvement in each vessel, intraobserver agreement was good to excellent between the axial and combined techniques (0.48 or = kappa < or = 0.82). Interobserver agreement averaged over five vessels was poor for imaging techniques except between observer 2 and observer 3 on the axial (kappa = 0.47) and combined techniques (kappa = 0.47). For grading of vascular involvement in each vessel, interobserver agreement for reformatted technique was poor (0.09 < or = kappa < or = 0.40). CONCLUSION: Multiplanar and volume-rendered techniques showed the highest intra- and interobserver variability in grading vascular involvement by pancreatic malignancy. These images should be used in combination with routine axial images to decrease observer variability.

Impact of multidetector CT on donor selection and surgical planning before living adult right lobe liver transplantation.

OBJECTIVE: This study was performed to document the impact of multidetector multiphase CT in facilitating patient selection and surgical planning in potential donors being evaluated for living adult right lobe liver transplantation. SUBJECTS AND METHODS: Forty consecutive potential donors were included in the study. There were 26 men and 14 women, (age range, 18-57 years; mean, 37 years) We performed CT using a multidetector scanner, after IV injection of 180 mL of contrast material at 5 mL/sec. Arterial phase images were acquired at 18 sec (collimation, 1.25 mm; table speed, 7.5) and portal phase images, at 60 sec (collimation, 2.5 mm; table speed, 15). Postprocessing was performed on a commercially available workstation. CT data included dual-energy assessment of liver parenchyma for fatty infiltration; depiction of arterial, portal venous, and hepatic venous anatomy and identification of important vascular variants; and determination of total and lobar liver volume. RESULTS: Of the 40 potential liver donors evaluated, 15 patients (37.5%) were excluded on the basis of CT findings, with most exclusions a result of portal vein anomalies (n = 8). Fatty infiltration resulted in four exclusions (10%), and small liver volume resulted in three exclusions (7.5%). CONCLUSION: Multidetector multiphase CT provided comprehensive parenchymal, vascular, and volumetric preoperative evaluation of potential donors undergoing living adult right lobe liver transplantation. This information had a major impact on patient selection because it was used to stratify patients. It allowed the surgeons to plan their surgical approach, and this planning may reduce postoperative complications.

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.

Nonenhanced helical CT and US in the emergency evaluation of patients with renal colic: prospective comparison.

PURPOSE: To compare nonenhanced helical computed tomography (CT) with ultrasonography (US) for the depiction of urolithiasis. MATERIALS AND METHODS: During 9 months, 45 patients (mean age, 44 years; mean weight, 92.5 kg) prospectively underwent both nonenhanced helical CT (5-mm collimation; pitch of 1.5) and US of the kidneys, ureters, and bladder. US evaluation included a careful search for ureteral calculi. Presence of calculi and obstruction and incidental diagnoses were recorded. Clinical, surgical, and/or imaging follow-up data were obtained in all patients. The McNemar test was used to compare groups. RESULTS: Diagnoses included 23 ureteral calculi and one each of renal cell carcinoma, appendicitis, ureteropelvic junction obstruction, renal subcapsular hematoma, cholelithiasis, medullary calcinosis, and myelolipoma. CT depicted 22 of 23 ureteral calculi (sensitivity, 96%). US depicted 14 of 23 ureteral calculi (sensitivity, 61%). Differences in sensitivity were statistically significant (P: =.02). Specificity for each technique was 100%. When modalities were compared for the detection of any clinically relevant abnormality (eg, unilateral hydronephrosis and/or urolithiasis in patients with an obstructing calculus), sensitivities of US and CT increased to 92% and 100%, respectively. One case of appendicitis was missed at US, whereas medullary calcinosis and myelolipoma were missed at CT. CONCLUSION: Nonenhanced CT has a higher sensitivity for the detection of ureteral calculi compared with US.

An investigation into causative factors in patients with bronchiectasis.

Bronchiectasis is a pathologic description of lung damage characterized by inflamed and dilated thick-walled bronchi. These findings may result from a number of possible causes and these may influence treatment and prognosis. The aim of this study was to determine causative factors in 150 adults with bronchiectasis (56 male, 94 female) identified using high-resolution computerized tomography. Relevant factors were identified in the clinical history; cystic fibrosis gene mutation analysis was performed; humoral immune defects were determined by measuring immunoglobulins, IgG subclasses and functional response to Pneumovax II vaccine; assessment was made of neutrophil function (respiratory burst, adhesion molecule expression, and chemotaxis); ciliary function was observed and those likely to have allergic bronchopulmonary aspergillosis (ABPA) were identified. Causes identified were: immune defects (12 cases), cystic fibrosis (4), Young's syndrome (5), ciliary dysfunction (3), aspiration (6), panbronchiolitis (1), congenital defect (1), ABPA (11), rheumatoid arthritis (4), and early childhood pneumonia, pertussis, or measles (44). Intensive investigation of this population of patients with bronchiectasis led to identification of one or more causative factor in 47% of cases. In 22 patients (15%), the cause identified had implications for prognosis and treatment.

Right lower quadrant pain and suspected appendicitis: nonfocused appendiceal CT--review of 100 cases.

PURPOSE: To determine the value of standard, nonfocused computed tomography (CT) in examining patients with right lower quadrant (RLQ) pain and suspected appendicitis. MATERIALS AND METHODS: The CT scans and medical records of 100 consecutive patients who presented to the emergency department with RLQ pain and were clinically suspected of having appendicitis were retrospectively reviewed. Helical CT of both the abdomen and pelvis was performed at 7-mm increments after oral and intravenous contrast material administration. CT scans were evaluated for the presence of appendiceal or other disease. Results were correlated with surgical and pathologic findings in 34 patients or with 3-month clinical follow-up in 66 patients. RESULTS: CT depicted abnormalities in 66 patients (66%). In 59 (59%) patients, the abnormality was located in the pelvis; 23 (39%) of these patients had appendicitis. Seven (7%) patients had abnormalities outside of the pelvis, a region not typically scanned during focused appendiceal imaging. Four of these seven patients required surgery. Thus, if only pelvic focused RLQ CT had been performed, overall sensitivity would have decreased from 99% to 88% (P <.05) and sensitivity for cases necessitating surgery would have decreased from 96% to 82% (P <.05). CONCLUSION: Both abdominal and pelvic CT examinations are necessary to increase sensitivity and identify the many possible causes of RLQ pain in patients with clinically suspected appendicitis.

MR cholangiopancreatography of bile and pancreatic duct abnormalities with emphasis on the single-shot fast spin-echo technique.

Magnetic resonance cholangiopancreatography (MRCP) is used for noninvasive work-up of patients with pancreaticobiliary disease. MRCP is comparable with invasive endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis of extrahepatic bile duct abnormalities. In patients with choledocholithiasis, calculi appear as dark filling defects within the high-signal-intensity fluid at MRCP. Benign strictures due to sclerosing cholangitis are multifocal and alternate with slight dilatation or normal-caliber bile ducts, producing a beaded appearance. Dilatation of both the pancreatic and bile ducts at MRCP is highly suggestive of a pancreatic head malignancy. Side-branch ectasia is the most prominent and specific feature of chronic pancreatitis. MRCP is more sensitive than ERCP in detection of pancreatic pseudocysts because less than 50% of pseudocysts fill with contrast material. Because the mucin secreted by biliary cystadenomas and cystadenocarcinomas causes filling defects and partial obstruction of contrast material at ERCP, MRCP is potentially more accurate in demonstrating the extent of these tumors. In patients with biliary-enteric anastomoses, MRCP is the imaging modality of choice for the work-up of suspected pancreaticobiliary disease. A potential use of MRCP is the demonstration of aberrant bile duct anatomy before cholecystectomy. MRCP is also accurate in detection of pancreas divisum.

Radiologic manifestations of sclerosing cholangitis with emphasis on MR cholangiopancreatography.

Magnetic resonance cholangiopancreatography (MRCP) is a relatively new, noninvasive cholangiographic technique that is comparable with invasive endoscopic retrograde cholangiopancreatography (ERCP) in the detection and characterization of extrahepatic bile duct abnormalities. The role of MRCP in evaluation of the intrahepatic bile ducts, especially in patients with primary or secondary sclerosing cholangitis, is under investigation. The key cholangiographic features of primary sclerosing cholangitis are randomly distributed annular strictures out of proportion to upstream dilatation. As the fibrosing process worsens, strictures increase and the ducts become obliterated, and the peripheral ducts cannot be visualized to the periphery of the liver at ERCP. In addition, the acute angles formed with the central ducts become more obtuse. With further progression, strictures of the central ducts prevent peripheral ductal opacification at ERCP. Cholangiocarcinoma occurs in 10%-15% of patients with primary sclerosing cholangitis; cholangiographic features that suggest cholangiocarcinoma include irregular high-grade ductal narrowing with shouldered margins, rapid progression of strictures, marked ductal dilatation proximal to strictures, and polypoid lesions. Secondary sclerosing and nonsclerosing processes can mimic primary sclerosing cholangitis at cholangiography. These processes include ascending cholangitis, oriental cholangiohepatitis, acquired immunodeficiency syndrome-related cholangitis, chemotherapy-induced cholangitis, ischemic cholangitis after liver transplantation, eosinophilic cholangitis, and metastases.

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.

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.